Late last month, a New York Times article about cancer screening started a media firestorm when it quoted an American Cancer Society (ACS) spokesperson saying they’d overstated the benefits of detecting many cancers with screenings. Now two of the most reliable screenings—Pap smears for cervical cancer and colonscopies for colon cancer—may be reason for continuing the debate over screening.
It all began in late October when the lengthy New York Times piece quoted Dr. Otis Brawley, chief medical officer for ACS, saying the organization was working on an official statement for their website, cancer.org, for early next year about breast and prostate screenings.
“We don't want people to panic,”' said Brawley, “But I'm admitting that American medicine has overpromised when it comes to screening. The advantages to screening have been exaggerated.”
The firestorm’s kindling was an analysis in that week’s Journal of American Medical Association in which authors outlined flaws in the current screening systems and called for new approaches.
The study’s lead author, Laura Esserman, MD, a breast cancer surgeon at the University of California San Franscisco Medical Center said, “Screening has value, but we need to understand what it can and cannot do. Part of the problem is that we’ve been too worried about keeping the message simple.”
Following the NYT’s piece, ACS CEO, Dr. John Seffrin, posted this mesage on the organizations web site attempting to ease public confusion about cancer screenings. He wrote: “We encourage women at average risk to get mammograms at age 40, to get Pap tests as soon as they are sexually active or no later than age 21, and both men and women at average risk to get screened for colon cancer starting at age 50.”
However, the organization’s message may have been the same overly simplistic messaging Esserman commented on in the first place, which the NYT wasn’t about to leave alone. This time Denise Grady took on the gray areas surrounding mammograms. She interviewed a handful of leading breast cancer experts, many of whom agreed that, “despite the cancer society’s guidelines, evidence was lacking for a benefit in screening women 40 to 50.”
Then last week, Pap smears, the screening test for cervical cancer, were called into questioning when a new study in the Annual of Internal Medicine, found doctors routinely perform many unnecessarily, ignoring guidelines from leading cancer organizations, including ACS.
If the public wasn’t thoroughly confused about screening by now and their confidence wavering, yet another screening study made headlines adding to the mix. It revealed colonoscopies are a weak link in preventing colon cancer. This time, however it isn’t so much the screening that’s faulty, but the health provider at the other end of the scope.
The study appearing in this month’s shows how effective your colonoscopy is depends on the time of day it’s delivered.
Researchers at the University of California, Los Angeles studied 477 patients undergoing routine colonoscopies and found that early morning procedures yielded 27% more polyps per patient that those perform later in the day.
Of interest, the authors mention early-morning bowel preps, (before 8:30 a.m.) tend to be more complete than those done later in the day, which may skew the final study outcome, however, they say much more emphasis was placed on their initial hypothesis of “provider fatigue” in which endoscopists simply get tired during the day and end up missing more polyps. The authors pointed their collective finger at the repetitive nature of the work, liking it to other professions with similar fatigue issues.
“Although individual patient risk is very low, multiplying this effect by thousands of patients across the United States could mean we're missing lots of polyps, some of which might turn into cancer one day," said Brennan Spiegel, MD, a digestive disease expert and one of the study authors in a news release. “More research needs to be done at a wide range of centers to pinpoint why there's a decrease in the number of polyps found later in the day and to identify ways we might improve outcomes”.
On his blog, Dr. Len Lichtenfeld, Deputy Chief Medical Officer for ACS wrote about the screening controversy of late. “As noted in the New York Times article, when the public gets a mixed message it takes that as a reason not to move forward with the most effective breast cancer screening modality we have available today. We do need better screening techniques …The sad part is that the women in this country may only read the New York Times, and leave it at that. They will miss the nuances of the experts’ arguments. They will not read the conclusions of the JAMA study, and if they do they probably won’t have the working knowledge that would put it in context. Hopefully they won’t miss the nuances that could impact their lives. That would be a tragedy.”
Esserman candidly summed up the current screening debate this way: “ We’ve done some good; we’ve done some harm; and we need to make screening better.”
Lynette Summerill, is an award-winning journalist who lives in Scottsdale, Arizona. In addition to writing about cancer-related issues, she writes a blog, Nonsmoking Nation, which follows global tobacco news and events.
Sources: Cost-Effectiveness of Human Papillomavirus Vaccination and Cervical Cancer Screening in Women Older Than 30 Years in the United States.
Jane J. Kim, Jesse Ortendahl,and Sue J. Goldie. Ann Intern Med October 20, 2009 151:538-545.
Fewer Polyps Detected by Colonoscopy as the Day Progresses at a Veteran's Administration Teaching Hospital. Michael Y. Chan, Hartley Cohen, Brennan M.R. Spiegel.Clinical Gastroenterology and Hepatology - November 2009 (Vol. 7, Issue 11, Pages 1217-1223, DOI: 10.1016/j.cgh.2009.07.013