So many screening tests, so little time to make sense of them all, never mind the ability to pay for them, or figure out if your insurance does. The American College of Physicians has decided “enough” of this lunacy of over testing , and has issued new clinical guidelines for five common types of cancer.
The recommendations for breast, prostate, colorectal, cervical and ovarian cancer are the result of the College’s High Value Care Task Force. They apply to people, according to the Los Angeles Times,“who have no signs of illness and no reason to suspect their cancer risk is higher than average.
The authors of the guidelines, released in May, said, “Cancer screening is more popular among the U.S. public and is done more frequently than in other countries.” And they weren’t boasting.
Although cancer screening makes sense for some people — indeed, can be critical for some people — as a society we do way too much. As the authors pointed out, “[L]ess-intensive screening leads to little loss in benefits and larger reductions in harms and costs.”
We are almost obsessed with cancer screening: Recent figures show that about 6 in 10 adults submitted to a colonoscopy more often than they needed to; 1 in 3 men who got a PSA test to screen for prostate cancer didn’t recall their doctor suggesting they do so; nearly 7 in 10 women who had their cervix removed during a hysterectomy still got tested for cervical cancer – that is, they were tested for an organ they no longer possessed!
As The Times story noted, “Some patients may be happy to get fewer cancer screening tests, but others may resist, the authors of the guidelines acknowledged. If so, doctors may need to help them change the way they think about screening.”
These guidelines, from the American College of Physicians, are for doctors. But patients should be familiar with them, and question any doctor who advises a screen that does not fit them:
- Doctors should encourage women to get mammograms once every two years when they are between 50 and 74 years old.
- Doctors should discuss the pros and cons (including the risk of overtreatment) of mammography with women in their 40s and order the test once every two years for patients who want it.
- Doctors should not order mammograms for women younger than 40 or older than 75.
- Doctors should not order an MRI or use another radiologic test called tomosynthesis to screen for breast cancer.
- Doctors should start an in-depth conversation about the “limited potential benefits and substantial harms” if a patient asks about getting a PSA test. The conversation should make clear that the test should be considered only for men between 50 and 69 years old.
- Doctors should order a PSA test only if a patient has thoroughly considered the benefits and harms and expressed a “clear preference for screening.”
- Doctors should never order a test for men younger than 50 or older than 69. The test also is not for men whose life expectancy is less than 10 years.
- Doctors should screen patients for colorectal cancer only if they are between 50 and 75 years old and have a life expectancy of at least 10 years.
- Doctors should offer patients one of four screening tests: a traditional colonoscopy, which should be repeated once every 10 years; a sigmoidoscopy, which should be repeated once every five years; an annual high-sensitivity fecal occult blood test (FOBT) or fecal immunochemical test (FIT); or a FOBT or FIT once every three years, plus a sigmoidoscopy once every five years.
- Tests should not be performed more frequently than necessary.
- Doctors should perform a Pap test when their female patients are 21 (but no sooner). If the results are normal, the test should be repeated once every three years.
- Doctors should reduce the screening frequency to once every five years after women turn 30, and may combine a Pap test with a human papillomavirus (HPV) test. HPV testing should not begin before a woman turns 30.
- Doctors should not perform regular screenings after a woman turns 65 if she has had all her recommended tests in the previous 10 years, and all of the results were normal.
- Doctors should not perform a manual pelvic exam to check for cervical cancer.
- Doctors should not do any kind of cervical cancer screening for women who have had their cervixes removed.
- Doctors should never screen asymptomatic, average-risk women for ovarian cancer. That means no pelvic exams, no transvaginal ultrasounds and no blood tests to check for a biomarker known as CA-125.