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Cancer screenings: Safe or superfluous?

TAMPA - As far as he knows, no one in Terry Boykin's family has had cancer. Still, in August, motivated by his wife's concern, the 42-year-old Pinellas Park man took a prostate cancer screening test. "I did it just to be sure," he said of the blood test that confirmed he was cancer-free. "I wasn't concerned or having any problems." His experience is similar to that of millions of Americans taking a preventive approach to cancer. A growing number of screenings are painless and easy to get; some are as convenient as visiting a health fair or sporting event.
"If it's available, I think you should get tested," Boykin said. But this "better-safe-than-sorry" approach to cancer has its risks. Looking for a disease before any symptoms appear may result in inaccurate diagnoses, unnecessary and potentially harmful procedures, and a lot of emotional anxiety, critics say. "We've been taught to believe that early detection is the only way to go," said H. Gilbert Welch, a Dartmouth College of Medicine professor and author of "Overdiagnosed: Making People Sick in the Pursuit of Health." Welch and others argue that the public has become convinced that precancer screenings are one way to thwart a fatal diagnosis. That belief ignores the downside, especially for older people, whose overall health can be adversely affected by any medical procedure, including a biopsy. There are plenty of places to place the blame for our prudent mind-set. There's the onslaught of new scientific technology, doctors who are afraid of getting sued for a missed diagnosis, a cure-crazed media and health care companies looking for more business. "Most people don't have cancer when they get screened. But a lot of people have to be screened to save a few," Roetzheim said. "You remember the ones whose lives were saved." Today, almost everyone knows someone, or of someone, who has cancer. An estimated 1.5 million Americans each year are diagnosed with cancer; 569,000 more die from the disease annually, the American Cancer Society reports. In 2010, more than 425,000 Americans were diagnosed with prostate or breast cancer. So it's not surprising that those diseases also have the most pervasive public programs to screen people who don't have symptoms. Florida Department of Health surveys show that in 2007, more than half of men age 50 and older had some form of prostate cancer screening, and 65 percent of women 40 years and older had undergone a mammogram screening. The mammogram, a common screening procedure for breast cancer, has been used and studied for decades. Still, there's conflicting evidence about its effectiveness in correctly identifying abnormalities that look like cancer. Reports of "false-positives" have been criticized for needlessly worrying women as they wait for results from unnecessary, invasive procedures such as biopsies, lumpectomies, and partial or total mastectomies. This sort of scientific uncertainty led the U.S. Preventive Services Task Force in 2009 to change a recommendation that all women 40 and older get an annual mammogram. Instead, it recommends that women 40 to 49 should decide whether to get tested after talking with their doctor. Those ages 50 to 75 should get a mammogram every two years, according to the group, which is made up of nongovernment scientists, doctors and health care professionals. Roetzheim, who said he respects the task force's guidance on screenings, worries that some women will see the recommendation as a reason to forgo mammograms. A University of Colorado study released this year reports there has been a drop in the number of women in their 40s being screened at its facility. That study argued for annual testing for women in their 40s, but it acknowledged those who are tested every year are likely to have one "false-positive" diagnosis. The recommendation, however, may have little real impact. A Harris Interactive/Health Day poll in April shows that two-thirds of women surveyed weren't aware of the new recommendations. Of those women, 57 percent felt the tests should start at age 40. The Preventive Services Task Force advises screenings only for breast and cervical cancers, and particularly for individuals at risk because of genetics or sexual behavior. The group also examined specific screenings for oral, prostate and skin cancer, and has declined to recommend for or against routine testing. Some tests, such as the Pap smear that looks for cervical cancer, are well-regarded for their rates of detection; others are not. Instead, the task force recommends hands-on examination. For example, skin cancer screenings using full-body scan technology are far less effective than a clinical exam, such as those held throughout the Tampa Bay area by Moffitt specialists. The American Cancer Society, which vehemently opposes the task force's mammogram recommendation, declines to recommend annual prostate cancer screenings. It encourages men 50 and older to talk with their doctor about the risks before choosing to get one. "Overdiagnosis is a huge issue with prostate screenings," Roetzheim said. "Most men die with their prostate cancer, not from it." Welch said the number of prostate cancer cases is increasing in part because of the way urologists conduct biopsies. Urologists insert a needle into six to 10 regions of the prostate to extract splinter-size tissue. Repeated studies say increasing the number of needle sticks boosts the odds of finding prostate cancer, although the cancer may be slow-growing and never become life-threatening. This creates a situation in which men have to decide whether to undergo painful cancer treatment and prostate surgery or opt to live with a cancer that will never grow enough even to present symptoms, Welch said. Roetzheim said all cancer screenings should better target at-risk populations. For prostate cancer, that would include African-Americans and men with a relative diagnosed with the disease. Unfortunately, those at risk are not always easy to identify or easy to persuade to get tested, he said. A more conservative approach would wait for symptoms before screening for cancer, Welch said. Personally, he prefers an annual physical exam with his primary doctor, checking on practical issues such as blood pressure. If an issue comes up, he can ask the doctor about it then or call between visits. Still, he knows that his way isn't the answer for everyone. "It's about how you want to pursue life. Do you want to look for disease, or pursue health and feel as well as you are?" he asked. "There's no clear answer." mshedden@tampatrib.com (813) 259-7365
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