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Cancer Screening: Doing More Harm than Good?
They say the prostate-specific antigen (PSA) test may do men more harm than good if they don't already have symptoms of prostate cancer. And they have similarly grim things to say about other widely used cancer screening tests
a growing group of scientific heretics -- published in highly respected medical journals, working at some of the most august institutions -- strongly believe that it's time to rethink our whole approach to cancer screening.
That's because screening tests pick up many small cancers that would never have caused any symptoms. "Screening for cancer means that tens of thousands of patients who never would have become sick are diagnosed with this disease," says H. Gilbert Welch, MD, codirector of the Outcomes Group at the Veterans Affairs Medical Center in White River Junction, Vermont, and a leading expert in cancer screening. "Once they're diagnosed, almost everybody gets treated -- and we know that treatment can cause harm." Tamoxifen for breast cancer can trigger life-threatening clots in the lungs, for instance.
Surgery for prostate cancer leaves 60 percent of men unable to have an erection. For that matter, some of the screening tests themselves carry risks: Up to 5 out of every 1,000 people who get a colonoscopy have a serious complication, such as a colon perforation or major bleeding.
The Damage Screening Can Do
unnecessary therapies for cancer are a tremendous drain on our health care budget, already strained to the breaking point
patients suffered serious side effects, even death, from treatment that they might not have needed says William C. Black, MD, a professor of radiology at Dartmouth-Hitchcock Medical Center
No one intentionally prescribes unnecessary treatment, of course. But it's often difficult to know if a patient really needs to be treated, so the tendency is to be aggressive, just in case
George Brown. At 75, Brown was still a practicing lawyer in Denver last year when he was diagnosed with prostate cancer. His doctor prescribed Lupron to block production of testosterone (which many prostate tumors need in order to grow). "I didn't realize that Lupron was chemical castration," says Brown. "I was extremely depressed. I was having hot and cold flashes. I cried at everything." Radiation therapy damaged his rectum and left him with little control of his bladder or bowels. He is now facing another round of a different testosterone-blocking drug.
Does Screening Save Lives?
only one cancer screening test, the venerable Pap smear, has truly slashed the risk of death. Between 1955 and 1992, according to the American Cancer Society, Pap smears cut the death rate for cervical cancer by 74 percent, and deaths have continued to decline each year.
Mammograms also offer a smaller benefit than many patients -- and doctors -- assume. Mammography's effectiveness has been hotly debated, but a carefully conducted 2005 analysis suggests it cuts the risk of dying of breast cancer by 15 percent, says the NIH's Kramer. That means a 60-year-old who gets regular mammograms shaves her risk of dying of the disease in the next decade from 7 per 1,000 to 6 per 1,000.
As for colonoscopy: It allows the doctor to remove polyps, growths that can turn into cancer. The best estimates suggest that colonoscopy can cut the risk of death from colon cancer by as much as 60 percent.
Eventually, researchers and doctors hope, better screening tests will be able to distinguish between cancers that need to be treated and those that don't. But until then, many experts believe, the decision to get screened should rest on an individual's values and his or her ability to handle uncertainty. "We have come to fear dying from disease more than dying at the hands of overzealous doctors," says Dartmouth's Dr. Black. The fact is, both are risks when we get screened for cancer.
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