Are Cancer Centers Doing Too Many Tests?

Let’s say you get a postcard in the mail reminding you to book a mammogram. Either the primary care physician orders a PSA test to check for prostate cancer in a man, or tells him that because he has been a smoker for many years, he should be screened for lung cancer.

These patients, in an attempt to be informed clients, can search the Internet for a cancer center to learn more about screening, when it is recommended, and for whom.

Perhaps this is not the best move. Medical societies and the independent US Preventive Services Task Force publish recommendations on who should be screened for lung, prostate, and breast cancer and how often, among many other prevention recommendations. But cancer center websites often diverge from these guidelines, according to three studies recently published in the journal JAMA Internal Medicine.

The researchers found that some sites discussed the benefits of screening but said little about the harms and risks. Some offered advice on the age at which screening should be started, but did not mention when it should be stopped, which is important information for older people.

“If we recognize that these websites are important sources of information based on review against the guidelines, we have room for improvement,” said Dr. Behfar Edaye, urologist at Memorial Sloan Kettering Cancer Center in New York and author prostate cancer screening guidelines study.

Screening refers to tests for patients without symptoms or signs of disease, including prostate-specific antigen tests, mammography, colonoscopy, and computed tomography.

The researchers analyzed more than 600 cancer center websites that recommended prostate screening and found that more than a quarter recommended screening for all men. More than three-quarters did not indicate the age at which routine testing should be stopped.

However, recommendations from both Preventive Services Target Group and American Urological Association state that men over the age of 70 should not be routinely screened because, according to the Task Force’s recommendations, “the potential benefits do not outweigh the expected harms.”

For men aged 55 to 69, both groups call for individualized decisions after discussing benefits and harms with a doctor. However, neither group recommends routine screening for young men at intermediate risk.

What’s more, the study found that 62 percent of cancer center websites contained no information about the potential harms of screening. Because prostate cancer grows slowly, it often causes no problems. But detection and treatment can lead to complications after surgery or radiation, including reduced quality of life due to urinary incontinence and sexual dysfunction.

Surveys have found similar problems on websites dedicated to other cancer screenings. AT study of more than 600 breast cancer centers, more than 80 percent of those who recommended starting age and intervals for screening mammograms did not meet the recommendations. The study did not look at the availability of information on websites about when to stop.

2016 Preventive Services Task Force Guidelines, which is currently being updated, recommend biennial mammograms for women aged 50 to 74; he found insufficient evidence of benefit and harm for individuals 75 years of age and older. American Cancer Society recommends annual or biennial screening for women over age 55 at moderate risk if their life expectancy is 10 years.

However, lung cancer screening only recommended for those at high risk due to history of smoking and advanced age. Here also analysis of 162 sites of cancer centers showed that about half did not pay attention to potential harm.

“We think it’s important to present balanced reporting,” said Dr. Daniel Jonas is an internist at the Ohio State University College of Medicine and senior author of the study. “It’s fair to say they could do better.”

Concerns about over-testing and over-treatment of some cancers in older people have persisted for years. “The harm from screening shows up early,” said Dr. Mara Schonberg is an internist and health researcher at Beth Israel Deaconess Medical Center in Boston. But the benefits of screening may take years to show; older patients with other health problems may not live long enough to experience them.

For example, in mammography, harms include false positives leading to repeat mammograms or biopsies, psychological consequences of which may last for several months, Dr. Schoenberg’s research showed.

And while most breast cancers diagnosed in women over 70 are at very low risk and may never progress, “almost all treated with surgery, ”Dr. Schonberg said, and sometimes after that with radiation and endocrine drugs, all of which can have negative side effects.

In terms of benefits, the data showed that 1000 women aged 50 to 74 she would have had to undergo mammograms for nearly 11 years to prevent one death from breast cancer.

Why do some cancer center websites omit features such as false positives, retesting, radiation exposure, or the effects of surgery? Why don’t they include information about how many lives screenings actually save at a given age?

“In the US healthcare system, the more procedures you do, the more you get paid,” the doctor said. Alexander Smith, palliative care specialist and researcher in geriatrics at the University of California, San Francisco. He noted that radiology, which is required for both lung and breast screening, “is one of the biggest sources of revenue for healthcare systems.”

Some websites may have been developed by marketers with minimal input from healthcare professionals. Jonas added. Talking about risks can discourage patients from clicking the “Make an appointment” button.

On the other hand, it can be difficult to dissuade older patients from screening, even if studies show little benefit.

Dr. Schonberg has developed and tested decision-making aids, pamphlets, to help women over 75 and their doctors come to informed conclusions about mammograms.

To a certain degree, they work. Older women who receive brochures are more knowledgeable and more likely to discuss benefits and risks with their physicians; they are less likely to continue screening. But over 18 months, about half of the women who received help making decisions got mammograms anyway, as did 60 percent of those who didn’t.

Dr. Schoenberg attributed this to habit or “the need for confidence”. Patients may also overestimate them risk level; the average 75-year-old woman has a 2 percent chance of being diagnosed with breast cancer within five years, she pointed out.

In addition, the choice of screening is related to an issue that some older patients (and physicians) prefer to avoid: life expectancy. The American Cancer Society and some medical groups use 10-year life expectancy, rather than age limits, as guidelines for when older patients may stop screening.

“Prognosis is one of the key factors in decision making,” says the doctor. Smith said. “Will patients live long enough to see the benefits?” This can be an uncomfortable conversation about age, health, and mortality.

How should older people inform themselves about cancer screenings? In addition to discussing the pros and cons with their doctors – Medicare requires such a visit before it covers lung cancer screening – patients can go to United States Preventive Services Task Force website for the latest ratings.

They may also use electronic forecast, an online guide that Dr. Schoenberg, Dr. Smith and colleagues at the University of California, San Francisco developed it ten years ago. Most visitors are healthcare professionals, but patients can also use the site’s calculators to determine if they could benefit from breast and colon cancer screening. They can use questionnaires to help determine their life expectancy, as well as several decision aids.

Of course, patients can also browse cancer center websites, but with an eye to what may be missing.