The question of who needs to be screened for cancer, when it should happen and what test should be used is not always clear cut.
Recently, screening guidelines for breast, colo-rectal, cervical, prostate and ovarian cancer have been under considerable "refinement." Basically they've changed repeatedly depending on who's writing the guideline. Now one organization is trying to tie it all together for people at average risk for these five common cancers.
The American College of Physicians reviewed cancer screening recommendations from major physician and cancer organizations, but their eye was on more than just clarifying confusing guidelines. They added emphasis on the value of screening to improve health while avoiding harm and eliminating waste.
"Overly intense screening can sometimes lead to over-diagnosis and lead to overtreatment," explained Dr. Wayne Riley, president of the American College of Physicians.
High value screening means there is a strong benefit compared to the harm and cost.
"An excellent example of a high value care screening would be one for colon cancer in those between the age of fifty and seventy-five," said Riley.
On the flip side, low value screening produces limited benefit for the risk or cost.
"Lower value would be screening women for cervical cancer who no longer have a cervix," said Riley. "Studies have consistently shown that approximately one third of the health dollars that we spend in the country are likely spent on treatments or screening that have very little impact."
There is growing concern that people overestimate the benefits and underestimate the limitations of screening. For example, the report very strikingly states that there is no screening available for ovarian cancer in average risk women.
The guidelines stress patients and doctors should discuss the unseen risks of screening, not just the potential benefits.
"There are significant harms that can result from overdiagnosis, overtreatment," said Riley.
Screening for Cancer: Advice for High-Value Care From the ACP
(Information From Table 1. High- and Low-Value Screening Strategies for 5 Types of Cancer*)
- Women aged 40–49 y: Discuss benefits and harms with women in good health, and order screening with mammography every 2 y if a woman requests it
- Women aged 50–74 y in good health: Encourage mammography every 2 y
- Women aged <40 or ?75 y and women of any age not in good
health and with a life expectancy <10 y: Any screening
- Women of any age: Annual mammography, MRI, tomosynthesis, or
regular systematic breast self-examination
- Women aged 21–29 y: Cytology testing every 3 y
- Women aged 30–65 y: Cytology testing every 3 y or cytology and HPV testing every 5 y
- Women aged <21 or >65 y with previous recent negative screening
results: Any screening
- Women of any age without a cervix: Any screening
- Women aged 21–65 y: Cytology testing more frequently than every 3 y
- Women aged <30 y: HPV testing
- Women of any age: Pelvic examination
- Adults aged 50–75 y: Encourage 1 of the 4 following strategies: High-sensitivity FOBT or FIT (every year); sigmoidoscopy (every 5 y); combined high-sensitivity FOBT or FIT (every 3 y) plus sigmoidoscopy (every 5 y); or optical colonoscopy (every 10 y)
- Adults aged <50 or >75 y or adults of any age not in good health
and with a life expectancy <10 y: Any screening
- Adults aged 50–74 y: Repeated colonoscopy more frequently than
every 10 y or flexible sigmoidoscopy every 5 y if results of previous colonic examination were normal (i.e., without adenomatous polyps)
- Any age: Interval fecal testing in adults having 10-y screening
colonoscopy or more frequently than biennially in adults having
5-y screening flexible sigmoidoscopy
- Women of any age: CA-125 screening, TVUS, or pelvic examination
- Men aged 50–69 y: Discuss benefits and harms of screening with men in good health with a life expectancy >10 y at least once (or more as the patient requests), order screening only if the informed man expresses a clear preference for screening, and order PSA testing no more often than every 2–4 y
- Men aged 50–69 y who have not had an informed discussion and
have not expressed a clear preference for testing after the discussion: PSA testing
- Men aged <50 y or >69 y and men of any age who are not in good
health and have a life expectancy <10 y: Any testing
(CA-125 = cancer antigen 125; FIT = fecal immunofluorescence testing; FOBT = fecal occult blood testing; HPV = human papillomavirus; MRI = magnetic resonance imaging; PSA = prostate-specific antigen; TVUS = transvaginal ultrasonography.
* This table provides information for persons at average specific cancer risk who do not have severe competing risk for mortality from another
condition. The least intensive recommended strategies are the minimal ones recommended by high-visibility medical groups and guideline
organizations (high value). The strategies that are not recommended represent general agreement among groups and signify low-value screening.
The rationale for not recommending strategies usually involves an unfavorable tradeoff between benefits and harms, a type of value calculation, but
does not include costs. Strategies that are not recommended are more intensive than recommended strategies.)