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New approach needed for breast and prostate cancer screening
Cancer rates are higher, more patients are being treated and aggressive disease has not decreased.
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After two and a half decades of breast and prostate cancer screening, the benefits of mammography and PSA testing are in question. Many experts now believe a new focus and approach to reducing breast- and prostate-related morbidity is necessary.
In the United States, 70% of women aged older than 40 report having a recent mammogram. Screening for prostate cancer is common as well: 50% of men at risk for prostate cancer have a routine PSA test and 75% have previously had one.
Yet the risk for developing breast or prostate cancer has increased since screening began, according to information in an article written by Laura Esserman, MD, MBA, and colleagues published in the Journal of the American Medical Association.
Incidence continues to increase
Since 1980, the lifetime risk for both prostate cancer and breast cancer has increased (see chart on cover).
Despite this, mortality has decreased during the past two decades; however, the contribution of screening is uncertain. Of the possible reasons why screening for these two cancers has not led to a more significant reduction in mortality in the United States are that screening increases the detection of indolent cancers and likely misses the most aggressive cancers.
“In other words, tumor biology dictates and trumps stage, so the basic assumption of these screening programs that finding and treating early-stage disease will prevent late-stage or metastatic disease may not always be correct,” Esserman and colleagues wrote. Additionally, periodic screening may not screen patients enough to detect lethal tumors in time to prevent death.
“Without the ability to distinguish cancers that pose minimal risk from those posing substantial risk and with highly sensitive screening tests, there is an increased risk that the population will be overtreated,” they wrote.
New approach necessary
Esserman and colleagues proposed a new approach to screening for breast and prostate cancer, which includes focusing on development and validation of markers that both identify and differentiate significant-risk and minimal-risk cancers; reducing treatment for minimal-risk disease; developing clinical and patient tools to support informed decisions about prevention, screening, biopsy and treatment; and working to identify the highest-risk patients and target preventive interventions.
“It is very appropriate that we occasionally step back, assess and reflect on what we in medicine are doing,” Otis W. Brawley, MD, professor of hematology, oncology and epidemiology at Emory University in Atlanta, said in a press release.
“In the case of some screening for some cancers, modern medicine has overpromised. Some of our successes are not as significant as first thought. Cancer is a complicated disease, and too often we have tried to simplify it and simplify messages about it, to the point that we do harm to those we want to help,” he said.
Esserman L. JAMA. 2009;302:1685-1692.