An article in this week’s issue of the Journal of the American Medical Association and a companion news story on the front page of the New York Times has created a firestorm of media interest.
The problem I have with both of the articles is: where’s the news?
Let me cut to the chase, in no small part because I am travelling today and have limited time to write this before and between flights: The American Cancer Society is not working on any stealth project to change commentary on our website to emphasize the shortcomings and risks of screening.
If we are, I would know about it, and I haven’t heard anything about such a plan. We don’t have to. You see, we already discuss these issues right there in plain view, including on this blog.
Second, the American Cancer Society has long recognized that screening for breast cancer with mammograms is not perfect.
Mammography misses lesions and mammography diagnoses lesions that would otherwise not cause harm to a patient. But when it comes to reducing deaths from breast cancer, we do believe that the evidence shows that mammography and newer methods of treating breast cancer have reduced deaths from the disease. If you don’t believe it, then just go look at the fall in death rates from breast cancer in this country, which have been declining since the early 1990’s. Before that, those death rates were absolutely unchanged for decades.
As to prostate cancer, lest there be no further confusion, the American Cancer Society has been very careful to state that we do not support routine screening for this disease. We do recommend that men have a clear understanding of the possible benefits, risks and harms from prostate cancer screening before they embark on a program of routine screening for this disease. We do not believe that the science has shown that routine prostate cancer screening reduces deaths from the disease. We also believe that treatment for this disease can cause significant harm for some men.
Men should understand that fact. Physicians, patients and families should start understanding what the science shows us about prostate cancer screening as opposed to what they want to believe—and have believed for the past 20 years—about the effectiveness of the prostate screening blood test, or PSA.
And here is another news bulletin for the press and the rest of the media: developing and accurately promoting guidelines are complex processes that don’t lend themselves to sound bite messaging. They are also a “living process” that requires continuing assessment of the evidence, and changing guidelines when the evidence warrants it. They are not written in stone for all time.
The American Cancer Society understands that, and provides an annual update reviewing its guidelines. We also periodically convene panels of experts to review the evidence and help us write up-t- date guidelines that are consistent with evidence and the best available expert opinion.
Understanding the limitations of screening and possible harms are well known to me and my expert colleagues who are responsible for writing and maintaining our guidelines. In fact, I write about that frequently in my blog. It is no secret to those of us who are involved in the guidelines process for the American Cancer Society or other well respected organizations that write cancer related guidelines, for that matter.
That said, different experts can look at the same data and come to different conclusions. That is not a particular surprise to those of us in this field. It is part of the constant give and take that between experts in the early detection and prevention of cancer that moves us along a path. We all have the same interests of doing the best we can, but we may not always agree how to get there.
Which brings me to the JAMA article. This was an opinion piece, not original research. It reiterated arguments that have been made before, and are certainly valid. But they represent the thoughts of several respected scientists, but not all who are involved in trying to reduce the burden of cancer in this country and throughout the world.
And while we may agree with the comments about prostate cancer, we do not agree with the negativistic comments about breast cancer. As noted in the New York Times article, when the public gets a mixed message it takes that as a reason not to move forward with the most effective breast cancer screening modality we have available today.
And we can agree on some of the points: we do need better screening techniques, and must invest in research to discover and validate those approaches. We must develop tests that can help us distinguish indolent cancers from more aggressive cancers. We do not agree that those tests are currently available, and we await clinical trials that will help validate or refute the concept that the currently available predictive tests can in fact be relied on before advising a woman that she does not need adjuvant therapy after initial treatment for breast cancer.
I am also comfortable in supporting the conclusion that there is much we need to do to learn about what we do as doctors for patients. We are far from that dream as I write this. But the goal is the right one, and the suggestion is an honorable one. The problem is that we are hamstrung by the limitations of our current health care system, and the lack of communication standards that prevents us from unlocking the real value of health information technology.
But to send a message that screening is wrong—which is what the headlines will do—or to suggest that the harms of mammography are so substantial that women continue to reduce their reliance on a proven, available and effective strategy, or that there are other accepted proven strategies available right now that permit us to tailor screening to those who would benefit is not being truthful regarding the limitations of our science.
We all seek a goal where we detect cancer early, treat only those cancers that require it, and avoid unnecessary tests and treatments. We must work toward that goal.
The reality is that we are not there yet. More importantly—at least for breast cancer—we have made progress in reducing deaths from this disease.
As I have written previously, I for one have no interest running an experiment today that will take us back to the “good old days” when women came in after they felt a lump, where their cancer was usually at least one inch in diameter at the time of diagnosis, where their lymph nodes were involved with cancer when they were diagnosed, and their death rates from breast cancer were unacceptably high.
So I will agree to disagree—as will many of my colleagues.
The sad part is that the women in this country may only read the New York Times, and leave it at that. They will miss the nuances of the experts’ arguments. They will not read the conclusions of the JAMA study, and if they do they probably won’t have the working knowledge that would put it in context.
Hopefully they won’t miss the nuances that could impact their lives. That would be a tragedy. But such is the risk of living in a sound bite world.
