Guidelines for breast cancer screening, Pap smear screening, PSAs, colonoscopy, and other preventative diagnostic exams have changed over the years.

Current recommendations, based on age and gender screening, seem to fly directly in the face of long-held beliefs. New recommendations and the old standards came from legitimate and credible medical resources, but new data has led to better recommendations. What should a conscientious person do? Who is correct? Is there a difference in what is appropriate for a community as opposed to an individual?

 

Senator Daniel Patrick Moynihan once famously stated, “Everyone is entitled to their own opinion, but not their own facts.” The facts in these situations are evolving toward more evidence-based guidelines (also known as “comparative effectiveness” when applied by the government to assess the efficacy of various diagnostic tests and therapeutic procedures). And that means we will have opportunities.

 

Many experts suggest mandating evidence-based medicine, which comprises guidelines for best practices, as established by practitioners from medical outcomes research studies. This would allow more predictable results for patients because the current 40% variation in treatment for the same diagnosis would be reduced to near zero. For example, only 59% of Medicare patients with cancer receive “best practices,” according to the National Quality Forum, while only 55% of all U. S. patients receive recommended care, according to an older RAND Corporation study.

 

Let’s consider the recent controversy about breast cancer screening, and start with some facts as shared in the United States Preventive Services Task Force paper. The original 21-page paper was published in the Annals of Internal Medicine in November 2009. It is entitled, “Effects of Mammography Screening Under Different Screening Schedules: Model Estimates of Potential Benefits and Harms.”  

 

The facts in the paper are based on 20 different screening strategies involving women born in 1960 and followed from age 25. The chance of a woman having breast cancer ranges from 12% to 15% with about 3% of women dying of this disease. Various screening schedules were reviewed for their value, which in this study was defined as mortality divided by cost.

 

In the conclusion discussion from this Task Force paper, there are two goals mentioned which are notably different, and point out that the goal for an individual is different than the results for a community. Here is the exact quote:

• “If the goal of a national screening program is to reduce mortality in the most efficient manner, then programs that screen biennially from age 50 years to age 69, 74, or 79 years are among the most efficient on the basis of the ratio of benefits to the number of screening examinations. If the goal of a screening program is to efficiently maximize the number of life-years gained, then the preferred strategy would be to screen biennially starting at age 40 years. Decisions about the best starting and stopping ages depend on tolerance for false-positives results and rates of over-diagnosis.”

 

False positive and false negative results are more common in the under-50 age group, which causes the authors to argue against starting the screening too early.

 

The bottom line for mammogram screening is that the goals are different for an individual versus the community. Most individuals want everything to be done and are willing to deal with the risks of false positives. Most individuals are less concerned about the overall cost to society. But the payors, insurance companies, employers, or healthcare system taking on risk are concerned about total value, which takes into account cost and results.

 

Another controversial area that has been recently reviewed with an eye to change is the Pap smear (which was named for Dr. George Papanicolaou, who invented the test). The current recommendation from the American College of Obstetrics and Gynecology has changed to an initial cervical cancer screening at age 21 and rescreening less frequently than previously recommended—from annually to once every two years. And thereafter, every three years starting at age 30 if the woman has had three negative tests. These recommendations will result in a significant decrease in the number of women who have Pap smears each year—which, in turn, will save on healthcare costs without affecting outcomes.

 

An important exception for both mammography screening and Pap smears relates to women at risk either through family history or exposure to known carcinogenic (cancer-causing) agents such as human papillomavirus.

 

So, to update Sen. Moynihan’s comment, we now have new facts to sort out, and new opinions to be formed.

 

While that’s taking place, the bottom line for an individual is to stay informed, be diligent, and be attentive to recommended screenings. The percentage of Americans who are participating in recommended screenings is surprisingly low. It’s only about one-quarter of the 50-64 age group, according to the U. S. Centers for Disease Control and Prevention, AARP, and the American Medical Association. Equally disconcerting is a report from NORC at the University of Chicago that only 14% of all cancers are detected by routine screening. The rest are uncovered when symptoms or signs of disease are recognized by the patient or the cancer is detected accidentally during another examination.

 

Prevention and appropriate screening will both improve your quality and length of life.