Stop 'Selling' Cancer Screening, Says Critic

Publicize Harms and Benefits

Nick Mulcahy

Authors and Disclosures

\

November 22, 2011 — Medical professional organizations and cancer advocacy groups need to "refocus on educating, rather than persuading," the public about cancer screening, according to a commentary published online November 21 in the Journal of the National Cancer Institute.

Most important, public information must highlight the "harms and benefits" of cancer screening, writes Michael Edward Stefanek, PhD, associate vice president of collaborative research in the office of the vice president at Indiana University in Bloomington.
In the past 30 years, the harms of screening have been largely unmentioned as various organizations have "maintained a focus on establishing who should be screened and promoting recommendations for which age groups should be screened," he says.

Organizations have done a dismal job of accurately informing the public.

Overall, mainstream organizations have done "a dismal job of accurately informing the public" about cancer screening, he contends. "The public still lacks basic knowledge about the harms and benefits of screening."
"It is easy to 'sell' screening," writes Dr. Stefanek. "Just magnify the benefit, minimize the cost, and keep the numbers less than transparent."
"Truth and clarity" are needed now, including messages that "reflect the complexity" of screening, he argues.

This commentary is the latest declaration in the ongoing debate about cancer screening. In one of the recent exchanges, a group of experts accused some of those expressing doubts as being "antiscreening."

Shared Decision Making
Dr. Stefanek explores evidence for the harms and benefits of lung, breast, and prostate cancer screening, and concludes that the best way forward is to engage patients in "shared decision making" about screening. To do so, he advocates for the use of decision aids with patients. "Informational resources" might include "simple 1-page balance sheets or brief texts that frame the trade-off of harms and benefits in absolute terms."
Dr. Stefanek falls short of explaining just how clinicians would implement shared decision making with patients; suggestions on how to implement the reform ideas are lacking.
Other experts have observed that today's practice environment presents few incentives or support tools for clinicians and patients who prefer a discussion rather than, for example, checking a box for prostate-specific antigen (PSA) testing on a laboratory requisition form.

For shared decision making about PSA testing to take place broadly in the United States, many things are needed, Steven H. Woolf, MD, MPH, and Alex Krist, MD, MPH, from Virginia Commonwealth University in Richmond, wrote in a 2009 editorial (Arch Intern Med. 2009;169:1557-1559). Required elements include reimbursement for discussion time and tort reforms to protect clinicians who present informed choice.

Paternalistic Stance
Dr. Stefanek also suggests that paternalism is at play in the United States.
Both breast and prostate cancer screening suffer from a "similar ambiguity of evidence," he points out. However, guidelines "have typically recommended that men make informed decisions about prostate cancer screening," whereas women have been summoned to breast cancer screening. "We have unintentionally adopted a very paternalistic stance," he writes.
The sex-based difference here is in need of review, says Dr. Stefanek.
"We must...question whether our practice of summoning women to have mammograms, while providing men informed choice for prostate cancer screening, is consistent with a scientific analysis of the relative harms and benefits," he writes.
Dr. Stefanek's commentary comes after what has been, more or less, a major defeat for one cancer screening effort in the United States.

In October, the US Preventive Services Task Force (USPSTF) issued draft recommendations against routine screening for prostate cancer using the PSA test in the United States. However, the PSA story did not erupt in the media like the outrage that followed the USPSTF breast cancer screening recommendations in 2009, and there were no press statements from prominent oncology organizations. In the end, urologists seemed to be alone in their fight against the recommendation.

Public Perceptions
Professional organizations and disease advocacy groups have "spent a staggering amount of time and energy over the past several decades developing, discussing, and debating guidelines," says Dr. Stefanek.
However, he asks: What does the public really know about screening?
Research says that the public "embraces the idea of screening," but is that support for screening based on solid evidence and understanding? Dr. Stefanek thinks the answer is no.
"One study found that 73% of respondents would prefer to receive a total-body CT scan than receive $1000 in cash. They are sold on the benefits of screening and are biased toward it even in circumstances without evidence of benefit," he writes.
These misunderstandings are understandable, given the lack of balanced discussion about harms and benefits. "We know that many women overestimate their risk of breast cancer, and in scientific articles about mammography, as well as patient-oriented brochures, there is a tendency to emphasize benefits much more than harms," says Dr. Stefanek.

The American Cancer Society Web site is a good example of this imbalance, he says. It "recommends and advocates strongly for mammography," but there is "very little transparent" educational information about the harms of mammography. Similar criticisms has been made about the information on mammography provided in the United Kingdom; the outcry there has led to a review of the national screening program.

Dr. Stefanek comes up with his own take on what balanced harm/benefit information should look like.
He writes: "About 5 in every 1000 women aged 50 to 59 years will die of breast cancer over the next 10 years. Annual screening over those 10 years would reduce that number to about 4 deaths, meaning that 999 women screened for 10 years will have gained nothing, and may have been subject to as many as 50% false-positive tests, unnecessary biopsies, overdiagnosis, and overtreatment for breast cancer."

Similar suggestions for more balanced information have been made by others — notably Gilbert Welch, MD, MPH, from the Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical School, Lebanon, New Hampshire, who even designed a poster for mammography for Medscape Medical News.

Dr. Stefanek has disclosed no relevant financial relationships.

J Natl Cancer Inst. Published online November 21, 2011. Abstract