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ACP Issues ‘High-Value’ Cancer Screening Advice
The American College of Physicians (ACP) has issued advice for screening average-risk adults without symptoms for five common cancers: breast, colorectal, ovarian, prostate, and cervical. The suggestions appeared in the May 19 issue of the Annals of Internal Medicine.
In a companion piece published in the Annals, the ACP also outlined a framework for thinking about the value of varying intensities of cancer screening.
“ACP wants smarter screening by informing people about the benefits and harms of screening and encouraging them to get screened at the right time, at the right interval, with the right test,” said Dr. Wayne J. Riley, president of the ACP. “Many people have a lack of understanding about the trade-offs of screening. Study after study has consistently shown that patients and many physicians overestimate the benefits and are unaware of and/or downplay the potential harms of cancer screening.”
The ACP reviewed clinical guidelines and evidence syntheses 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, the American Urological Association, and the ACP.
“We found much common agreement on high-value care screening among different organizations,” said Dr. Tanveer Mir, a member of the ACP’s High-Value Care Task Force, which developed the papers. “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.”
Various screening strategies exist for each of the cancers highlighted in the paper. High-intensity screening strategies (i.e., screening broader populations, more frequently, and/or with more-sensitive screening tests) are not necessarily high-value care. The ACP defines high-value care as the delivery of services providing benefits that make their harms and costs worthwhile. The ACP encourages physicians to implement a health care strategy that focuses on tests or treatments that improve health, avoid harms, and eliminate wasteful practices.
Screening average-risk adults aged 50 to 75 years for colorectal cancer with high-sensitivity fecal occult blood testing every year is an example of high-value care. Screening women without a cervix for cervical cancer is an example of low-value care.
“The largest harm that can result from overly intense screening is over-diagnosis and overtreatment,” Riley said. “The more sensitive the test we use or the lower the threshold we establish for an abnormality, the more abnormalities we find –– many of which will never lead to health problems. But because doctors cannot know which of these would or would not cause problems, we tend to treat them. Treatment for cell and tissue abnormalities that will likely not cause health problems cannot provide benefits.”
Prostate cancer, for example, detected with the prostate-specific antigen (PSA) test never becomes clinically significant in a patient’s lifetime in a considerable proportion of men. Screening using the PSA test in average-risk men under the age of 50 years or over the age of 69 years can open the door to more testing and treatment that might actually be harmful. If cancer is diagnosed, it will often be treated with surgery or radiation, which increases the risk for the loss of sexual function and the loss of control of urination compared with no surgery. This does not apply to men considered to be in high-risk groups, such as African-American men and/or those with a family history of prostate cancer.
The ACP’s advice applies to adults without symptoms who are at average risk.
In its companion paper, the ACP speculates about pressures that encourage overly intensive low-value screening. The paper lists and discusses five general concepts:
- Screening is a cascade of events rather than a single test.
- Cancers are heterogeneous. Optimal-intensity screening strategies seek to find the subset of abnormalities that has the greatest probability of progressing to cause health problems and that is more treatable at an early, asymptomatic stage.
- Individuals are heterogeneous. Optimal-intensity screening strategies focus on people with a sufficient risk of having a potentially fatal cancer who also have low competing health risks from other causes.
- Although screening leads to important benefits for some cancers and some people, it can also lead to significant harms for many more people than those receiving benefits.
- Determining the value of screening strategies is complex but not impossible.