American College of Physicians Offers Advice on High-Value Screening in Five Cancers

Key Points

  • The American College of Physicians reviewed clinical guidelines on screening strategies in breast, cervical, colorectal, ovarian, and prostate cancers for asymptomatic, average-risk adults to provide guidance on high-value cancer care screening strategies.
  • Overly intensive, low-value screening is common. According to the study, 20% of women aged 30 to 39 received a physician recommendation for mammography, and 23% to 35% in this age group had mammography.
  • In addition, one-third of surveyed primary care physicians screen with ultrasonography and MRI as well as mammography in women not at an increased risk for breast cancer.

To provide guidance on high-value cancer care screening strategies, the American College of Physicians (ACP) recently reviewed clinical guidelines issued by various medical organizations for screening strategies in five common cancers for asymptomatic, average-risk adults. The five cancers focused on in the study include breast, cervical, colorectal, ovarian, and prostate.

In the study, high value was defined as the delivery of services providing benefits that make their harms and costs worthwhile; low-value screening strategies were defined as those that return disproportionately small health benefits for the harms and costs incurred. The study by Wilt et al is published in the Annals of Internal Medicine.

Study Methodology

The screening strategies for asymptomatic, average-risk adults for five common cancer types were evaluated by reviewing clinical guidelines and evidence synthesis from the American College of Physicians, U.S. Preventive Services Task Force, American Academy of Family Physicians, American Cancer Society, American Congress of Obstetricians and Gynecologists, American Gastroenterological Association, and the American Urological Association. To evaluate costs associated with cancer screening strategies, the study authors reviewed data from the National Cancer Institute’s Physician Data Query system, UpToDate, modeling studies from the National Cancer Institute’s Cancer Intervention and Surveillance Modeling Network, and MEDLINE for articles about the costs and resource use of cancer screening published over the last 5 years.

For each of the five cancer types, the authors listed the least intensive screening strategies that all organizations recommend—defined as high-value care—and strategies that organizations either did not recommend or recommended against—defined as low-value care. They then used the information to develop high-value care advice statements.

Advice for High-Value Cancer Screening

The American College of Physicians offers the following advice for high-value screening in asymptomatic, average-risk adults in these five cancers.

Breast Cancer

  • Clinicians should discuss the benefits and harms of screening mammography with average-risk women aged 40 to 49; and order screening with mammography every 2 years if a woman requests it.
  • Clinicians should encourage biennial mammography screening in average-risk women aged 50 to 74.
  • Clinicians should not screen average women younger than 40 or aged 75 or older for breast cancer or screen women of any age with a life expectancy of less than 10 years.
  • Clinicians should not screen average-risk women of any age for breast cancer with MRI or tomosynthesis.

Cervical Cancer

  • Clinicians should not screen average-risk women younger than 21 years for cervical cancer.
  • Clinicians should start screening average-risk women for cervical cancer at age 21 once every 3 years with cytology.
  • Clinicians should not screen average-risk women for cervical cancer with cytology more often than once every 3 years.
  • Average-risk women aged 30 to 65 should have cytology testing every 3 years or cytology and human papillomavirus (HPV) testing every 5 years.
  • Clinicians should not perform HPV testing in average-risk women younger than age 30.
  • Clinicians should not screen average-risk women of any age who have had a hysterectomy with removal of the cervix for cervical cancer.
  • Clinicians should stop screening average-risk women older than 65 years for cervical cancer who have had three consecutive negative cytology results or two consecutive negative cytology plus HPV test results within 10 years, with the most recent test done within 5 years.
  • Clinicians should not perform cervical cancer screening with a bimanual pelvic examination.

Colorectal

For average-risk adults aged 50 to 75, clinicians should encourage one of the four following strategies:

  • High-sensitivity fecal occult blood testing or fecal immunochemical test every year
  • Sigmoidoscopy every 5 years
  • Combined high-sensitivity fecal occult blood testing or fecal immunochemical test every 3 years, plus sigmoidoscopy every 5 years
  • Optical colonoscopy every 10 years

Ovarian

  • Clinicians should not screen average-risk women for ovarian cancer.

Prostate

  • Clinicians should have a one-time discussion with average-risk men aged 50 to 69 who inquire about prostate-specific antigen (PSA)-based prostate cancer screening to inform them about the limited potential benefits and substantial harms of screening for prostate cancer using the PSA test.
  • Clinicians should not screen for prostate cancer using the PSA test in average-risk men aged 50 to 69 who have not had an informed discussion and do not express a clear preference for screening.
  • Clinicians should not screen for prostate cancer using the PSA test in average-risk men younger than 50 or older than 69 or those with a life expectancy of less than 10 years.

Overly Intensive, Low-Value Screening Is Common

According to the study, overly intensive, low-value screening is common. For example, 20% of women aged 30 to 39 received a physician recommendation for mammography, 23% to 35% in this age group had mammography, and most women who have mammography have it annually. In addition, one-third of surveyed primary care physicians screen with ultrasonography and magnetic resonance imaging as well as mammography in women not at an increased risk for breast cancer.

“We advise clinicians to consider value when discussing cancer screening with their patients. Implementation of high-value strategies and avoidance of the overly intensive, low-value strategies that we outlined as widely agreed-on would increase cancer screening value,” concluded the study authors.

Timothy Wilt, MD, MPH, of the Minneapolis Veterans Affairs Health Care System and the Center for Chronic Disease Outcomes Research, Minneapolis, is the corresponding author for the Annals of Internal Medicine article.

The study authors reported no potential conflicts of interest.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.


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