Many men were surprised this week when a government advisory panel recommended that doctors stop using the PSA test to screen healthy men for prostate cancer.
Yet health experts say the recommendations by the U.S. Preventive Services Task Force are a part of a broader trend that’s been building for years. People are taking a closer look not just at cancer screenings, but at all medical tests and procedures, says Steven Woloshin, co-director of the Center for Medicine and the Media at the Dartmouth Institute for Health Policy and Clinical Practice. Concern about “overtesting” and “overtreating” patients is growing because of a rising recognition that these interventions often have risks and serious side effects.
“There is something going on, not just in cancer,” Woloshin says. “There is some sort of shift, and it’s encouraging. It feels like this is the beginning of a sea change in attitudes towards testing, treating and overdiagnosis.”
Doctors are taking a “less is more” approach on several fronts.
Last month, for example, nine physicians’ groups launched the “Choosing Wisely” campaign to discourage 45 frequently overused tests and procedures. The groups, which included the American College of Cardiology, noted many common interventions are unnecessary, including stress tests during routine annual exams.
Many of these overused tests involve trying to “help the well stay well by looking for things to be wrong,” says H. Gilbert Welch, a physician and author of Overdiagnosed: Making People Sick in the Pursuit of Health.
The American College of Radiology also is leading campaigns called Image Wisely, to reduce unnecessary radiation exposure in adults, and Image Gently, to reduce exposure in children. The campaigns address growing concerns over the risk of cancers related to medical radiation, which has been estimated to cause up to 29,000 cancers a year. Researchers estimate that one-third of CT scans may be unnecessary, according to a 2009 report in the Archives in Internal Medicine.
And in the past four years, medical groups have voted to restrict several types of cancer screenings. That’s partly because science has evolved to help doctors better understand how cancers progress and how best to use screening technology, and also because doctors better understand the risks and limitations of treatment, says Lisa Schwartz, also co-director at the Dartmouth Center.
•In 2008, for example, before the task force voted against the PSA entirely, it recommended offering it only to men under age 75, reasoning that older men would not likely be helped by a test that largely detects slow-growing cancers.
•In 2009, the task force recommended against routine mammograms for women under 50, and suggested women over 50 get screened every other year, instead of annually. That recommendation drew fierce protests from women, radiologists and many politicians.
•In March, in a less controversial move, the American Cancer Society revised its cervical cancer recommendations, suggesting that women get screened every three years, instead of every year, between the ages of 21 and 29. Older women can wait five years between tests, and stop screening at age 65, a change that reflects the slow-growing nature of these tumors.
•Last week , medical groups endorsed using CT scans to screen for lung cancer, but only in a very specific group: smokers and ex-smokers ages 55 to 74 who smoked the equivalent of a pack a day for 30 years, and who still smoke or quit within the past 15 years.
Younger people, or those who smoked less, are not advised to get screened for lung cancer, because the odds of being harmed by the test – which can lead to invasive lung biopsies – is so high, and the chance of being helped is much lower, says Peter Bach, director of Memorial Sloan-Kettering’s Center for Health Policy and Outcomes, who wrote an analysis of available evidence published May 20 in the Journal of the American Medical Association.
Bach says it was important to avoid repeating past mistakes. With other screening tests, medical organizations have recommended them broadly for everyone in a particular age category – often before studies showed they did what they were intended to do.
The PSA was approved in 1986 to monitor patients with diagnosed prostate cancer, and in 1994 to screen healthy men — before researchers had determined whether the tests improved survival. For years, many medical groups recommended the PSA for all men over 50.
“The PSA test was unleashed on the male population without any evidence that it provides any benefit and without any quantification of the potential harm,” Bach says. “We didn’t realize we would cause thousands of men to become impotent.”
Yet convincing people that they could be better off with fewer screenings could be a tough sell, says Virginia Moyer, chair of the U.S. Preventive Services Task Force and a pediatrician at the Baylor College of Medicine. Public health groups spent decades persuading reluctant men to give blood samples for PSA tests and frightened women to get their breasts compressed by mammography machines. Today, many people see screening as essential to health, she says.
And the science of screening -and the reasons why it can harm – aren’t easily boiled down into a soundbite. “We’ve been a victim of our own success,” Moyer says.
But Welch, the physician and author, agrees the tide is turning.
There’s a growing recognition that, “when you are dealing with well people, the balance is really fine: It’s hard to make a well person better, but it isn’t hard to make them worse,” says Welch. “We need to have really high thresholds before we start doing things to well people.”
By Liz Szabo, USA TODAY