A value framework for cancer screening

The American College of Physicians (ACP) is advising clinicians to take a smart, judicious approach in screening asymptomatic adults for colorectal, ovarian, breast, cervical, and prostate cancers.

Cancer is the cause of one in four deaths in the United States. Compared to other nations, the U.S. medical system invests a great deal in cancer screening, but according to ACP, not all of its screening practices yield high-value returns. Clinicians in many instances are overusing these screening methods, which can result in overdiagnosis, overtreatment, unnecessary costs, and stress to patients.

ACP issued specific “high value care advice” on these five common cancers in an article that appeared in the Annals of Internal Medicine.

“A screening program is considered low value when persons in whom the benefits clearly outweigh the harms and costs are not being screened intensively enough or when persons are being screened overly intensively,” the article stated.

ACP drew upon its own clinical guidelines and evidence syntheses, in addition to 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, to issue these screening strategies for common cancers.

“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 ACP President Wayne J. Riley, MD, in a statement. “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.”

Improving cancer screening requires increasing high-value screening in patients who have adequate access to care, while decreasing the use of low-value screening strategies to all populations, regardless of whether they have adequate access, ACP advised.

As an example, ACP cautioned against screening average-risk women younger than age 21 for cervical cancer, in addition to average-risk women who are older than 65. This is provided that these older women have had three consecutive negative cytology results or two consecutive negative cytology plus human papillomavirus test results within the last decade, “with the most recent test done within 5 years,” wrote the authors.

ACP generally recommended a reduction in the screening frequency for cervical cancer from every year to every 3 to 5 years. All of the recommendations address the concern “that more intensive screening would lead to few benefits but many more harms, including increased psychological and physical complications from colposcopy follow-up of false-positive screening test results, overdiagnosis, overtreatment, and higher costs,” according to the article.

Similarly, ACP’s research concluded that there is no need to screen for prostate cancer screening using the prostate-specific antigen test (PSA) for average-risk men younger than age 50 or older than 69 or those expected to live less than 10 years.

For many men, prostate cancer detected by PSA never becomes a clinically significant problem. ACP in its statement indicated that “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 loss of sexual function and loss of control of urination compared to no surgery.”

ACP also advised against colorectal cancer screening in average-risk adults younger than 50 or older than 75 or those expected to live fewer than 10 years, and ovarian cancer screening for average-risk women.

In a companion piece, ACP explored the pressures that patients and physicians face in selecting high-intensity, low-value screening methods, and explains the rationale behind value-based screening.

The article made the point that both cancers and individuals are heterogeneous, and may not neatly fit into the categories of optimal-intensity screening strategies. Such strategies tend to focus on cancer abnormalities that are the most aggressive but also the most treatable when found at the asymptomatic stage, and on people with a high risk of developing potentially fatal cancer but who otherwise don’t have major health concerns to compete with the cancer.

“Overdiagnosis is due to detection of not only slowly progressive cancer but also any type of cancer in patients with serious noncancer health risks that will end their life before the cancer becomes symptomatic,” the article stated. As an example, a woman in her 50s whose breast cancer is detected early through screening might not reap any benefit at all if she suffers from life-threatening noncancer risks such as end-stage renal disease, cirrhosis, or severe diabetes.

There’s no easy path toward assessing the value of cancer screening strategies, but it’s not impossible, ACP contended. “The exact strategy that optimizes value may vary among individual patients and groups.”