Yes, cancer screening is one of the strategies that has saved lives, but maybe the pendulum swung too far on the other end, where we start realizing that there are harms of each and every one of these tests.
—Amir Qaseem, MD, PhD, MHA, FACP
Finding agreement on high-value cancer screening among organizations publishing screening guidelines, the American College of Physicians (ACP) issued advice listing the least-intensive screening strategies that all the organizations recommend—as well as strategies not recommended—for five common cancers: breast, colorectal, ovarian, cervical, and prostate. Publishing the advice in the Annals of Internal Medicine, the ACP High Value Care Task Force stressed that the advice applied to asymptomatic adults at average risk for the five cancers.1
The report has received national media attention, including CBS News, the Los Angeles Times, AP, and Reuters, and generated interest among its target audience of clinicians. “It has only recently been published, but generally we have received very positive feedback,” one of the paper’s lead authors, Amir Qaseem, MD, PhD, MHA, FACP, told The ASCO Post. “All these recommendations that we have summarized in this paper are evidence-based clinical recommendations from reputable guideline groups. So it is not a surprise that everyone is in agreement,” added Dr. Qaseem, Director of Clinical Policy of the ACP and President Emeritus of Guidelines International Network.
“There is no doubt that screening is one of the strategies to reduce cancer deaths. No one is arguing that. The issue that people have started to come to realize is that more intensive screening does not result in any additional reduction in cancer deaths but increases the harm. As intensity increases beyond a certain level, the increase in benefits is not really there, but the harms keep on going up, and, hence, the value of any kind of screening test starts going down,” Dr. Qaseem stated. “We wanted to focus on appropriate screening, to do the high-value screening and avoid the low-value screening. That is what we tried to clarify in this paper.”
Review of Guidelines and Evidence
The ACP High Value Care Task Force based its advice on a review of clinical guidelines and evidence synthesis from the ACP, U.S. Preventive Services Task Force, American Cancer Society, American Academy of Family Physicians, American Congress of Obstetricians and Gynecologists, American Urological Association, and American Gastroenterological Association.
Strictly defined, a guideline is “a systematic review of evidence,” Dr. Qaseem noted. The ACP Task Force did not review primary literature or evidence because that had already been done by those organizations. “What we tried to do was essentially look at the guidelines that are already out there and identify areas of agreement, and there are plenty of areas of agreement, across most of these organizations,” Dr. Qaseem said.
Areas of Common Agreement
Breast Cancer: The review of guidelines from all the organizations cited previously found that “all groups recommend mammography screening, or discussions about screening, at least every 2 years for women aged 40 to 74 years,” the ACP Task Force noted. “No group recommends regular systematic magnetic resonance imaging (MRI) or tomosynthesis screening for average-risk women.”
Colorectal Cancer: “All organizations recommend screening persons aged 50 to 75 years with one of four strategies,” the ACP Task Force noted. These strategies are high-sensitivity fecal occult blood test or fecal immunochemical test every year, sigmoidoscopy every 5 years; combined high-sensitivity fecal occult blood test or fecal immunochemical test every 3 years plus sigmoidoscopy every 5 years; or optical colonoscopy every 10 years.
Ovarian Cancer: “All organizations recommend against pelvic examinations, cancer antigen 125 blood tests, and transvaginal ultrasonography for ovarian cancer screening.”
Cervical Cancer: “All organizations recommend starting screening with cytology without human papillomavirus (HPV) tests every 3 years at age 21 years, regardless of sexual history. At age 30 years, women have the choice of continuing cytology screening every 3 years or cotesting with cytology plus HPV testing every 5 years. Do not screen in women who had a hysterectomy and the cervix was removed.”
Prostate Cancer: “No organization recommends prostate-specific antigen (PSA) testing for prostate cancer screening without a discussion of the benefits and harms and a patient’s expressed, clear preference for screening.”
It’s Not Just About the Money
As defined by ACP, “value is determined by an intervention’s health benefits vs its harms and costs,” the Task Force wrote. “High-value strategies return large health benefits for the harms and costs incurred; low-value strategies return disproportionately small benefits for the harms and costs. Although high-intensity strategies aim to maximize cancer detection, value is optimized by finding the level of intensity that best balances benefits with harms and costs.”
The authors searched databases, models of screening effectiveness, and national studies for information on costs, but that was just one factor and not a major focus in formulating the screening advice. “We need to differentiate between this value and costs,” Dr. Qaseem said, so that the screening advice is not misinterpreted merely as a means to save money. “A cheap test can actually still be a low-value test. And an expensive test actually can still be of high value.”
‘A Classic Example’
“Screening average-risk adults aged 50 to 75 for colorectal cancer with a high-sensitivity fecal occult blood test every year is an example of high-value care. Screening women without a cervix for cervical cancer is an example of low-value care,” according to an ACP press release announcing the publication of the screening advice.2 And according to the published article, “Nearly 70% of women without a cervix received a Pap test for cervical cancer screening in 2002.”3
Really? “Yes, it still happens. Dr. Qaseem confirmed. “The Pap test is one of those tests that is being overused for sure. It’s a classic example. Just a simple Pap test is actually a low-cost test. But it still is of low value if you are going to do it on an annual basis.”
Screening Is Popular
“Regardless of value, cancer screening is popular among the U.S. public and is done more frequently than in other countries,” the article pointed out. Among adults receiving colonoscopies, 60% had them more frequently than guidelines recommend, “and screening often occurs in adults with life expectancies of 5 years or less,” the authors reported. “Most persons having PSA testing received annual cancer screening, and one-half of men aged 75 to 79 years had recent screening,” the authors added. Overall, more than 50% of men and women older than 75 years report that their physicians continue to recommend screening, according to the article.
The ACP Task Force found “20% of women aged 30 to 39 years received a physician recommendation for mammography, and 23% to 35% in this age group had mammography. Most women having mammography receive it annually. One-third of surveyed primary care physicians screen with ultrasonography and MRI, in addition to mammography, in women not at increased risk for breast cancer.” Not only is cervical cancer screening “commonly done earlier and more frequently than recommended,” but it continues to be done in 38% of women aged 80 years or older.”
‘Perfect Storm of Overuse’
In a companion article4 outlining a framework for thinking about the value of varying intensities of cancer screening, the ACP Task Force noted: “Physicians and patients are under great pressure from many sources to use the ‘maximal cancer detection’ framework rather than the value framework.”
Factors that could contribute to this pressure include a lack of knowledge or understanding of the harms of screening, fear of cancer, belief that earlier detection is always better, media messages about screening, stories of survivors, belief that action is better than inaction, and intolerance of uncertainty. “The relative importance of these factors in stimulating the use of overly intensive low-value screening strategies is underinvestigated and largely unknown,” the authors acknowledged. “However, many factors seem to encourage this practice, creating what has been described as a ‘perfect storm’ of overuse.”
‘Cascade of Events’
“Screening is a cascade of events rather than a single test,” the ACP Task Force members noted in the companion article.
“Absolutely,” Dr. Qaseem resolutely concurred. “Because once you do the test and you find something, it always leads to the next test. You never just leave it at that. It just does not happen. Once you find something, it is going to lead to more tests, more biopsies. Once you are in that cycle, it gets very difficult to get out.”
Freeing Up Time and Money
Reducing the intensity of screening would not only reduce the harms associated with it, but “the other benefit is that you are going to spend time talking about other services that might provide higher value,” Dr. Qaseem said. “So in the 10 to 15 minutes you have to sit down and to talk to patients, rather than talking about something that might not provide much benefit, you can spend time discussing things that actually might have much added value. It could be about exercise. It could be about their cholesterol. It could be about their hypertension.”
Moving to the value approach to screening could redirect funds to increase screening among disadvantaged groups, people for whom screening is not popular because they haven’t been able to afford health care. If funds were so redirected, Dr. Qaseem said that he hoped it would be for screening based on the ACP advice and not past practices.
“Hopefully, funds will be directed to the right place, where we need the money, to the uninsured, or the folks who may not have enough, the underserved population.” He cited the example of colorectal cancer, for which high-value screening is available, but it currently is not being used in many average-risk, asymptomatic adults. “We are not even screening the people who should be screened, and on the other hand, we are actually overscreening people who are already in the system,” Dr. Qaseem said.
Understanding of Concepts Increasing
At the conclusion of the value framework article, the authors noted, “There is reason to believe that understanding of these concepts is increasing.” They credit campaigns to increase professional and public awareness of overly intensive low-value screening, as well as articles and books about screening harms and costs.
In addition to publishing and publicizing the high-value screening advice, ACP is sponsoring education programs in several formats for physicians. A summary of the screening advice for patients also is available at acponline.org.
“Slowly, definitely, things are changing,” Dr. Qaseem said. “It comes back to how the message is being conveyed. Yes, cancer screening is one of the strategies that has saved lives, but maybe the pendulum swung too far on the other end, where we start realizing that there are harms of each and every one of these tests.” ■
Disclosure: Dr. Qaseem reported no potential conflicts of interest.
1. Wilt TJ, Harris RP, Qaseem A, for the High Value Care Task Force of the American College of Physicians: Screening for cancer: Advice for high-value care from the American College of Physicians. Ann Intern Med 162:718-725, 2015.
2. American College of Physicians: American College of Physicians releases high value care screening advice for five common cancers. May 18, 2015. Available at http://www.eurekalert.org/pub_releases/2015-05/acop-arh051215.php. Accessed June 11, 2015.
3. Sirovich BE, Welch HG: Cervical cancer screening among women without a cervix. JAMA 291:2990-2993, 2004.
4. Harris RP, Wilt TJ, Qaseem A, for the High Value Care Task Force of the American College of Physicians: A value framework for cancer screening: Advice for high-value care from the American College of Physicians. Ann Intern Med 162:712-717, 2015.
Issuing advice for high-value care in screening for five common cancers, the High Value Care Task Force of the American College of Physicians (ACP) stated: “The target audience for this paper is all clinicians. The target patient population is average-risk, asymptomatic patients.”
“What we tried...