Enthusiasm for Cancer Screening in the United States

Abstract & Commentary

Synopsis: Most Americans believe that screening tests for cancer save lives and that it is irresponsible not to undergo recommended periodic screening. The presence of a large "market" for cancer screening may make Americans vulnerable to unproven and unnecessary testing.

Source: Schwartz LM, et al. JAMA. 2004;291:71-78.

The aim of the present investigation was to document American’s attitudes toward cancer screening using a telephone survey and a well-honed and validated inventory. The study was limited to women older than age 40 and men older than age 50 who were free of the diagnosis of cancer. Five hundred respondents were queried about 5 possible domains: general screening, colonoscopy or sigmoidoscopy, Pap smears and mammography in women, and prostate-specific antigen in men. The interviews ranged from 10 to 54 minutes.

Most adults (87%) believed that routine cancer screening was a good idea and that screening saved lives. Two-thirds would want to be tested even if nothing could be done if a cancer were discovered. Whereas 35% believed that they had had too few screening tests, only 2% felt that they had had too many. If told by a physician that they needed less frequent testing, most would overrule their physician and want to be tested. Indeed, 77 % of men would undergo PSA testing even if their physician would not advise it, and 58 % of women would want a Pap smear even if their physician said it was unnecessary. Despite the "bad press" regarding the use of mammography, most women believe it is worthwhile. Most respondents felt that it was "irresponsible" to not undergo screening, even if the age of the individual to be screened were 80 years old. More than half of the respondents had had a false-positive screening test in the past, but 98% of those were glad they had the test and were planning to undergo additional testing. After being told that a total-body CT could "look inside your body" and give a very detailed picture of internal organs and that it was quick and painless, 86% volunteered to have one for free. When offered $1000 cash in exchange for the test, most still wanted the test.

Comment by Sarah L. Berga, MD

In a recent issue, I reviewed the pros and cons of optical vs conventional colonoscopy for screening for colon cancer. I had just seen a huge billboard advertising optical colonoscopy along the highway and it had garnered my interest in the use of this new technique. Apparently, I am not alone in being interested in new ways of being screened for cancer. The present article documents just how thoroughly indoctrinated most Americans are with regard to the necessity and value of cancer screening. Apparently, for the vast majority of us, physicians or not, more screening is clearly better, regardless of cost, discomfort, false positives, and emotional distress. This is a very important and timely topic for those of us practicing obstetrics and gynecology, because a prime reason our patients see us annually is to have their Pap smear and to make sure that they are up to date on well-care screening, especially mammography. Because many patients groan at least a bit when you remind them of the need for interval screening, I was surprised to find that these protests do not actually reflect what patients truly feel and think. Indeed, as noted above, even if the physician said that screening was unnecessary, most would still want to be screened.

Is screening necessary and if so, what type and how often? While physicians and public health experts debate the topic on the basis of cost, cost per saved life, risk, false negatives, and false positives, patients think, "more is better." Indeed, they may lose faith in a physician who does not screen often or thoroughly enough. If the results of this study ring true, then the prudent physician should be certain to create a checklist to review with patients regarding screening exams. The American College of Obstetricians and Gynecologists has created a helpful pamphlet that reviews what is needed by age categories for women. In the meantime, I expect that the hype about newer and more costly methods of screening for cancer will escalate. Those who make and/or perform these tests are well aware of the appetite and market that exists. Schwartz and colleagues conclude that these attitudes make Americans vulnerable to unproven and uninterpretable testing, such as screening for "cancer genes." Physicians have an opportunity and responsibility to provide a balanced viewpoint to counter aggressive marketing.  

Dr. Berga is James Robert McCord Professor and Chair, Department of Gynecology and Obstetrics; Emory University School of Medicine, Atlanta, GA.