Will all the data against cancer screening ever reduce cancer screening?

[pathstudent]

I saw this article in Sliver's blog about how thyroid carcinoma rates have increased many fold in South Korea since they started screening for it. Yet thyroid cancer morality hadn't been changed at all.

http://fivethirtyeight.com/features/the-case-against-early-cancer-detection/

After years of mammography stage 3 and 4 breast cancer have only declined 5% yet stage 1 and 2 have about doubled. Obviously almost all of these stage 1 cancers never become stage 4 (and hence possibly cause an early death for the woman). And do we really know how much of that 5% is really due to screening?

http://www.nytimes.com/2013/04/28/m...war-on-breast-cancer.html?pagewanted=all&_r=0

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[WEBB PINKERTON]

What cracks me up is all the new thyroid tests hitting the market. Got an email about a new one just a few weeks ago. I think I read there are like 500,000 thyroid FNAs done annually in the united states. Many companies are seeing dollar signs even if the indeterminant number is 10 percent . Totally unnecessary and I doubt those tests prevent any surgeries.

Too many lawyers in this country to shut down the screening programs completely. It's sad that litigation keeps many of us in a job. The number of path specimens should be nowhere near what it currently is. We have a false market for sure and many patients are overtreated.

 

[schrute]

I love the Afirma people...they tout the benefits of avoiding the trauma and costs of surgery, which has some merit, but they heavily push the approach of having all FNAs sent to their facilities in TX, even if it's not for dx but for reflex testing in the event of an AUS/FLUS....from the pathologist standpoint that's stupid, but from the idiot endocrine people it's great--1 stop shopping, and the ability to potentially avoid situation of uncertainty.
>95% sensitivity...great--so negative test, you're probably fine.
~50% specificity...so a positive test means...what, repeat FNA?

 

[WEBB PINKERTON]

None of the ENTs in my area have any interest in the test. They own their own surgery center so they have no interest in these tests.

I was shocked to read that over 525,000 thyroid FNAs were done in 2011. Unbelievable.

 

[Amerek]

FNA screening for thyroid cancer will never go away, but it will be improved by molecular testing and, perhaps, some better cytologic criteria.

Increased diagnosis of follicular variant of PTC is responsible for much of the rise in cancer incidence. Mortality has not changed because the fact of the matter is that the majority of these lesions are non-invasive and have genetic characteristics like follicular adenomas. For decades, pathologists have been calling these cancers simply because they have PTC-like nuclear features and sometimes undergo malignant transformation.

 

[bberlioz]

Thyroid cancers are particular because they are usually detected early due to its location (clinical enlargement/nodules which are palpable on the thyroid). Thus, they are often removed at an earlier stage than other cancers, which can be one of the biases of their apparent "indolent" behavior (on top of their more benign biology).

Furthermore, the fact that PTC do in fact metastasize, if not treated in a timely manner, means that screening is worthwhile. Yes I know you need to calculate the cost-effectiveness/NNT/benefits vs risks. But in my opinion, all patients who have worrisome findings on a non-invasive thyroid ultrasound, should be offered FNA screen.

Unless you're willing to let a family member walk around with an enlarged thyroid (with possible PTC), every case of metastatic PTC is a tragedy because it is usually cured when detected early.

Finally the fact that mortality hasnt decreased much despite screening does not necessarily mean that screening isnt working. Screening is not only about disease-specific mortality but also disease-free survival which is equally important and well established in thyroid screening.

This can be applied to other forms of cancer screening. I think people are a bit quick in diminishing the role of screening, when they should carefully take the time and interpret what the data actually means.

 

[yaah]

The issue with screening is more psychological than scientific. You can give all the data you want, but the individual person is still going to base their decision on their life goals and past experiences. Lots of people "want everything done" or want to do things "just to be sure" because they don't want to be that outlier who has the fatal cancer that could have been caught early. People know about risks, but typically they underestimate risk from complications and overestimate risk from actual disease. They would rather take the 30% risk of symptoms like incontinence as opposed to the 10% risk of fatal cancer. On the other hand, some people "don't want to know" and would rather avoid screening than live through years of uncertainty. They would rather find out they have an incurable cancer and then decide how to spend their last years without hospitals being involved.

 

[pathstudent]

The issue with screening is more psychological than scientific. You can give all the data you want, but the individual person is still going to base their decision on their life goals and past experiences. Lots of people "want everything done" or want to do things "just to be sure" because they don't want to be that outlier who has the fatal cancer that could have been caught early. People know about risks, but typically they underestimate risk from complications and overestimate risk from actual disease. They would rather take the 30% risk of symptoms like incontinence as opposed to the 10% risk of fatal cancer. On the other hand, some people "don't want to know" and would rather avoid screening than live through years of uncertainty. They would rather find out they have an incurable cancer and then decide how to spend their last years without hospitals being involved.

The problem is that too many people make their living off screening and treating. Isn't our first order "do no harm". Well clearly we are harming people with our cancer "prevention". And again it really isn't clear how many deaths are truly prevented. Like it the data in the article shows, you can screen 1000 men for prostate cancer and you will prevent as few as 0 and at most 1 death. If physicians educated people, then maybe they could get over the psychologic fear of cancer. But the people that should be educating make their livings by screening and treating. It's a bad system.

Then their is the big picture question of is it worth spending 10s of millions of dollars to prevent one person from dying a few years earlier.

 

[jp123ok]

Then there is the big picture question of is it worth spending 10s of millions of dollars to prevent one person from dying a few years earlier.

I agree that there needs to be a rational discussion about how health care funds can best be spent. However, given how divisive politics is in the USA, who knows if it will ever happen. Even suggesting that health care funds should not be squandered on ineffective screening programs or on futile treatments will encourage talk of "death panels" as per Sarah Palin back in 2009.