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Cancer Screening: Avoiding Too Much Of A Good Thing

PHILADELPHIA – To screen or not to screen. That is the question for average-risk adults without symptoms for five common cancers: breast, colorectal, ovarian, prostate, and cervical.

To answer that question and recommend the best screening for patients at different stages of life, the American College of Physicians (ACP) reviewed its own clinical guidelines and evidence synthesis as well as those issued by the U.S. Preventive Services Task Force, the American Academy of Family Physicians, the American Cancer Society, the American Congress of Obstetrics and Gynecology, the American Gastroenterological Association, and the American Urological Association. The results were published recently in the Annals of Internal Medicine.

"We found much common agreement on high value care screening among different organizations," said Tanveer Mir, MD, chair of ACP's Board of Regents and a member of ACP's High Value Care Task Force, which developed the review. "Our advice puts that agreement together in one convenient place for physicians and patients. Many major physician organizations are seeking to implement strategies that best optimize the known benefits and harms of cancer screenings."

"The largest harm that can result from overly intense screening is over-diagnosis and overtreatment," explained Wayne J. Riley, MD, MPH, MBA, president of the ACP.

In general, screening for the five cancers is not recommended in patients with a life expectancy under 10 years. Here is a summary of the other high-value recommendations:

  • For breast cancer, clinicians should encourage biennial mammography screening in average-risk women aged 50 to 74 years but not screen average-risk women younger than 40 years or older than 75, unless specifically requested by the patient. Magnetic resonance imaging (MRI), or tomosynthesis should not be used to screen average-risk women
  • For cervical cancer, average-risk women who still have their cervix should not be screened until 21 and then have Pap tests without HPV tests no more frequently than every three years; a combination of Pap and HPV testing might be used once every five years in average-risk women aged 30 years or older who prefer screening less often than every three years. For average-risk women older than 65, screening should end after three consecutive cytology results or two consecutive negative cytology plus HPV test results within 10 years, with the most recent test done within five years. What should not be done is HPV testing for average risk patients under 30 or screening with a bimanual pelvic examination for anyone.
  • For colorectal cancer, average risk patients 50 to 75 should be encouraged to have screening by one of four methods: fecal occult blood test (FOBT) or fecal immunochemical test (FIT) every year; sigmoidoscopy every five years, combined FOBY or FIT every three years plus sigmoidoscopy every five years, or optical colonoscopy every 10 years. Clinicians should not screen for colorectal cancer more frequently than recommended in the four strategies nor conduct interval screening with fecal testing or flexible sigmoidoscopy in adults having 10-year screening colonoscopy. No screening should be performed in average-risk adults younger than 50 years or older than 75 years.
  • For ovarian cancer, average-risk women should receive no screening.
  • For prostate cancer, average-risk men 50 to 69 should be told about the limited potential benefits and substantial harms of screening for prostate cancer using the prostate-specific antigen (PSA) test and then tested only by patient request. The PSA test should not be used in average-risk men younger than 50 or older than 69.