Posts Tagged ‘guidelines’

Breast Cancer Screening- Does Screen Save Lives?

December 1, 2013

In 2013 there will be nearly 250,000 new cases of breast cancer and 40,000 deaths from breast cancer. Now there is a move to decrease screening for this most common cancer in women. This blog will discuss the guidelines from the Task Force on Preventive Healthcare.

Summary of the task force guidelines. Women 50-69 years of age should have mammograms every 2-3 years instead of every year. Women under 50 should not have mammograms. Clinical examinations by a doctor and breast self-exams have no benefit. Routine screening with MRI scans is not recommended.

These guidelines do not apply to women at high risk. These are women with a family history of breast cancer. Also includes women who test positive for the BRCA gene 1 or 2.

Self-examination has been the suggestion for women for decades. Experts say it is not a good idea.

Screening for women is not the lifesaver it was once thought to be. The task force looked at 2100 women between 40 and 59 years of age would have to be screened every 2-3 years for an eleven year period to prevent one breast cancer death. This suggests a very small benefit over a very large number of screenings. The task force even pointed out that screenings more do more harm than good. Nearly 700 of the 2100 women would have had a false mammogram requiring further imaging. 75 of these 700 women would have a biopsy just to confirm that they do not have breast cancer and at least 10 women would have part or all of their breast removed. This does not include all the anxiety that surrounds a positive mammogram and the waiting and discomfort associated with the biopsy.

What’s my advice? Certainly if a woman is in the high-risk group, mammography and screening is imperative. Women should have a discussion with their doctor and make an informed decision and weight the risks vs. the benefits of screening. This is not a doctor only decision it is a doctor-patient decision. Patients who become informed and have a discussion with their doctor will be the ones that make the best decision. Finally, I am not agreement with the recommendation on the breast self-exam. I still believe this a low cost valuable test that can detect small lesion in the breast before they become clinically relevant.

My next blog will discuss the guidelines on prostate cancer screening.

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Screening For Prostate Cancer-New Guidelines and One Doctor’s Advice

May 10, 2013

Prostate cancer is the most commonly diagnosed non–skin cancer among U.S. men. It can be life-threatening, and many men have cancer without knowing it. For those reasons, doctors sometimes look for prostate cancer in healthy men (screen for cancer) by measuring blood levels of prostate-specific antigen (PSA), a protein secreted by the prostate gland. High PSA levels can be caused by cancer and may lead a doctor to take a sample of prostate tissue to see whether cancer is present (biopsy). Most prostate cancer grows very slowly, however, and many men with prostate cancer die of other causes. Neither PSA testing nor prostate biopsy tells doctors with certainty which cases of prostate cancer are threatening and which require treatment. As a result, many men with slow-growing cancer have biopsies and treatment after PSA testing that they would not have needed if doctors had never tested them.

The value of the PSA test has recently come into question, however, with several studies suggesting it causes men more harm than good — spotting too many slow-growing tumors that, especially in older patients, may never lead to serious illness or death. In 2012, the U.S. Preventive Services Task Force, an influential government-appointed panel, advised against any routine use of the PSA test for prostate cancer in all men.

Since most urologists consider the Task Force’s guidelines and global ban on PSA testing far too stringent For that reason, a group of experts at the recent 2013 American Urologic Association’s annual meeting in San Diego recently recommended against annual testing and prostate biopsies at certain PSA levels, usually a level greater than 4.0ng\ml. It is possible that using the PSA test differently (for example, by testing less often) would still be useful but reduce the harms of unnecessary treatment such as urinary incontinence and erectile dysfunction that come from more frequent testing.

What are the new AUA recommendations? There are several ways of using the PSA test to help men make the diagnosis of prostate cancer while reducing the harms of testing. The first way is to stop screening after age 70 years because men older than 70 years tend to have higher PSA levels without having prostate cancer, or if they have cancer, it is usually the slow-growing variety and does not result in a cause of older men’s mortality. Another way to use the new guidelines included measuring PSA levels less frequently such as every two years in men whose levels are normal especially when the initial PSA levels are less than 1.0ng\ml. Finally, the doctor caring for older men might recommend that they have higher levels of PSA before recommending a biopsy and possible unnecessary treatment.

It is hoped that the new recommendations by the American Urologic Association will result in more personalized health management where discussions will take place between doctor and patient and where the risk of having prostate cancer and the age of the man are balanced against the value of screening.
The new AUA guidelines are more nuanced. The group does recommend against the PSA test for men under age 40 or for those aged 40 to 54 at average risk for prostate cancer.

The AUA says, however, that men aged 55 to 69 should talk to their doctors about the risks and benefits of PSA screening and make a decision based on their personal values and preferences.

Routine PSA screening is not recommended for men over age 70 or any man with less than a 10- to 15-year life expectancy.

The best evidence of benefit from PSA screening was among men aged 55 to 69 screened every two to four years. In this group, PSA testing was found to prevent one death a decade for every 1,000 men screened. The guidelines also said PSA screening could benefit men in other age groups who are at higher risk of prostate cancer due to factors such as race, i.e., African American men and men with family history of prostate cancer. These men should discuss their risk with a doctor and assess the benefits and potential harms of PSA testing.

Bottom Line: What do I recommend that you tell patients? I agree with the guidelines that men over age 70 probably do not need to be tested. Also men younger than age 50 do not need to be tested. The exception is African American men and men with a family history of prostate cancer. I would not test a man with multiple chronic conditions, which would decrease his life expectancy to less than 10 years. I would also suggest that men with very low PSA levels, i.e., less than 1.0ng\ml, be tested every two years.

Finally, the discussions between a patient and his doctor on the PSA test are extremely important. I suggest you ask the man if he gets a PSA test, would he submit to a prostate biopsy and if he has prostate cancer would he accept treatment for the condition? If the answer is no, then I would document this in the chart and not obtain the test.