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NY Times article on Cancer Screening

July 17, 2009
FORTY YEARS' WAR
In Push for Cancer Screening, Limited Benefits

By NATASHA SINGER
“Don’t forget to check your neck,” says an advertising campaign encouraging people to visit doctors for exams to detect thyroid cancer.

In another cancer awareness effort, Representative Debbie Wasserman Schultz, a Florida Democrat, has more than 350 House co-sponsors for her bill to promote the early detection of breast cancer in young women, teaching them about screening methods like self-exams and genetic testing.

Meanwhile, the foundation of the American Urological Association has a prostate cancer awareness campaign starring Hall of Fame football players. “Get screened,” Len Dawson, a former Kansas City Chiefs quarterback, says in a public service television spot. “Don’t let prostate cancer take you out of the game.”

Nearly every body part susceptible to cancer now has an advocacy group, politician or athlete with a public awareness campaign to promote routine screening tests — even though it is well established that many of these exams offer little benefit for the general public.

An upshot of the decades-long war on cancer is the popular belief that healthy people should regularly examine their bodies or undergo screening because early detection saves lives. But in fact, except for a few types of cancer, routine screening has not been proven to reduce the death toll from cancer for people without specific symptoms or risk factors — like a breast lump or a family history of cancer — and could even lead to harm, many experts on health say.

That is why the continued rollout of screening campaigns, and even the introduction of a Congressional bill, worries some health experts. And these experts say such efforts add to the large number of expensive and unnecessary treatments each year that help drive up the nation’s health care bill. Rather than heed mass-market calls for screening, these experts urge people without symptoms or special risks to talk to their own doctors about what cancer tests, if any, might be appropriate for them.

Blanket screenings do come with medical risks. A recent European study on prostate cancer screening indicated that saving one man’s life from the disease would require screening about 1,400 men. But among those 1,400, 48 others would undergo treatments like surgery or radiation procedures that would not improve their health because the cancer was not life-threatening to begin with or because it was too far along. And those treatments could lead to complications including impotence, urinary incontinence and bowel problems.

Then there is the economic cost. There are no credible estimates for the amount that routine cancer screening contributes to the approximately $700 billion spent each year in this country on unneeded medical treatment of all types. But health policy experts say such screenings and the cascade of follow-up tests and treatments do play a role.

For example, Americans spend an estimated $4 billion annually on mammograms, according to Dr. David H. Newman, author of the book “Hippocrates’ Shadow: Secrets from the House of Medicine.” Some of those tests cause false alarms that lead to unnecessary follow-up surgery on normal breasts, at a cost of $14 billion to $70 billion over a decade, according to Dr. Newman, the director of clinical research in the department of emergency medicine at St. Luke’s Roosevelt Hospital Center in Manhattan.

Check Your Neck?

Cancer awareness campaigns can be a disservice to the public by making people overestimate their risk of dying from cancer, according to Dr. Steven Woloshin, a researcher at the Dartmouth Institute for Health Policy and Clinical Practice. Thyroid cancer, for example, is a rare disease that kills an estimated 1,600 Americans a year. But the campaign called “Check Your Neck” makes it seem as if everyone should worry about the disease, Dr. Woloshin said.

“Confidence kills. Thyroid cancer doesn’t care how healthy you are,” reads the text of one ad that has appeared in national magazines like People. The ads promote a quick physical exam, called palpation, in which doctors feel for unusual lumps in the thyroid, a small gland in the front of the neck. “Ask your doctor to check your neck. It could save your life.”

The campaign is part of an effort by the Light of Life Foundation, an advocacy group for thyroid cancer patients founded by Joan Shey, who was told she had the disease in 1995.

A Manhattan advertising agency designed the ads as a pro bono project after one of its own employees was found to have the disease. Bernie Hogya, one of the creators behind the “Got Milk” ads, created the cancer awareness campaign. Full-page ads valued at $800,000 have run free in national magazines like Sports Illustrated.

Ms. Shey said the campaign was intended to save lives through the early detection of cancer.

Dr. R. Michael Tuttle, an endocrinologist at Memorial Sloan Kettering Cancer Center in Manhattan who is on the foundation’s board, said he hoped the campaign would remind busy family care doctors and gynecologists to check routinely for the disease. The campaign could also prompt people with symptoms like nodules or swollen lymph nodes in their necks to see their doctors, Dr. Tuttle said.

But there is no evidence that routine neck exams reduce the risk of dying from thyroid cancer, said Dr. Barnett S. Kramer, the associate director for disease prevention at the National Institutes of Health, which has a cancer Web site describing the potential benefits and risks of many cancer screening tests. Most thyroid cancers are so slow-growing and curable that early detection would not improve their prognosis, he said, while a rarer form of thyroid cancer is so aggressive that a surge in screening would be unlikely to have an impact on the death rate.

But routine screening, he said, does have the potential to do harm because neck exams can find tumors that would not otherwise have required treatment, potentially setting off a cascade of unnecessary events like ultrasounds, needle biopsies in the neck, operations to remove the thyroid and complications like damage to the vocal cords. Meanwhile, Dr. Kramer said, the exams can miss some life-threatening cancers that are not detectable by touch.

The “Check Your Neck” campaign is one of many that prompt Dr. Kramer to compare mass cancer screening to a lottery. “In exchange for those few who win the lottery,” he said, “there are many, many others who have to pay the price in human costs.”

Dr. Ned Calonge, the chairman of the United States Preventive Services Task Force said, “There are five things that can happen as a result of screening tests, and four of them are bad.” His group consists of independent medical experts that Congress has commissioned to make recommendations, based on medical evidence, about what preventive measures actually work.

When Screenings Are Bad

The one good result of screening, Dr. Calonge said, is identifying a life-threatening form of cancer that actually responds to timely intervention.

The possible bad outcomes, he said, are results that falsely indicate cancer and cause needless anxiety and unnecessary procedures that can lead to complications; that fail to diagnose an existing cancer, which could lull a patient into ignoring real symptoms as the cancer progresses; that detect slow-growing or stable cancers that are not life-threatening and would not otherwise have required treatment; and that detect aggressive life-threatening cancers whose outcome is not changed by early detection.

Experts like Dr. Calonge say screening is useful only if, on balance, the deaths prevented by treating cancers outweigh the harm done by treatments that are not medically necessary. The problem is, most current screening tests are not sophisticated enough to determine which cancers might not require treatment — or to predict which life-threatening cancers will respond to treatment.

He is among those suggesting that people consult their doctors about whether to be screened and not make decisions based on public awareness campaigns. And doctors, experts say, should make sure they understand the pros and cons of screening and be sure to tell patients about the possible risks.

No one advocates that people eschew tests if they have symptoms or special risk factors. “Once something bothers you or changes or is unusual, this is no longer routine screening,” Dr. Calonge said.

But, for otherwise healthy people with no symptoms, he said, only a few routine tests have proven to significantly reduce cancer deaths among certain age groups. The task force recommends pap smears for cervical cancer beginning no later than age 21; regular mammograms to screen for breast cancer in women starting at age 40; and tests for colon cancer starting at age 50. And the task force notes that the evidence supporting the breast cancer screening is not as strong as for cervical and colon cancers.

Most other types of screening, meanwhile, have not been proved to reduce the death toll from cancer, said Dr. Kramer at the National Institutes of Health.

“You need a high bar of evidence to start advertising screening to healthy people, most of whom will not benefit,” Dr. Kramer said.

Indeed, the federal Centers for Disease Control makes it clear on its Web site: there is no medical proof yet that routine screening for lung, ovarian, prostate and skin cancer reduces deaths from those cancers.”

Legislation in Congress that deals with breast cancer has become a flashpoint in the debate over cancer screening for the general public.

The bill, introduced in the House in March, is called the Breast Cancer Education and Awareness Requires Learning Young Act of 2009, or the Early Act. It mandates an education and media campaign, aimed at women under 45 and their physicians, on the early detection of breast cancer.

A Teaching Campaign

The bill would spend $45 million over five years to teach young women and their doctors to recognize breast abnormalities. It would promote lifestyle changes like eating habits to reduce the chances of getting the disease. It would focus special attention on members of certain racial or ethnic groups who are at higher risk for more aggressive cancers. It would also provide grants to groups supporting young women with breast cancer.

The bill’s sponsor, Ms. Wasserman Schultz, was told she had breast cancer in 2007. Breast-cancer advocacy groups, like the Young Survival Coalition and Susan G. Komen for the Cure, said they hoped the bill would teach young women to notice changes in their bodies, talk to their doctors and seek second opinions when necessary.

“It is worth spending the federal government’s money, because it will save lives,” Ms. Wasserman Schultz said in an interview.

But critics say the House bill promotes techniques like breast self-exams that have not proved to find cancer at an earlier stage or to save lives. The concern is that the technique could cause younger women — a group for whom breast cancer is a rare disease — to find too many medically insignificant nodules that would lead doctors to perform unneeded biopsies, in which tissue is removed for testing.

Scarring from biopsies could make breast cancer harder to detect when the women are older and have a much higher risk of getting the disease, critics say. And such false alarms can also cause women to distrust the medical system and skip mammograms later in life when the tests have been proved to reduce the death toll, said Dr. Otis W. Brawley, an oncologist who is the chief medical officer of the American Cancer Society.

The breast self-exam is a formal procedure in which women are taught to examine their breast tissue monthly, inch by inch and layer by layer, in a grid pattern. But instead of such a thorough probing, which might detect minute irregularities of no medical significance, many cancer institutions now recommend a less formal process called “breast self-awareness”. Its premise is that women should become familiar with their breasts and seek medical attention if they notice a change like a persistent lump or rash.

Opposition to the Early Act surfaced soon after its introduction, in a specialist newsletter called the Cancer Letter.

In it, some prominent public health and cancer experts attacked the bill’s central tenet — that lifestyle changes and early-detection methods had been proved to reduce breast cancer deaths in women in their 20s and 30s who have no special risks for the disease.

Routine mammograms, for example, which have been shown to reduce deaths from breast cancer in older women, have not proved to reduce the toll in women in their 20s and 30s, said Dr. Susan M. Love, a breast cancer surgeon in Santa Monica, Calif. That is because breast tissue in younger women is typically too dense for routine mammograms to be effective. And this test can needlessly expose young women to radiation, Dr. Love said.

“Once you have made women more ‘aware’ of their potential risk, you will have nothing to tell them to do!” Dr. Love wrote in a letter to Ms. Wasserman Schultz asking her not to pursue the bill.

Dr. Love and other critics have also argued that a public health campaign could cause younger women to overestimate their chances of dying from breast cancer. Of the estimated 41,000 deaths a year in the United States from breast cancer, about 1 in 14 involve women younger than 45, according to the C.D.C. Only 1 in 33 breast cancer deaths — about 1,200 a year — occurs in women younger than 40.

Defending the Bill

Ms. Wasserman Schultz says her bill is necessary because too many women do not pay attention to their breast health until they are 40 or older. “Leaving young women in the dark, just because there is a group of experts who believe we don’t know what to tell them, isn’t right,” she said. Ms. Wasserman Schultz said a panel of experts overseen by the federal Centers for Disease Control and Prevention would create the breast cancer campaign based on the latest medical science. She said the legislation did not endorse any particular methods of early detection. Yet it does call for a report to measure the campaign’s impact — including the percentage of young women who perform breast self-exams and the frequency of such exams.

Ms. Wasserman Schultz’s bill has been referred to committees in both the House and Senate. “Ultimately,” she said, “Congress will decide.”

But Dr. Brawley of the American Cancer Society said the Early Act reminded him of the 1960s, when the cancer society teamed up with the advice columnist Ann Landers for an awareness campaign to promote routine chest X-rays for the early detection of lung cancer. The test later proved to increase medical complications without reducing the cancer death toll, he said.

“It is a real problem,” Dr. Brawley said of well-meaning members of Congress. “They are doing things that might actually harm the people they want to help.”

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