Will cancer screening actually save your life? - Macleans.ca

Will cancer screening actually save your life?

Science-ish looks at the evidence on PSA testing, mammograms and the true benefits of screening


(Bruce Powell/AP Photo/University of Chicago Medical Center)

“There is a powerful narrative among support groups and cancer survivors: Screening saves lives. . .  For the most part, it’s wishful thinking. And it demonstrates the growing gap between what screening (and science more generally) can offer, and what the risk-averse public wants it to be.”—Globe and Mail, May 21, 2012

A recent recommendation by a U.S. government advisory panel to ditch the PSA test for prostate cancer has reignited the call for a cancer screening rethink. It’s no longer okay to abide by the “screen early, screen everybody” maxim, the conversation goes, echoing the one that emerged when the frequency of routine screening for breast cancer was scaled back last year.

Now, it’s good to be having these discussions: We do need to change how we think about cancer screening. In recent years, with the advent of incredible technologies that detect diseases before we feel sick, we’ve seen the emergence of “overdiagnosis.” The term describes cancer that is diagnosed but would not necessarily cause death or even symptoms because the cancer never grows, it regresses, or it spreads so slowly, the person dies before knowing any harm. That’s right, not all cancers are deadly or even harmful. As well, every single body displays at least a couple of benign abnormalities that can be seen as trouble. This is why mass screening has the potential to “rapidly turn perfectly healthy people into patients,” says the Canadian health policy researcher and author of Seeking Sickness, Alan Cassels.

Science-ish, though, wondered whether PSA testing and mammograms—usually the inspirations for the anti-screening cri de coeur because they can lead to overdiagnosis and unnecessary surgeries—are the exceptions in cancer screening or the rule.

According to Dr. Gilbert Welch, who has studied and written books on the problems created by early disease detection, breast and prostate screening are not alone. Mass screening has led to overdiagnosis in kidney, thyroid, and lung cancers, as well as renal cell carcinoma and melanoma. In one interesting case study in Japan, researchers did spiral CT screening in a community and found ten times as much lung cancer as they had previously detected in the same population using chest x-rays. “The really amazing part,” said Welch, “was that they found the same rate of cancer in smokers as non-smokers.” Since we know there’s a much greater risk of smokers dying from lung cancer than non-smokers, Welch explained, “This woke everybody up to the problem that there are a lot of cancers in the lungs that don’t go on to cause problems.” So early detection in these cases would have led to unnecessary treatment and stress.

Then there’s the contentious cancer survivor mythology. “The survivor has been seen as someone who has undoubtedly benefited from treatment for cancer,” said Welch. But the evidence shows many supposed “survivors” would have lived on anyways—because they didn’t need treatment to begin with. Welch’s Archives of Internal Medicine study on whether a woman with screen-detected breast cancer is likely to have had her life saved by treatment concluded that in most cases the answer was “no.”

That’s not to say, though, that all cancer screening is ineffective. Colorectal screening has been shown to dramatically save lives as a result of early detection, and the Pap test turned cervical cancer into a largely curable disease. Even mammograms and PSA testing—the poster children for overdiagnosis—find cancers in people who would have otherwise died from them. That’s the screening paradox. “Screening can both help people and hurt people at the same time,” Welch said. “It’s not one or the other.” Or, as Siddhartha Mukherjee put in his biography of cancer, The Emperor of All Maladies, “The trouble is that overdiagnosis and underdiagnosis are often intrinsically conjoined, locked perpetually on two ends of a seesaw.”

So where does this leave patients and their doctors? “We need to understand that cancer is not one disease,” University of Manitoba professor Alan Katz told Science-ish. “All cancers are different and we need to look at each one separately.” This means patients should ask about their individual risk of developing a particular disease—based on their medical history, age, risk factors, and symptoms—and how those weigh against the benefits of screening. For example, a young woman with no history of breast cancer in her family, and no risk factors or symptoms, can probably avoid getting screened until later in life, as both U.S. and Canadian guidelines suggest.

This flip flopping can undoubtedly be worrisome and confusing. But such is the reality of evolving science. PSA testing, like mammograms, once seemed to benefit more people than it harmed, but now the evidence suggests otherwise. As Welch put it: “The power of our technology to detect abnormality now far exceeds our knowledge of what we should do about it and in many cases the right answer is nothing.”

Science-ish is a joint project of Maclean’s, the Medical Post and the McMaster Health Forum. Julia Belluz is the associate editor at the Medical Post. Got a tip? Seen something that’s Science-ish? Message her at julia.belluz@medicalpost.rogers.com or on Twitter @juliaoftoronto


Will cancer screening actually save your life?

  1. If I get it, I get it. In the meantime enjoy your life everyday

  2. My Doctor recommended a PSA screening test some 12 years ago. Glad he did because it turned up positive but biopsy indicated it was slow growing. Caused me to live life at it’s fullest while at a younger age. Now, with finally a radiation treatment, life is still great, however age slows down how the body reacts.

  3. So we will throw the people under the bus who could be helped by screening because the rest of us become anguished when a potential tumor is detected? There are two replies to this article: 1) we can put up with watchful waiting, which means periodic observation of a possible tumor to see if it’s growing or recessing; 2) improve the technology we have, to the point where it actually detects most tumors before they metastasize (spread and form additional tumors). Our current technology falls down on the ability to do both of these, especially mammography and prostate cancer detection. Some screening fails precisely because it is not good enough. Research on improving screening is underfunded.

  4. I simply want honesty and some respect for our right to the actual facts, good and bad, and some respect for the individual and our legal right to make up our own minds and have that accepted by the medical profession…try saying no to a pap test and mammogram, especially the former. We’re expected to file in like ignorant sheep, to do as we’re told, it’s paternalistic and unacceptable. I did my own research and as a low risk woman have always declined pap testing, my risk of cervical cancer is near zero while the risks of testing are high, very high in Australia where we seriously over-screen women, we have high and hidden over-treatment rates. There was never a need to worry and harm so many women as Finland has shown with their 6-7 pap test program, 5 yearly from 30 to 60, that’s been in place since the 1960s, they have the lowest rates of this rare cancer in the world and refer far fewer women for colposcopy/biopsies (fewer false positives) The Dutch had the same program, but will move with the evidence and shortly introduce a new program, 5 hrHPV primary triage tests offered at ages 30,35,40,50 and 60 and ONLY the roughly 5% who are positive and at risk will be offered a 5 yearly pap test (there is also a reliable self-test HPV device for those who prefer it, the Delphi Screener) – most women (about 95%) will be HPV negative, not at risk and they will be offered the remaining HPV primary tests over their lifetime. Those HPV negative and confidently monogamous or no longer sexually active can forget all further testing. This is likely to save more lives and scarce health resources and spare countless not-at-risk women from a lifetime of unpleasant pap testing and the high risk of over-treatment. (that can lead to cervical damage and cervical incompetence or cervical stenosis, premature babies, miscarriages, infertility, c-sections etc)
    Yet here we’re STILL telling women they NEED 2 yearly pap testing from 18 to 70 (some start even earlier) a huge 26 or even more pap tests…this is very bad medical advice (and they know it) that can only worry and harm huge numbers. Yet it’s allowed to go on and on…no one warns women, no one challenges this “advice” or program. The dishonesty and lack of proper ethical standards is concerning, IMO, they simply don’t care about women and their health (or bodily privacy), this is some insane quest to drag as many women as possible into serious over-screening and over-treatment. This generates high profits for the profession at a very high cost to healthy women.
    We see the same thing in breast screening – they cherry-pick research and only tell women about studies that support screening, they pressure and mislead and have zero respect for informed consent and our health and well-being. They TELL women how they should feel and what they should do, others make decisions for us and accept risk on our behalf. I was relieved to find the Nordic Cochrane Institute had prepared a decent and thorough summary of the evidence to enable women to make an informed decision,”The risks and benefits of mammograms” is at their website. I’d suggest you toss the Breast Screen brochure in the rubbish bin, it does not provide a balanced and complete account of risks and actual benefits.
    It’s time these programs were removed from current influences and control and refocused on what’s best for women. Programs that are not evidence based simply worry and harm women.