Cancer Society Clarifies Screening Guidelines

A new article in the Journal of the American Medical Association says that breast and prostate cancer screenings are turning up more innocuous cancers, but the screenings are not significantly reducing the number of deadly cancers. The American Cancer Society is clarifying its guidelines on screenings. Steve Inskeep talks to Dr. Otis Brawley, an oncologist and chief medical officer of the American Cancer Society, about the organization's advice.

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STEVE INSKEEP, host:

Many advocates in the debate focus on the cost of needless medical tests. So it was noteworthy when the journal of the American Medical Association published a study questioning the value of widespread testing for prostate cancer and breast cancer. That is provocative information after years when doctors called for everyone to be tested. Dr. Otis Brawley of the American Cancer Society wants to clarify his advice on prostate cancer. He says he just wants doctors and patients to talk it over.

Dr. OTIS BRAWLEY (American Cancer Society): That does not mean men should not get screened. It does not mean men should get screened. There's this over-promise that screening is clearly the right thing to do and that's the wrong thing to say. And to say screening for prostate cancer clearly should not be done, that too is the wrong thing to say. We have a lot of things we don't understand about prostate cancer screening yet and we don't know if it saves lives, but it might.

INSKEEP: Well, let's try to figure out why that would be, because the thinking seems obvious with something like prostate cancer: try to catch it early because if you catch it early it's less severe and you have a better chance. That's the presumption that we would have if somebody encouraged us to take a test. What makes it makes it more complicated than that?

Dr. BRAWLEY: That is the presumption that we've got to get away from. Some of the prostate cancers that we find and treat are cancers that were never going to metastasize, never going to spread, and the cost of that treatment can be severe in terms of morbidity and even some mortality.

INSKEEP: You're saying that finding it early might be helpful, but there might be other cases where you find it early and it expands anyway, or you find it early and it turns out not to have been serious and the cure is worse than the disease would have been?

Dr. BRAWLEY: That's right.

INSKEEP: And so you end up with approximately the same rates of serious prostate cancer, even though millions more men are being tested today.

Dr. BRAWLEY: That's exactly right. And I stress again that I and the American Cancer Society are not against screening, but we're for men knowing that there are some questions here as to whether screening is effective and then making a decision that they are comfortable with.

INSKEEP: How does this fit into the larger health care debate now where people are asking the question about unnecessary tests and unnecessary costs that don't really make us healthier? Is this an example of that?

Dr. BRAWLEY: Well, I would not say it's an example of that, but it gets close to it. Now, I actually like to talk about all the tests that we know save lives. For example, we know that mammography and clinical breast exam saves lives for women over the age of 50 and probably women over the age of 40, and we know that a substantial number, at least a third to 40 percent of women in the United States who should be getting those tests are not getting them.

INSKEEP: So you still favor tests in some cases, and breast cancer is one of those cases where you would urge women to be tested?

Dr. BRAWLEY: Yeah. We don't want to over-simplify it by saying mammography is great. We want to say mammography is a tool which in seven studies has been shown to decrease risk of death. We recommend women have mammography even though we do know that a few women are going to be treated needlessly for their breast cancer. And to prevent that from happening in the future, we need research to figure out the cancers that need to be treated versus the cancers that need to be watched.

And that message actually is true in prostate cancer as well. You know, in the United States we used to either radiate or do surgery on 85 to 90 percent of the localized prostate cancers found. There is a paradigm shift in the last year or so where many urologists are saying let's step back and let's watch you. Let's not be aggressive and treat so quickly.

INSKEEP: That must be extraordinarily hard for a patient to - because the impulse is I want this fixed. Take care of it, take care of it now.

Dr. BRAWLEY: Yes, and we in American medicine for 50 to 80 years have been preaching find it early and cut it out. And we need to refine our message. In my mind this is an ethical issue because misleading people is the absolute wrong thing to do in medicine. You really must tell people what you know, what you don't know, and label it accordingly.

INSKEEP: Dr. Otis Brawley is chief medical officer of the American Cancer Society. Thank you very much.

Dr. BRAWLEY: Thank you.

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