Cancer Screening in Real World Practice
Today’s clinicians are busier than ever. The managed care revolution, reimbursement, loss of autonomy, and the Internet have all affected today’s physician. The generalist is being asked to do more each day with less, and seems to be losing the war over billing, paperwork, independence, and turf.
Because traditional CME frequently has been shown to be of limited value both to physicians and in gaining desired behavior changes, I have taken a more focused approach. I know that you don’t have time to waste with excess verbiage, political correctness, endless statistics, molecular genetic jargon and obscure details that are irrelevant to your busy, real world practice.
Getting your patients the cancer screening tests they’ll optimally benefit from is important. You know this because you’re reading this. This course cuts through the blather, the fluff, and the picayune minutiae you don’t need, so that you can quickly do the course, take the quiz, get the CME credits, save your patient’s life, and get back to your own. Which is the way it should be!
A word of caution from the author: I take no responsibility for your construing of this educational material as you apply it to your practice and cannot be held liable for errors or miscalculations that you, your patients, your colleagues, or anyone in your sphere of influence believes was related to this course. Although I recommend that you focus your efforts towards certain cancer sites, I am in no way telling you to ignore signs or symptoms or necessary workups attendant to everyday practice. I do not practice and am in no way offering any medical advice here.
What is this thing called “screening”?
Clinical “screening” generally involves the search for evidence of disease states in persons without relevant complaints.
Screening is actually a misnomer for what doctors look for in their typical outpatient population. When you do a PAP test or a colonoscopy you are really performing an “early detection” test. The difference is not simply semantic. “Screening” connotes doing the same test for large numbers of people who may be easily categorized by age or gender.
Checking every single newborn in the US for phenylketonuria is considered screening. Since there are usually age AND gender AND family history influences on cancer screening practices, these tests are probably better characterized as “early detection” or “case finding” tests.
Since “screening” is a shorter term that is probably more familiar to most, we will use the term “screening” here, for now. As you might guess, samples of blood, saliva, urine or other body fluids may be “screened” for countless conditions.
This course will focus on addressing YOUR needs. It assumes that you are an overburdened generalist clinician who wants to catch clinically significant early cancers in your patient population, without incurring the wrath of bean counting HMOs or inpatients who are kept waiting in your waiting room.
One important point differentiates cancer screening from some other screening tests. Unlike other less patient-centered testing, cancer screening tests must be discussed with patients so that shared decisions can be made with the physician. Just as one wouldn’t perform a test for Huntington’s Chorea or HIV without some initial background discussions, patients should be given sufficient information before submitting to screening tests for a disease that is as frightening as cancer.
Most often, the intent of screening is to find disease in a relatively “early” state. Since the 1960s, it has been widely held that the key to improving cure rates for most cancers lay in finding the disease before it spread. This concept has been validated for many, though not all, types of cancer. Higher screening rates are certainly part of the reason that US cancer incidence and mortality rates are declining. The classic target population for cancer screening usually includes adults ages 50-74.
Since costs, logistics, testing capacity and inaccuracy are barriers to mass screening of all adults for all cancers, both patients and physicians must make choices. These choices are influenced by many factors, including scientific panels, government, insurers, media, celebrities and friends. However, in study after study, the most important relationship influencing cancer screening behavior in your patient remains the one between the patient and his or her physician.
Screening is discouraged for rare diseases or for diseases without any known effective treatment. When a patient has a relevant complaint, strong family history or personal disease history, testing for cancer should be considered to be part of a surveillance regimen or a diagnostic workup, and NOT screening.
Not all screening tests have been proven in blinded trials to save lives. It is important to take notice of the fact that in all likelihood, some tests in this country are more or less likely to be done because of economic, social, political or reimbursement pressures. These pressures may have little to do with valid scientific trials, sensible public policy or good public health practice.
As testing becomes more affordable or more publicized, consumers may demand or utilize newer tests in hopes of staying ahead of “the curve.” The physician is a vital resource in keeping patients appraised of the unforeseen risks and benefits of these newer tests that are particularly promising.
1. Clinical screening tests look for pre-clinical evidence of common, treatable disease.
2. Physician recommendations are often the strongest influence on screening behavior.
3. Symptomatic patients need workups, NOT screening.
Why are Cancer Screening Recommendations so Hotly Debated?
Cancer rates are dropping according to all the major American scientific organizations. However, since the “War on Cancer” was declared a generation ago, millions of people have been diagnosed as the population lives longer. One out of every 2 men, and one in three women will eventually develop some form of cancer.
As the baby boomers grow older and the Internet empowers more Americans, more adults will be screened for and diagnosed with cancer, resulting in more folks getting on the Web seeking information about cancer, resulting in more people joining cancer activism groups, and thus the cycle continues. Thus, even though cancer rates have been dropping overall, Americans perceive that little progress is being made in cancer.
Finding the disease early is believed by the public to be the best weapon against cancer. Yet people without complaints may feel that being screened for cancer is similar to bringing over their old tax returns to the local IRS office just to make sure everything was filled out ok. They may say to themselves, “why look for trouble”?
That’s why some screening programs engender so much controversy. Tests cost money, breed uncertainty, cause anxiety, produce false positives and often lead to more invasive diagnostic procedures. If scientists, bean counters, public health experts, insurers, or politicians aren’t convinced that these programs will save lives, the plans probably won’t be implemented without a whole lot of arguing.
Also, some past screening no-brainers didn’t pan out. We all figured that screening kids for neuroblastoma and adults for lung cancer would save lives, but the studies didn’t bear this out.
When the public is asked about its most important personal concern, health is usually the leading answer. And of all diseases the public can name, cancer is usually cited as the one they fear most. There is therefore great demand for newer and better screening tests.
The public has been inundated for decades with television ads and celebrity endorsements that cancer must be found early through screening. They rightly feel that any new screening test for cancer must be a lifesaver, and couldn’t possible be “harmful,” since it was played up on the evening news.
However, recent studies strongly suggest that if men and women over 50 are screened for common cancers such as lung, breast, prostate and colon cancer, most people will eventually be faced with at least one falsely positive test. On the other hand, randomized, controlled trials are expensive and take years, making it difficult for newer tests to receive the blessing of the “evidence-based” medicine community. Still, the primary care doctor’s #1 malpractice charge is failure to diagnose cancer in a timely fashion.
The primary care physician must help patients make hard decisions about cancer screening. “Just do it” may be fine for the sneaker industry but not for cancer screening. Physicians must discuss these issues or provide relevant brochures or videos to truly insure shared decision making about screening.
1. Despite varied perceptions on the issue, the total US cancer death rate is dropping.
2. Past studies have suggested that cancer screening tests may not always save lives.
3. Clinicians should tell patients about possible consequences of cancer screening tests.
Screening vs Early Detection vs Testing vs Checkups
So if screening is such a controversial issue, why use the word at all? Why not say we’re looking for, checking for, or testing for a certain condition?
In the future, “testing” or “checking” will probably replace “screening”. Patients have heard the word screening, but many still don’t know what it means. Many may feel that an exam is different than a test. They may think that a “screening exam” is less thorough than a “cancer checkup.”
The labels “early detection” or “case-finding” make more sense when discussing the issue in the formal literature. However, your community may feel comfortable doing a free “screening” program. So it’s important to be comfortable with different names for the same tests.
Patient comfort with language and literacy has been shown to influence decisions about cancer screening. Patients with lower literacy levels may not be able to read a pharmacy label or even a simple brochure. Even if the brochure is at or below 5th grade reading, it may not be effective. Patients seem to preferentially understand the “testing” concept, leading to brochures using phrases such as “PAP test” or “colon test.” Longer or more obscure words such as rectals, smears, sigmoidoscopies or biopsies may not have any significance for the average American, no matter how often she’s seen the television program"ER."
Are there any true screening tests for cancer? Not really. Full inspection of the skin is usually too involved to label as a screening test. A rectal or oral exam is part of the standard physical exam. Mammography, PSA testing, colonoscopy and helical CT are all early detection tests. They may also serve as “piece of mind” assurances to your patients.
Patients who make special visits or come for annual checkups are probably worried in some way about cancer. They may have symptoms they never mention. Thus “screening” may actually be workup for the less thorough or more rushed practitioner.
Regardless of the semantics, the bottom line is the same as during your first year of med school. Don’t look for a tumor if no treatment would be offered under any circumstances. Early cancer detection may make no sense in some younger patients, and be perfectly appropriate in a 79-year-old. Cancer screening guidelines must be seen as flexible, along with the relevant terminology that is used.
1. Screening is NOT synonymous with early detection in every circumstance
2. Cancer screening tests are better defined as “case-finding” or “early detection” tests
3. Screening guidelines and nomenclature must be viewed with flexibility
Is Screening Better than Primary Prevention?
In a word, no.
Unfortunately, cancer is a predictable occurrence in the US because of our western lifestyle, our genes, and our environment. In a perfect world…
In the real world of the USA there are roughly 1.2 million cases of cancer annually and about 600,000 deaths labeled as due to cancer. Autopsy studies suggest that cancer is often underdiagnosed. Still, about 25% of all US deaths are attributed to cancer, and cancer may soon surpass heart disease as our #1 cause of death. Unfortunately, even if every American stopped smoking tomorrow, cancer would continue to be a major cause of death in this country for another century.
Since cancer rates of different sites may vary as much as 100-fold from country to country, causal theories abound regarding the effects of diet and environmental exposures. Currently, most evidence suggests that the traditional Mediterranean and Asian diets are associated with a lowered risk of many cancers. It appears likely that cancer rate disparities among various ethnic groups may be attributed to variances in diet, tobacco use, exposures, exercise, and access to health care.
In the real world of clinical medicine, screening is better than lifestyle. Here you’ve got the patient in your office, but you can’t control what his next meal will be or whether he’ll get out of his car and walk to the park to eat it. Does screening save more lives overall than smoking cessation, exercise, etc? I don’t really know (PAP testing probably does). Sure you can do fancy modeling studies and send them into journals, but that doesn’t always settle the issue.
Should you spend more time with your patients getting them to live healthier lives? Yes. Will you also have time left over to screen all your patients yourself? Probably not. Cancer experts and the “ivory tower” public health wonks pile on lists of things that primary care docs should do (my tower went condo last year, but they refuse to paint). And each disease has its own list of experts with their own guidelines. What to do?
Remember, I’m not from the government. I’m here to help. Let’s talk about what’s quickest, what you need to focus on, what you can delegate, and what works in guiding your patients to a healthier cancer-free lifestyle. Sure it may not work, but it’s easy to do, and you’ll sleep better:
1. Tobacco – ask all patients if they smoke, how much, what brand; do they want to quit? If so, set a quit date in the next month and avoid holidays and tax day. If they won’t set a date, ask if they’ll switch brands. Most will need several attempts to quit, but quit rates do improve with physician intervention. Still, studies show that even with physician assistance, most patients will fail to quit. But since there are so many smokers, any increase in quit rates translates to big gains. If a patient needs a cigarette in the morning, try one of the nicotine replacements. If they’ve tried to quit before without success try Zyban. Make your time with pregnant women, heads of households, and people with small children in the house a priority. Emphasize wrinkles, expense, clothing odor, sexual dysfunction, and poor exercise tolerance. If all else fails, refer the patient to a cardiologist, pulmonologist, or hypnotist.
2. Activity – I know, I know. It’s generally a waste of time talking to patients. Just tell your older patients to walk. If they golf, that’s fine. Just a mile of walking a day can affect mortality. Set a prescription pad aside with official looking recommendations for the patient to walk daily and give it to the patient. Delegate after the first attempt. One of the oldest Nobel Prize winning theories relating to cancer suggests that we aren’t as oxygenated as we should be. Even your office staff can encourage patients who cannot exercise to take 20 long, deep breaths daily. Can’t hurt.
3. Diet – No one really knows what the right diet is. Sure, push fruits and vegetables, but you don’t have time to deal with this. Just focus on finding out what your patient already likes from the following list and ask them to eat more if medically appropriate: raisins, dark grapes, soy products, tomato products, onions, garlic, apples, oranges, watermelon, prunes, salmon, tuna, olive products. I don’t know anyone who started eating kale on his doctor’s advice. You can encourage patients to drink an extra pint of cold water a day, which may lower the risk of bladder, prostate and colorectal cancer. Anything beyond this advice you may defer to the nutritionist. If your patient’s a heavy drinker he/she is probably not too concerned about cancer at the moment anyway and is probably smoking as well.
4. Occupation/Environment – Power lines, cell phones, electromagnetic waves all may indeed slightly raise one’s cancer risk, but the evidence to support this is scant. The evidence may be stronger for pollution, second hand smoke and pesticide exposure. People who have worked in smoky bars, auto repair shops, or chemical plants probably already know about their exposures (by law, folks handling hazards are to be told). Inquiring further about hobbies, second hand smoke (including marijuana), and activity levels at work makes sense.
5. Supplements/Meds – Rather dubious legislation has left the issue of the safety and efficacy of OTC supplements up to consumers. “Caveat emptor” is the watchword until tragedy strikes. Still, there is decent suggestive evidence that some of the following may lower one’s risk for certain types of cancer: folate, vitamin E, selenium, soy isoflavones, broccoli (indole-3 carbinol), pycnogenol, resveratrol (varied anti-oxidants, not surprisingly derived from varied fruits and vegetables), vitamin C, calcium, lycopene. If you can’t sort through it all, I suggest folate, selenium (up to 200 mcg/d) and a cruciferous vegetable supplement. No one is really sure what works and your patient needs to know that. Every now and then a study like the ATBC shows that a supplement increases the risk of cancer in some group. Still, the days of saying that Americans have the most expensive urine without benefit are gone. A multivitamin probably makes sense for most Americans over 40. And you can always look up new supplements on the Web if you’re not sure about something. As for drugs, NSAIDS (prostate, colon), ASA (colon, prostate), tamoxifen/raloxifene (breast), finasteride (prostate) and the pill (ovarian) probably prevent certain cancers, but we’re not yet at the stage where we know what to recommend routinely. If I were on a desert island I’d probably want to bring along an NSAID or ASA—-and Maryann as opposed to Ginger (had to sneak that in).
1. Cancer is the #2 cause of death in Americans.
2. Tobacco, diet, activity, and exposures are key lifestyle contributors to cancer rates.
3. If you only discuss one lifestyle issue with a smoker, discuss a quit date.
Before You Screen – Taking a Family History Without Taking All Day
So you’ve read this far and you’ve put up all your guidelines charts lines and you think you’re ready to start screening. You’re not!
Most people with cancer do NOT have a family history of that cancer site. When there is a significant family history, the “screening” regimen offered may instead be labeled a “surveillance” regimen. The following example will illustrate the difference and how it can affect your management:
A 65-year-old non-smoking male with no family history of colon cancer sees his primary care doctor, a gastroenterologist. A flexible sigmoidoscopy and a fecal occult blood test (FOBT) are negative during this annual checkup, and the patient later changes doctors. The patient is never advised to undergo colonoscopy. Four years later the patient is dying of right-sided colon cancer. In the hospital hallway, the patient’s sister casually mentions to the patient’s children (who are all physicians) that the patient’s mother and aunt both died of colon cancer and that the patient had apparently mistakenly believed it had been “stomach cancer.”
Unfortunately, we have no way of knowing how many situations similar to this crop up annually. Apart from the tragedy, the specter of medico-legal consequences hangs over this type of episode. Standard family history forms are indeed adequate to handle basic documentation for the typical patient. But when red flags are evident you must tread carefully.
While we are all excited by the completion of the Human Genome Project, it will be years before there are practical applications of this knowledge for the clinician. For you to save your patient’s life, you don’t need to master the issues of BRCA, I1307 or whether or not the prostate cancer gene is located on chromosome 1 or 11. Remember:
The most important cancer-related service you can provide for your non-smoking patient is to clarify the family history and proactively discuss the most aggressive screening and surveillance options that are appropriate.
Studies show that family histories are notoriously inaccurate and must be taken as vague at best. Remember, every family historian is a POOR historian until proven otherwise via corroboration or pathology report. This has been documented most clearly regarding colon cancer, perhaps because of the embarrassing nature of that area of the body in western culture.
Still, this doesn’t mean you have to start sending off for death certificates or running up phone bills. Simply have a member of your nursing staff follow up on a patient’s vague family history of cancer (stomach, abdominal) with a call to the patient’s spouse, sibling, or parent.
Clearly there are patients with unusual family cancer syndromes (MEN, FAP, lymphoma etc) who need a painstakingly good history and a referral. But common situations are much more common than common sense it seems. Let’s discuss a few caveats that you and your staff can keep in mind regarding family history:
Breast Cancer – BRCA genetics has made this area very specialized and ever changing. If a woman has a mother, sister, or aunt with the disease, the current climate may compound her fears. Regular mammograms, genetic testing, or even prophylactic surgery may be suggested earlier than age 40. My advice is to refer these patients to the nearest geneticist or breast surgeon for follow up given the fluidity of the field. As we’ve discussed, if your patient already has breast cancer, further testing is surveillance, NOT screening. BRCA genetics should be discussed with all Ashkenazi Jewish females with a family history of breast cancer. Studies do NOT support a higher risk of breast cancer in Ashkenazi Jews overall.
Colorectal Cancer – Colorectal (hence forth to be known here as colon cancer) polyps or cancer in a blood relative raises the risk of the same. Patients may believe a relative with colorectal cancer had “stomach” or “liver” cancer. Screening strategies alter greatly depending on the family history. A family history of breast, ovarian, or endometrial cancer also raises the risk of colon cancer. About 20% of colon cancer cases are linked to hereditary conditions, which may not be easily apparent (several relatives over 3 generations or multiple relatives under age 60). Patients with multiple relatives over 60 with colon cancer carry the designation of familiar colon cancer syndrome and will have a different surveillance schedule.
Prostate Cancer – Men with brothers, fathers or uncles who have prostate cancer should be approached about screening before age 50. The best age to start is unknown. A family history in a brother appears to be most significant. A relative with breast cancer may also increase the risk in the index patient. Studies proving that an earlier surveillance schedule saves lives have not been conducted. Again, some men may have died from prostate cancer a generation ago when families did not receive more specific information than a “cancer” diagnosis.
Ovarian Cancer – As with breast cancer, ovarian cancer has a strong familial component. I believe that women with any strong family history should be offered the option of the new, non-validated detection regimens (CA-125, ultrasound, newer biomarker as well) when the issue of mammography is discussed. Anything further or newer needs to be discussed with the patient’s GYN doc.
1. Family histories are notoriously unreliable – always confirm with a sibling or parent.
2. Most patients with a diagnosed cancer do not have a directly relevant family history.
3. Patients with significant family histories need surveillance, NOT screening.
Willie Sutton, MD/Hero – Finding the Common, Curable Cancers
Because that’s where the money is.
When my colleagues on rounds would suggest essential mixed cryoglobulinemia, type II, I would chime in with thyroid storm or TB. Why? Because they’re easy to diagnose, treat, and cure. ALWAYS think treatable before getting into the untreatable conditions.
To be a hero, you have to think clearly and simply. Early detection of a glioblastoma isn’t very likely to help the average patient. Doctors simply aren’t referring every patient for appropriate, routine cancer screening tests. Unscientific, anecdotal data suggests that doctors screen more if they themselves have been screened for certain conditions.
Most lawsuits involve missing common causes of cancer death – lung, breast, colorectal, prostate, skin, bladder, gynecologic, pancreatic, hepatobiliary, hematologic, stomach and esophageal. Here are some hints to help you stratify some patients at higher risk for common cancers:
- African Americans have the highest death rates from lung, prostate, and colorectal cancer; lung cancer kills far more African American men than prostate cancer.
- Ashkenazi Jews appear to have very high colorectal and ovarian cancer rates, but low prostate cancer and lung cancer rates
- Hispanics and Asians have relatively low rates of prostate and colorectal cancer death.
- Native Americans, Hispanics, and Asians have low overall cancer death rates.
- Whites and African Americans have higher cancer death rates than other groups.
- White women have the highest rates of breast cancer.
- Colorectal cancer is the cause of more premature death (< age 75) in American men than prostate cancer.
Let’s discuss specific cancer sites in the context of a busy practice:
Lung Cancer – This is by far the most common cause of cancer death in western civilization. Smoking accounts for about 90% of all cases and the risk rises with more pack years. In 1895, only about 1% of US adults smoked and lung cancer was undoubtedly rare. By 1964, about 42% of Americans were smokers, and today only about 25% of adults smoke. Stage I lung CA is often curable, while stage IV is basically hopeless. Few cases are currently found early. Still, death rates are dropping in men because fewer men are smoking today. Risk of the disease goes down dramatically after quitting for a decade. Earlier studies using periodic CXR surveillance were inconclusive regarding mortality and are being reevaluated. Currently, scientists are studying periodic helical thoracic CT scans in people with a significant pack years history. If your patient can afford $1000 and hasn’t smoked in 5 years, it may be reasonable to refer the patient to a pulmonologist or radiologist for a discussion of the issue and possible enrollment in a trial. There are few data as yet regarding helical CT surveillance. However, given the public health effect of lung cancer in the US, and the terrible prognosis for advanced disease, it would seem prudent for clinicians to offer this option to the well-informed ex-smoker who has a reasonable life expectancy. Again, the above regimen does NOT constitute screening. The patients at risk are folks with an exposure to the combination of toxic substances found in cigarettes. This option is therefore a surveillance regimen aimed at early detection of lung cancer in patients with a known, powerfully influential, risk factor. Bottom line, concentrate on urging patients to quit. When they do, let them know about the as yet unproven option of surveillance.
Breast Cancer – The first definitive evidence that large-scale early detection of a cancer could affect mortality was gathered in the 1960s by HIP’s famed randomized trial of mammography. Recently, death rates from breast cancer have leveled off and are finally dropping. Is it because of screening? Probably. Is there agreement? Absolutely not. Breast cancer is now a cause celebre, a political agenda that constitutes the #1 health issue for women in this society according to many indicators. Every woman who walks into your office is worried about this. You should refer even women in their 20s who bring it up. Take any breast complaint or concern very seriously! Of course every lump must be biopsied in this day and age. So what else can you do to help find more early disease? Women who have had several uncomfortable mammographic experiences may need cajoling. Older women may need reminding. A good breast exam is still good to know. But you’re better off referring to the surgeon or the radiologist. Missing a breast cancer is the #1 cause of lawsuits against primary care docs. We may have thermography and better ultrasonic views of the breast in the future. Remember, women get breast cancer earlier than men get prostate cancer. Don’t get complacent.
Prostate Cancer – PC has quickly become the third rail of politics. Celebrities are telling your patients to get checked and most American men have probably already had at least one PSA blood test since it was released 12 years ago. Whether or not finding early disease is always the best course continues to be debated. Early disease may never bother a man of 60, whereas advanced disease can kill quickly. Prostate cancer death rates seem to have dropped dramatically over the past 6 years. I believe this is mostly due to better, more aggressive treatment, patient centered lifestyle changes, and to some unknown degree, early detection. The drop occurred too soon after 1988 to be mostly due to early detection of disease. “Free” PSA levels, and perhaps complexed PSA or Kallikrein levels, are better able to predict a better yield on biopsy and possibly a longer post-op freedom from PSA recurrence. The point here is that men in their 40s and 50s should be able to know if they may have PC. You are then also obligated to tell them they’re being screened, and about the uncertainties that remain regarding treatment, life expectancy, and the disease’s natural course. Prostate cancer death rates are currently highest in African Americans and in the Southeast.
Colon Cancer – The ultimate cancer to look for. Over 90% of cases are found in Americans over 50 years of age. In the US, incidence and mortality rates are 40% to 50% higher in males than in females, with the highest rates found in the northeast US. The disease is highly preventable, and easily curable when detected early. If you tell your patients that they need to be screened, studies show patients will get screened, despite concerns over discomfort and expense. It’s that simple. The studies prove that the screening tests saves lives, are cost effective, and even PREVENT cancer from developing. Just keep track of who needs what by enlisting your office staff liberally. Still, most Americans haven’t been tested even though the screenings don’t have to be done annually under some regimens. Every doctor I know has gotten a total colon exam. Eventually recommendations will probably be made for everyone to have at least one colonoscopy by age 60. Medicare now covers multiple options for colorectal cancer screening. Recent studies have cast doubt on the performance of DC barium enema, paving the way for the virtual colonoscopy industry. Flex sig + FOBT is fine but watch your step!! No patient with even a hint of fatigue, abdominal discomfort, bloating, constipation, diarrhea, weight loss, BRBPR, anemia or any GI cancer history in the family should be getting a flex sig!! Those patients need a workup or surveillance and only a total colon exam is acceptable. Remember, a patient with any signs or symptoms cannot be screened! Biomarkers aren’t coming anytime soon so read this paragraph again carefully.
Cervical, Ovarian, and Uterine – The PAP smear may be replaced by newer technology but is still state of the art for cervical and uterine cancer. Cervical cancer is associated closely with HPV, tobacco use, and may be found in older women who have forgone screening. It remains a great irony that PAP smears remain standard while trials were never done. If appropriate, leave testing up to the GYN doc and ask for confirmation. Ovarian cancer should be considered in all women with any vague GI complaints where you would consider gallbladder, appendiceal or stomach pathology. There is no routine screening test for ovarian cancer as yet. Ovarian red flags: Ashkenazi Jews, women with even mild unexplained pelvic/abdominal pain, bloating or discomfort, and women with aunts or mothers who died of a “long illness” or cancer with unknown primary. Ovarian cancer rates haven’t changed much for decades. A single CA-125 is not a valid early detection test. This all adds up to very little routine screening for the average non-GYN PCP to deal with.
Skin – Women are getting more disease on their faces and legs; men are getting more on their backs. Only dermatologists should do total skin exams. Be more vigilant with redheads and people with lighter skin, Florida snowbirds, and folks who work/play outdoors. Survey obvious marks at the initial exam. Remember, African Americans can get skin cancer on palms and soles. Since sunburn undoubtedly causes cellular disruption (whether at the beach or on Star Trek), sunscreen of 15 or higher (without PABA) is still a good idea. Recent studies showing little effect probably can’t control for reapplication and longer time spent in the sun. Self-tanners aren’t nearly as popular as they should be. It is often said that most sun exposure occurs under the age of 20 in most Americans. Melanoma rates are indeed rising but the disease still causes fewer than 2% of all American cancer deaths.
Lymphoma/Leukemia – Routine screening is not recommended. Surveillance in certain higher risk populations, including patients with HIV or certain exposures, may be defensible. The disease appears to be increasing in frequency though this may be solely a function of HIV and other immune modulating conditions. Many asymptomatic patients do receive CXR and blood work, which could be classified as opportunistic screening. Parental smoking may be a risk factor for leukemia in their children.
Pancreatic/Hepatobiliary/Stomach/Esophageal – Since advanced disease is almost always fatal, a biomarker would certainly be a breakthrough for all these diseases. Endoscopic visualization as a screening tool is not justified in this country (Japan has attempted mobile screening for gastric cancer). Diet and cigarettes are the most studied risk factors. Hepatitis B, C increases the risk for liver cancer. Again, the PCP has no responsibility for routine screening of average risk, otherwise healthy, asymptomatic patients for these diseases.
Bladder – Urinalysis with cytology does help identify this disease. Further routine “screening” is not necessary. The disease is more dangerous in men, and is apparently related to smoking and certain dyes. Remember, if your patient has vague abdominal complaints with trace hematuria and is found to have bladder cancer, continue the workup as above. Synchronous ovarian or colon cancer must be ruled out.
1. Most US cancer deaths are due to lung, colorectal, prostate and breast cancer.
2. Lung cancer is by far the leading cause of cancer death in the US.
3. Cancer death rates in blacks and whites are generally higher than in other groups.
Should You Screen for the Less Common, Treatable Cancers?
So are there less common cancers you should be looking for? Are there any that merit routine screening? If there is no family history, should you screen your patient for rare tumors?
No. No. No.
Today’s primary care physician should take a good H & P, review of systems, family history, social/occupational history and medication review. Unless your otherwise healthy patient with no exposures has a significant family history of cancer, it’s unlikely you’ll find out much to assist you in finding the unusual sarcoma or myxoma. Of course, most cancer deaths occur in patients over age 50.
Again, there is nothing you need to do regarding screening for the less common or rare cancers outside of your usual standard care practice. For the sake of completion we’ll discuss a few examples to illustrate that screening for less common cancers is impractical:
Testicular Cancer – This disease gets a great deal of press because it can affect young male athletes. The progress made in TC over the past 25 years is a testament to modern allopathic oncology. The disease tragically does kill several hundred men annually. Even well advanced disease is highly treatable and usually curable. Self-examination and early detection may be beneficial. “Screening” for the disease may be done via a thorough physical exam.
Thyroid Cancer – Thyroid function testing is standard on many routine blood panels. Beyond a good physical exam of the thyroid, the PCP need do little else. Surveillance of people with other endocrine neoplasias or prior exposure to ionizing radiation may be indicated.
Brain Cancer – Perhaps 10 years from now surveillance of a kind may be demanded by adults living near electromagnetic power lines, or by habitual cell phone users or phone operators. Now with phototherapy and proton beam accelerators, there’s more hope than ever for treatment. However, no real screening test is available. The disease may be more common in certain ethnic groups and it does appear that the disease, though still quite uncommon, may be increasing in frequency. Patients with headaches, personality changes, paresis or dyskinesias clearly need workups, NOT screening.
Hodgkin’s Disease – Another triumph of modern oncology. The disease is often curable even in stage IV. It still causes about 1500 deaths annually. Its etiology and epidemiology are far from clear. Of course people with prior treatment for cancers may undergo surveillance for a myriad of hematologic conditions, but such a regimen does NOT constitute screening.
Zebras – Uncommon conditions are rarely screenable in adult populations. If you’re suspicious for any reason, have your nurse or partner repeat the review of systems and physical. Every now and then somebody does get a synovial sarcoma.
1. Most rare cancers cannot found by routine screening tests.
2. Cancer is much more common in Americans over 50.
3. Curable cancer such as testicular CA & Hodgkin’s should always be considered.
Outsourcing your Screening Efforts
One of the biggest debates that repeats itself in the cancer control community is over the issue of “prevention” or “screening” centers. Should dedicated sites be set up just to do preventive medicine?
In a word, yes.
In a perfect world you would screen every patient yourself. But you’re a busy practitioner who needs to spend his/her time on the things you do best: Listening, advising, clarifying a history and exam, diagnosing, and referring when appropriate.
Most reimbursed medicine in the US is for taking care of the sick, ie people who have complaints. Despite all the cost-effectiveness studies, preventive medicine is usually viewed by insurers and wonks as more expensive and more expendable than “sick care” medicine.
Screening is about doing tests when your patient feels ok and has no signs of disease. Most people who are screened are ok and therefore insurers are unhappy about laying out money for no reason. Since your practice thrives on reimbursement it makes sense to refer patients for screening as much as possible. Plus, experts in those areas tend to be more up-to-date on testing in their areas.
Still, you must be able to do a good family history, handle good documentation, explain basic pros, cons, and consequences of screening tests, and perform a reasonably good physical exam, which includes the breast and the rectum.
You may be able to rely on specialists to do everything else if you are comfortable with them. To see how comfortable you really are with these referrals, take this short quiz:
1. Does your local radiology group have someone dedicated to reading just mammograms?
2. Do you trust your GI group to get to the cecum and find polyps under 10mm?
3. Does your favorite urologist routinely ask for a free PSA, take 6 core biopsies and welcome 2nd opinions?
4. Are your lung people considering a pilot study to do CT surveillance on ex-smokers?
5. Do you get regular reports from your GYN colleagues on patients they screen for breast, cervical cancer, and occasional ovarian cancer surveillance?
If you answered yes to all these questions, you’re all set. If you still feel overworked and can’t see doing one more thing, have your nurse talk to every one of your patients about colorectal cancer testing. That way you can focus solely on breast cancer in your female patients and prostate cancer in your male patients. You can use a simple tickler/reminder system for referrals for mammography and colon testing. That leaves a few minutes to mention to your male patients that you’d like to talk briefly about their prostates (and colons, for reinforcement).
1. Cancer screening and prevention is usually poorly reimbursed.
2. Referring patients for screening is often appropriate care, not abandonment.
3. If you’re confident of the patient’s family cancer history, proper screening is easy.
Current Controversies in Cancer Screening
By now you should be aware that screening engenders much controversy because of issues attendant to doing individual “screening” vs large scale screening programs. A list of further issues includes
- Monetary Costs
- More invasive follow up tests
- Lack of trials to prove that some forms of screening saves lives
- Health care groups promoting screening when they have a proprietary interest
- Screening promotes more patients being labeled as having cancer
- Newer studies may show a screening test’s poor specificity or lack of effect on mortality
- Lay press/media/celebrities offering unscientific endorsements of certain tests or technologies
- Public perception that cancer rates are increasing and that since the “war on cancer” is being lost, more screening (and not less) must be the answer
- Age cutoffs
A full discussion of the above issues is beyond the scope of this course. I’d like to put forward a simple analogy to place screening controversies in perspective and illustrate how we can try to avoid trouble during these discussions:
Screening in its simplest form is simply a fishing expedition. When you go out fishing, the lake looks calm. There are no signs of fish on the surface and no way to know if the fish are “biting.” The only way to tell if there might be fish in the lake is to put your pole in the water.
As the fishing process is not perfect, we may not catch a fish even if there are fish in the lake (false negative). Or we might just cast our line for a fish but instead catch a stray tire or sneaker (false positive). Because fishing is an inexact means of catching fish, spending money on equipment and risking being stranded in a rowboat in a storm constitute inherent “risks” in an otherwise apparently innocuous, even relaxing activity (unless you are Fredo Corleone).
The screening “pole” is used by the clinician because of an implied or explicit decision made with the patient that said patient is comfortable attempting to try to “catch” a cancer early, regardless of consequence (i.e. we may fish and catch nothing, or catch something that might seem at first like a fish but turn out to be nothing). If the patient or the insurer can afford to rent a boat, a pole and some bait, and if the patient is duly informed of the pros and cons of such a fishing expedition, little controversy should attach to your practice and its screening processes.
It may still be difficult to explain to anyone how fishing could engender any detriment to an avid fisherman. That is the challenge facing the evidence-based physician. Of course, NCI’s PLCO trial may make some sense of screening issues over the next decade. However, for now let’s explore in more detail a few of the hottest issues currently debated regarding the early detection of certain cancers:
1. Lung Cancer Surveillance – A helical chest CT may cost upwards of $300 to $500 and no one really knows if the expense is justified. You must go over the downstream consequences of biopsy, false negatives, lung resection, etc with your patients who pursue this or who are looking for a trial.
2. Cervical to Malleolar CT – Dr McCoy would have been proud. Currently this is an expensive “piece of mind” test for celebrities, but will it become a status symbol of health? Your role will be to pick up the pieces and refer when something is found. Could a negative scan (head CT included), privately paid for, be used to lower an individual’s life insurance premium?
3. Breast Cancer Detection – Even mammography has been attacked lately by experts from Finland to Harvard to Canada. They say there are too many false positives accrued over time, average women from age 40 to 49 don’t really benefit, and that if you look at ALL the data very closely (like through 3D glasses) you’ll see no effect on mortality. There is no real controversy in the US. Mammography is standard of care. If a woman has dense breasts or a family history or has a lump, examine and refer. Mammography is probably saving lives though not as many as the public has been led to believe.
4. Prostate Cancer Detection – Whitmore was right. We don’t know whether cure is always necessary, likely, or even possible. The question for the average man remains: why should he take chances with his life when he doesn’t have to? As American men live longer the issue is moot. Most men want to know if they have cancer and claim to be satisfied with treatment later for a host of reasons. Just remember to tell a man that you’re screening him for prostate cancer. And if your patient is assertive enough to want to know that he has prostate cancer, he certainly must be offered aggressive screening for colorectal pathology.
5. Colorectal Lesion Detection – If we only had a PSA biomarker for colorectal polyps. Though mortality rates are dropping for all of the above cancers, only colon screening tests can actually prevent cancer. By removing early polyps, you can actually perform primary prevention. So where’s the controversy? What age to start, which testing method, etc. What should you do? FOBT is part of the physical-it does NOT discharge your responsibility for screening. Most patients will develop polyps if they live long enough. Recent studies emphasize colonoscopy as the initial test for patients over 65. Since colonoscopy is powerful but invasive, use it wisely in asymptomatic patients under 55, ie refer, especially if there’s a tricky family history. Flex sig is an option only for the low risk patients under 60. Kaiser knows best how to screen large groups with this system. Elsewhere, rely on total colonic exams when reimbursement isn’t an issue. Barium enema is an option when endoscopy cannot be reliably done or reimbursed. Virtual colonoscopy offers some advantages, but bowel cleansing is still necessary. Try the new Senna protocol over the polyethylene glycol protocol, which is awful. In my opinion, everyone should have at least one colonoscopy by age 60. Because colorectal screening tests are so effective, testing should be offered to people in their 40s. Remember, colon cancer mortality rates are currently highest in the Northeast US, in African Americans, Ashkenazi Jews, Hawaiian Japanese, adults over 50, and men.
1. The public and the epidemiologists often disagree on the merits of screening.
2. Controversies continue because of the difficulty doing large, lengthy trials.
3. Trials such as PLCO are years from completion, so uncertainties will remain.
Reimbursement and Cost-Effectiveness Issues in Screening
While a great deal is published every year on cost-effectiveness estimates on various technologies and screening tests, much of the discussion is specious. Nothing in this world is cost-effective except in relation to something else. What would any of us pay to prevent a loved one from dying from cancer in the next 6 months?
Recent evidence suggests that screening for breast and colorectal cancer is as cost-effective as cholesterol screening and dialysis, both of which are now almost universally covered. I am not going to bore you with money amounts per year of life gained and all the math gymnastics involved. Mammography is a HEDIS measure, which means that it is considered a benchmark performance measure upon which insurers may be graded. A HEDIS measure for colorectal cancer screening is supposedly in testing.
It is not possible to measure the true cost-effectiveness for prostate cancer screening at present. However, since PSA testing + DRE is quite conveniently and cheaply done, it can be argued that any positive effect screening has on prostate cancer mortality will probably be worth the cost given the climate in our society.
Quality of life measurements are also being guesstimated. The issues remain straightforward. What are the upfront costs to your patient, how much will you be reimbursed for going over the test’s pros and cons, will follow up care be available, and will a true negative test set your patient’s mind at ease? Unfortunately, I doubt whether QOL and cost-effectiveness estimates will ever be able to truly answer these questions.
Are there other “cost-effective” screening methods? Again, because the incidence of each and the yield of the test are important factors, checking for the common cancers is most justifiable. Whether further surveillance methods make sense are questions for trials. PAP testing along with colorectal and breast cancer testing are often labeled “cost-effective,” and for good reason.
Whether colonoscopy is cost-effective in every clinical setting is still being studied. I would venture to say that a screening schedule of a flex sig at 50 and colonoscopy at 60 is likely to be cost effective as suggested by recent studies at Kaiser Permanente. Can large groups of women from age 40 to 49 do almost as well with mammography every 2 years? Probably. At least according to the Canadians. But the issue has evidence on all sides and it is best to be aggressive for now.
What about your overanxious, affluent patients who are very health conscious and who want regular overkill scans? Cost-effectiveness and reimbursement are irrelevant to those who can afford unlimited care. How much time can you afford to take with an inveterate smoker who can’t quit? Doing flex sig instead of colonoscopy on your entire HMO population at age 50 might save you millions. Or will it? So what should you do?
The real answer is that I don’t know. No one knows for sure. Even when the studies pour in, including PLCO, we’ll never really be sure. Screening and cancer prevention are large-scale efforts at common sense with a few studies thrown in for rationalization. Randomized trials are great to have, but recent studies suggest that even this hallowed methodology may not be necessary.
The real point again is that you’re the patient’s physician. Just make sure you have some sort of policy or someone’s guidelines hanging in your office, and that you ensure that you or your staff discuss cancer screening and prevention with patients of appropriate age. Ironically, discussing smoking cessation has been shown to be the most cost-effective cancer prevention activity you can do. But what about your time and the reimbursement problems? And if you don’t have the time, can you enlist your office staff to push appropriate brochures or to do counseling?
The answers will come to you once you take a history and a family history and once you know how risk-averse your patient is about cancer. Once you’ve read somebody’s guidelines and this course, you’ll know what to do. Remember, you already know everything you need to know to cut the cancer mortality rate in half in your practice.
1. Some cancer screening tests are as cost-effective as dialysis and cholesterol screening.
2. Mammography is currently the only cancer screen test in the HEDIS set.
3. Smoking cessation is the most cost-effective cancer prevention activity for the PCP.
Current Mandates and Legal Ramifications
Mandated screening is generally a function of local government and public health law set up under the police powers or “promoting the general welfare” sections of the constitution. Apart from the testing for infectious diseases, few states have mandates regarding screening adults for serious health conditions.
Your locality may have a requirement that a PAP test be documented in an inpatient chart. Or that a mammogram was discussed and offered. California passed a largely unenforceable statue several years ago regarding discussing prostate cancer screening and treatment options. Virginia and Missouri have recently considered legislation mandating payment for certain screening testing options for colorectal cancer.
It is very unlikely that you will ever wake up in the morning bound by law to perform a screening test for cancer. You may be mandated to offer screening along with specific counseling in some manner (along the lines of HIV mandates), but since screening may lead to invasive tests, the state isn’t likely to tell doctors they have to screen adults for cancer against a patient’s will. However, there are “mandates” relating to breast and prostate cancer throughout the US, while only a few states have laws relating to colorectal cancer.
It has been shown time and again that doctors do not always follow preventive service guidelines. States are generally considering ways to remind doctors to offer screening tests to their patients and are insisting that insurers including the federal government pay for these tests. These laws may affect your practice as more patients ask for testing that is now being reimbursed, and you might offer it more often. Without belaboring the point, a major part of the cancer control day is spent trying to get physicians to recommend screening more often than they currently do.
Legal ramifications of failure to screen have been discussed. Even though prostate cancer screening remains controversial, failure to screen suits have already been brought. Colorectal cancer screening suits will follow.
The public will likely remain suspicious of mass testing for cancer genes, fearing discrimination from insurance companies and employers. Therefore, specific genetic tests and markers have not been emphasized here. Again, the chief role of the overworked, underreimbursed family physician is to clarify the patient’s family history, identify patient screening and values preferences, and coordinate the patient’s interface with specialists and the reimbursement bureaucracy.
Finally, don’t let the big guy beat you. Why did Babe Ruth, Lou Gehrig, and now Ken Griffey, Jr get so many walks? Because it makes no sense to get beat by the common things. Sure your patients are all going to die of something. But cancer, heart disease and stroke are the most common causes. And your patients fear cancer the most. So if you’re going to be a little over the top in any area, most patients want you to be careful with cancer. If you’re going to discuss cancer screening with them, you have a moral if not legal, obligation to discuss the big screening issues and options with them – (lung, colorectal, breast, prostate, cervical) plus their pros and cons.
1. Failure to screen may be construed as negligence in a medicolegal context.
2. Disclosure of test availability plus pros/cons may soon be legally required in some states.
3. Medicare now pays for screening for cervical, prostate, breast, and colon cancer.
Screening is simply looking for disease in patients without complaints. Cancer screening may have seemed scary at the start of this course. But now you know how to focus your efforts and keep your eye on the ball.
Most cancer deaths are caused by just a few cancers. Lung, colorectal, breast, prostate, pancreatic, and ovarian cancer cause the overwhelming majority of cancer deaths annually in the US. Lung cancer is the leading cause of cancer death in this country among virtually every ethnic group. Men are more likely than women to develop cancer over a lifetime.
While the purpose of screening is to find cancer early, which in turn may improve overall prognosis, improvements may not always be the case. Since testing adults without symptoms may have unforeseen consequences, there remain controversies surrounding certain screening tests. Until controlled trials are completed, many of these controversies will continue to swirl though the public may wholeheartedly adopt new tests with little skepticism.
The primary care physician is most responsible to the patient sitting before him/her. These responsibilities include: documenting tobacco use; encouraging a quit date if appropriate; clarifying the family history with the patient and another relative; clarifying any toxic exposures; and discussing, performing and/or referring for colorectal, breast, prostate, skin, cervical and lung cancer testing. A brief colloquy regarding the uncertainties and downstream consequences of various screening tests is incumbent upon primary care physicians today.
The public must be assured that cancer rates are dropping and will continue to drop. Screening “fatigue” may be setting in as many people fail to sense that we are “turning the tide” against cancer. Encouraging patients to adopt healthier lifestyles and enter screening trials are part of the proper cancer prevention approach in practice. Exercise, fruits and vegetables, plus more fish, soy, olive and tomato products, and an overall shift to a more Mediterranean and Asian diet may be of benefit.
Remember, aggressive screening for cancer isn’t the only way to bring down cancer rates. It may not even be the best way. But along with taking a scrupulous family history and review of systems, and encouraging tobacco abstention, it remains your best shot at reducing your patient’s risk of premature cancer death.