 |
|
|
Ron Adler, MD |
As conflicting cancer screening guidelines create confusion, it is essential for patients to have a frank discussion with their doctors about when and how often to be tested, said Ronald N. Adler, MD, associate professor of family medicine & community health, who has lectured widely on the topic of overdiagnosis.
Dr. Adler employs a patient-centered approach to care and strongly advises that physicians balance screening recommendations with patient priorities as a means to reduce chances of overdiagnosis and overtreatment.
“We’ve done such a good job of educating people about cancer and how early detection can make such a difference,” Adler said. However, treatment of indolent cancers, such as many cases of prostate cancer or ductal carcinoma in situ (DCIS) breast cancer, could be harmful because of unnecessary radiation or disfiguring surgery, he said.
“Many cancer screening advocates make the mistake of thinking that our job is to find every cancer. But we don’t want to find all cancers—only those that are likely to cause harms; we want to save lives, we want to reduce morbidity. Finding and treating indolent cancers not only doesn’t save lives, it increases morbidity,” Adler said.
The family physician, who recently spoke on the topic with colleague Stephen A. Martin, MD, assistant professor of family medicine & community health, at the third annual Preventing Overdiagnosis conference held on the National Institutes of Health campus in Maryland, said screening, by design, is used to test a population that has no signs or symptoms.
“When we seek to do that to a healthy population, the potential benefits must outweigh the potential harms. This is OK as long as people realize that there is a gray zone in which there are trade-offs. This is why it’s so important to elicit patient opinion,” Adler said.
For example, in a case of early stage breast or prostate cancer, Adler recommends that patients consider active surveillance in lieu of pursing immediate treatment.
Regarding the American Cancer Society’s recent revision of its longstanding guidelines for mammography, Adler agreed with the direction of the change, which recommends postponing a healthy woman’s first mammogram until age 45 and continuing the screening annually until age 54 and then every other year as long as the woman remains in good health.
“This will help retain most of the benefits and reduce many of the harms, such as overdiagnosis and false positives,” Adler said.
He said, most importantly, the cancer society’s recommendation acknowledges that there are potential benefits and potential harms to mammography, and that it’s best to discuss options with your doctor, a method called shared decision-making.
“It’s a challenge and takes a lot of time, but it lays out the pros and cons and helps a patient explore their own values and preferences,” Adler said.
As science advances, physicians are being supplied with tools to get better at stratifying cancer risk in the population and at fine-tuning screening, Adler said. Cervical cancer screening is a good example. There is now less testing for low-risk women. Also, the Pap test has been augmented with a test for the human papillomavirus (HPV), which causes cervical cancer, Adler said.
Another advance is the discovery of the BRCA gene to identify a subset of the population that is at high risk for breast and other cancers. Women with BRCA gene mutations should consider getting high intensity screening, i.e., earlier and more often.
“Maybe we’ll find a gene marker that is the opposite of BRCA, a gene that is protective, then we don’t have to screen or we can do low intensity screening on that population,” Adler said.
