To Screen Or Not To Screen:
That Is The Question?
Dr. Isabella Martire
Since 2009, the United States Preventive Service Task Force (USPSTF) recommendations for screening have dramatically changed:
1) Breast cancer screening with mammogram was not recommended for women age 40 to 50 and every two years was recommended for women 50 to 74 years of age.
2) Pap smears every three years for women over the age of 21 is the current recommendation from the USPSTF.
3) The latest recommendation from the USPSTF is that routine PSA screening is no longer to be performed for the men of any age with the premise that is does not affect survival or mortality.
It is very interesting that these new recommendations come in a day and age when the economy is poor and it is necessary to “save” or “budget”. I want to give you some information that can guide you in making decisions regarding your screening.
Last year the results of ERSPC (European Randomized Study of Screening for Prostate Cancer) which included > 1 million men revealed a decrease in prostate cancer death of 27% after 9 years of follow up and 56% after 14 years. The Prostate Screening Antigen or PSA test costs between $30 to $100 dollars. A biopsy of the prostate is $1500 dollars. The sensitivity of PSA is 63 – 83% and specificity 90%. Free PSA, PSA density and PSA velocity can improve screening sensitivity and specificity. Prostate cancer is the leading cause of cancer in the United States males and 2nd leading cause of cancer death. Early prostate cancer is curable. So, if you are “high risk”: have a family history of prostate cancer, are African American or BRCA positive, you “should” be screened unless your life expectancy is very poor because of comorbidities.
Cervical cancer used to be the leading cause of cancer death for women in the United States 40 years ago but thanks to routine pap smears that can detect precancerous lesions the mortality has decreased significantly. Still >12,000 women will be diagnosed with cervical cancer and ~ 4000 will die of the disease. The lowest incidence of cervical cancer in the world is in Sweden where home kits are mailed to the entire population. HPV or Human papilloma viruses is the primary risk factor for cervical cancer and the likelihood of contracting HPV is increased with a higher number of sexual partners. Granted the HPV vaccine will help the future generations provided people comply with recommendations but let us not go back to the dark ages. If you are “not” sexually active or if you can guarantee that you are in a monogamous relationship then it is fine to have a pap smear every three years, in all other cases it should probably be more frequently, discuss your situation with your gynecologist.
We all remember the controversy that sparked from the 2009 USPSTF that recommended against screening women < 50 years old with mammograms. Well, now the recommendation extends screening women 50 to 74 years of age, every two years with mammogram. Again, if you have a history of atypical hyperplasia, family history of breast cancer, difficult to examine breasts, have been on post menopausal estrogen or you just feel more comfortable having a mammogram yearly than you “should”. It is very interesting that this USPSTF panel “never includes oncologists”. Let’s just tell it like it is, these are tough times and it is necessary to “cut costs”. Interestingly, ASCO (American Society of Clinical Oncology) post 11/09/2011, Dr. Derek Raghavan, MD, PHD questions whether the USPSTF needs to exist at all.
ASCO and ACS (American Cancer Society) recommend yearly screening mammograms starting at age 40 and continue doing so as long as individuals are in good health. Yearly MRI and mammogram is recommended for high risk women.
As of current statistics, only 53% of women greater than 40 years of age have screening mammograms. The ACS goal for 2015 was to increase breast cancer screening in women greater than 40 years of age to 90%. The sensitivity of digital mammography compared to film screen mammography, in women 40 to 49 years of age is 82% versus 75%. In women age 50 to 59, 85% versus 80%. Women age 60 to 65 years of age the comparison is 89% versus 83%. Digital mammography is also cost effective since there are fewer number of recalls and additional costs compared to screen film mammography.
The relative risk reduction in breast cancer mortality is 15% by using mammography. Non mammography identified tumors that are usually larger, with a higher incidence of lymph node involvement and worse cancer specific mortality.
The rough yearly incidence of
breast cancer will be ~ 240,000 new cases, 39,000 will die of their disease.