Cancer screening updates leave doctors unclear about frequency (ACP annual meeting)

Physicians at the American College of Physicians meeting discussed the challenges in deciding what screening recommendations to follow and educating patients about them.

By Christine S. Moyer — Posted May 17, 2010

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Physicians have been inundated, over the last year, with revised guidelines from major medical agencies and organizations that call for changes in cancer screening.

For example, the U.S. Preventive Services Task Force, in November 2009, said women younger than 50 do not need routine mammography screening. Four days later, the American College of Obstetricians and Gynecologists recommended that Pap smears for cervical cancer screening start at age 21 and continue every two years through age 29.

The intent of such changes is largely to reduce unnecessary testing and the potential harms that accompany it, doctors said. But the flurry of new guidelines has left physicians assessing which screening advice to follow and patients uncertain about when they should be screened.

At the American College of Physicians annual meeting April 22-24 in Toronto, medical experts tried to clarify the guidelines and help doctors determine which ones to follow.

"It's challenging when new guidelines come out that offer different recommendations than those [physicians have] become accustomed to," said Durado Brooks, MD, MPH, director of prostate and colorectal cancer at the American Cancer Society.

Dr. Brooks suggested that physicians review the new guidelines and investigate the data behind them. But he advised doctors not to reassess their screening practices every time a guideline is updated. "There are too many organizations out there issuing, unfortunately, totally different sets of recommendations," he said.

Internist Mike Barry, MD, attended a session on breast cancer screening, looking for updates on screening recommendations. Breast cancer is one of his female patients' biggest concerns, he said.

"When women find something [during breast self-exams], they're absolutely convinced" they have cancer, said Dr. Barry, staff physician at the Charles W. Schiffert Health Center at Virginia Polytechnic Institute and State University.

The ACS calls for educating women on the benefits and limitations of doing breast self-exams starting when patients are in their 20s.

The USPSTF, however, recommends against physicians teaching women how to examine their breasts. Task force Chair Ned Calonge, MD, MPH, suggested that doctors tell patients to be aware of their bodies and see their physicians if they feel anything on their breasts that concern them.

The task force's updated guidelines also say women age 50 to 74 should get a mammogram every two years. The revision marks a shift from the task force's 2002 guidelines that called for a mammogram every one to two years for women older than 40.

Some physicians are concerned that the revised task force guidelines, which recommend against routine screening of women in their 40s, will lead to breast cancer deaths that could have been avoided with early detection.

Breast cancer is the second leading cause of cancer deaths, after lung cancer, among U.S. women, according to the ACS. In 2009, an estimated 192,370 new cases of invasive breast cancer were diagnosed, and about 40,170 women were expected to die from the disease.

Early detection is partially credited for the steadily declining breast cancer death rate among women younger than 50, according to the ACS. Since 1990, the death rate for women in that age group has decreased 3.2% annually.

However, mammograms for women younger than 40 might not be useful, according to a study published online May 3 in the Journal of the National Cancer Institute. Researchers analyzed data on 117,738 women who had their first mammogram between age 18 and 39. The study found that mammograms in women younger than 40 resulted in high rates of return visits for additional testing but low rates of cancer detection.

Physicians at the ACP meeting said many women request mammograms despite data showing screening is not necessary for their ages.

"Tell them about the false-positive [results]. Tell them there is no guarantee that a mammogram will detect cancer," said Ellen Warner, MD, a medical oncologist at Sunnybrook Health Sciences Centre in Toronto, who led a breast cancer screening session at the meeting.

If patients still request a mammogram after physicians discuss the benefits and drawbacks, Dr. Calonge said it is the doctor's responsibility to screen them. "If a woman makes an informed decision based on her values, we as doctors need to support that."

Prostate cancer screening

Informing patients about screening uncertainties is a key change the ACS made to its prostate cancer screening guidelines, released in March.

Since then, Dr. Brooks, of the ACS, has heard from physicians who say they don't have time for such detailed screening discussions. Others say patients may not understand the potential risks.

"I don't perceive that as a reason for patients to go uninformed. ... [Doctors] have to find other ways to make sure patients are educated," Dr. Brooks said. He suggests physicians use written materials or videos with balanced, up-to-date information to inform patients.

Internist Oliver Sartor, MD, who led a session on prostate cancer at the meeting, said he spends about 90 minutes with newly diagnosed prostate cancer patients. He discusses the disease with patients, their prognosis if they choose not to be treated and the possible side effects of treatment.

Prostate cancer patients need to understand that more men are diagnosed with the disease than die from it, he told physicians at the meeting.

"When I talk to patients, I try to differentiate [prostate] cancer from others. I talk to them very bluntly about their overall expected survival if left untreated," said Dr. Sartor, professor of cancer research in the departments of medicine and urology at Tulane University School of Medicine in New Orleans.

Prostate cancer is the most commonly diagnosed cancer among U.S. men and remains the second leading cause of cancer death in males, after lung cancer, according to the ACS. In 2009, about 192,000 men were diagnosed with prostate cancer, with 27,000 expected to die from the disease.

The ACS recommends yearly screening for men who have a PSA level of 2.5 ng/mL or higher. The ACS says men with a PSA of less than 2.5 ng/mL might need to be retested only every two years. Dr. Sartor screens his prostate cancer patients annually.

Most men diagnosed with the often slow-growing disease will not die from it, he said. Many will experience more problems from the side effects of treatment than from the disease, he added.

In determining whether treatment is necessary, Dr. Sartor considers multiple factors, including the patient's age, Gleason score, PSA level and number of positive biopsies.

Confusion about screening

Internist Alice Fuisz, MD, said patients seem to be receiving mixed messages from physicians in the wake of all the screening updates.

Some patients in her Washington, D.C., practice continue to see their gynecologists annually for Pap smears. Others stopped visiting their gynecologists because they believe they no longer need to be screened. "There's no clear message for women," Dr. Fuisz said.

The cervical cancer screening update issued by ACOG in November 2009 says women age 30 and older who have had three consecutive negative Pap smears may be screened once every three years. Women with at least three consecutive negative Pap tests and no abnormal tests in the previous 10 years should stop the screenings at age 65 to 70.

Obstetrician-gynecologist George Sawaya, MD, led a session on cervical cancer screening at the ACP meeting. He said physicians who implement new screening practices should consider how patients feel about the change.

Dr. Sawaya discusses the new Pap test guidelines with patients, explaining that, in many cases, annual tests are not necessary. Then he asks for their thoughts.

"If they say they want to come back in one year [for screening] I say, 'Great. I will see you in one year,' " said Dr. Sawaya, an associate professor in the department of obstetrics, gynecology and reproductive sciences at the University of California, San Francisco.

Internist Gilbert Welch, MD, MPH, said cancer screening guidelines are shifting to start screening later.

"We've been so enthusiastic in our promotion of early detection and have never suggested there are any downsides to it. It's a real paradigm changer to suggest there may be some harms in" detecting early signs of cancer, said Dr. Welch, professor of medicine at Dartmouth Medical School and the Dartmouth Institute for Health Policy and Clinical Practice in New Hampshire.

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Cancer screening guidelines

Some organizations have revised their screening recommendations for breast, cervical and prostate cancer.

U.S. Preventive Services Task Force breast cancer screening, November 2009

  • Women younger than 50 do not need routine mammography.
  • Women age 50 to 74 should get a mammogram every 2 years.
  • Physicians should not teach women breast self-examination.

American College of Obstetricians and Gynecologists cervical cancer screening, November 2009

  • Women should start getting Pap smears for cervical cancer at age 21 and continue every 2 years through age 29.
  • Women 30 and older who have had 3 consecutive negative Pap smears may be screened once every 3 years.
  • Women with at least 3 consecutive negative Pap tests and no abnormal test in the previous 10 years should stop receiving screening at age 65 to 70.

American Cancer Society prostate cancer screening, March

  • Physicians should inform patients of the benefits and harms associated with screening.
  • Doctors should enhance their discussions with written information or videos with balanced, up-to-date information.
  • Patients should be involved in the decision to screen.
  • For men who are unable to decide, the screening decision should be left to the health professional.
  • Men who have had a PSA test do not necessarily need a digital rectal exam.

Sources: U.S. Preventive Services Task Force; American College of Obstetricians and Gynecologists; American Cancer Society

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Treatment tips

Here are some treatment tips from the ACP annual meeting.

Herpes testing recommended among certain patients: Although routine screening is not recommended for genital herpes, physicians should test for the virus when patients have recurring genital ulcers, atypical genital lesions or a new sexual partner, said Myron Cohen, MD, professor of medicine and microbiology, immunology and public health at the University of North Carolina School of Medicine.

Dr. Cohen, who led a session on STDs and HIV at the meeting, said 50 million to 60 million Americans are infected with genital herpes.

An April Centers for Disease Control and Prevention study found that about one in six Americans age 14 to 49 is infected with herpes simplex virus type 2. Of those who tested positive for the virus, more than 80% did not know they were infected.

Physicians urged to test patients for HIV: Physicians should test all patients age 13 to 64 for HIV, said John Bartlett, MD, professor of medicine in the division of infectious diseases at Johns Hopkins University School of Medicine in Baltimore.

When patients without HIV have a new risk factor, such as acquiring a new sexual partner or beginning to inject drugs, they should be screened again, he said.

Dr. Bartlett, who led a meeting session on what internists should know about HIV, said HIV tests are reliable and inexpensive.

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IMG recruitment needs revamp

The U.S. and Canada need policies for recruiting international medical graduates that prevent draining physicians from developing countries, said Dr. James Orbinski, associate professor of medicine and political science at the University of Toronto.

Dr. Orbinski, keynote speaker at the ACP annual meeting, said about 24% to 28% of physicians in the U.S. and Canada are trained overseas. Of those doctors, about three in four come from impoverished countries where physicians are needed, said Dr. Orbinski, former international president of Médecins Sans Frontières/Doctors Without Borders.

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External links

Internal Medicine 2010, American College of Physicians annual meeting (link)

"Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement," abstract, Annals of Internal Medicine, Nov. 17, 2009 (link)

"Effects of Mammography Screening Under Different Screening Schedules: Model Estimates of Potential Benefits and Harms," abstract, Annals of Internal Medicine, Nov. 17, 2009 (link)

American College of Obstetricians and Gynecologists' revised cervical cancer screening guidelines, November 2009 (link)

"American Cancer Society Guideline for the Early Detection of Prostate Cancer: Update 2010", abstract, CA: A Cancer Journal for Clinicians, published online March 3 (link)

"Performance of First Mammography Examination in Women Younger than 40 Years," abstract, Journal of the National Cancer Institute, published online May 3 (link)

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