Putting Cancer Screening to the Test

By MARY DUENWALD

opular methods of screening for breast cancer and prostate cancer are coming under fire. Recent studies have suggested that the techniques — including mammograms, breast self-examinations and blood tests for prostate-specific antigen, or P.S.A. — do little to improve survival rates.

Yet no other tests exist to detect the diseases, the most common forms of cancer in men and women. Doctors and their patients have been left to draw their own conclusions.

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For decades, breast self-examination and mammography were considered the first line of defense against breast cancer, which kills nearly 40,000 women each year. But in September, researchers reported the results of a 10-year study in China, which found that women who did breast self-exams found more lumps and had more biopsies on benign ones, but they did not discover actual cancers any earlier than women who did not examine themselves.

As for mammography, Danish scientists who reviewed seven large studies of mammography a year ago found the research flawed and concluded that the X-ray screening technique was ineffective in saving lives or preventing mastectomies.

The news reignited a debate in the United States over the value of mammograms for women in their 40's. Nearly six years ago, a panel of experts convened by the National Institutes of Health declared there was no evidence that the test prevented cancer deaths in women under 50.

Still, after reconsidering the issue early last winter, the United States Preventive Services Task Force, a government-financed group that issues screening guidelines, continued to recommend regular mammograms for women beginning at age 40. The American Cancer Society and various physicians' organizations followed suit.

The P.S.A. test for prostate cancer detects the disease at an early stage, but because this form of cancer is typically slow-growing, many men who have it never develop symptoms.

Prostate cancer can be deadlier in younger men. The disease kills about 30,200 men in the United States each year.

No studies have yet shown that P.S.A. tests reduce deaths from prostate cancer. Two large-scale trials are under way and are expected to report results in the next couple of years.

The American Urological Association and other physicians' organizations recommend that all men over 50 talk to their doctors about having the test annually or every other year. Black men, who have a higher risk for prostate cancer, and men whose relatives have had prostate cancer are advised to consider the test starting at age 45.

The recent news has caused many doctors and patients to revisit the recommendations. Although most say they will still follow the official guidelines, they voice increasing uncertainty about the value of existing screening techniques.

Dr. Susan L. Troyan
Breast surgeon, Beth Israel Deaconess Medical Center, Boston
I'm still having my patients get mammograms once a year when they're over 40. I'm pretty upfront with them that I don't think mammography is as good as it needs to be. But it does make a difference in a small percentage of cases, and it's still worth doing it when we have nothing else.

When it comes to breast self-examination, the data's been out there for years that it does not decrease mortality from breast cancer. What I tell women is that if you like to do a breast self-exam, because you're into knowing your body and feeling for things, go ahead. But if you don't like to do it, don't feel compelled.

Everybody will say, yeah, but so and so found their own lump. But most women who found their own cancer found it while they were showering or putting on clothes or driving. I've even had a couple patients who dreamed that they had a lump and woke up with their hands right on it.

By the time we find a tumor on regular breast self-examination, it's had more than enough time to spread. What's going to make a difference in mortality is how sensitive that tumor is to chemotherapy.

What we've really learned from re-evaluating all the studies is that we're still not finding cancers early enough.

Lillie Shockney
Breast cancer survivor, registered nurse, Johns Hopkins Breast Center, Baltimore
I'm a huge fan of mammography. My cancer was found accidentally on a mammogram. It was 10 years ago. I was 38, and I had a baseline mammogram. I had found a lump on my right breast, which ended up being a cyst.

But they found an invasive tumor in my left breast. It was just four millimeters, very tiny, and would only have been found on a mammogram. If I had waited until I was 40 to have my baseline, I probably would not be talking with you right now.

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I had no family history, no known risk factors, like smoking or early menstruation or having a first child after age 30. Seventy percent of women with breast cancer have no known risk factors.

Mammography is still at this moment in time our best weapon for early detection. I cannot imagine a woman not pursuing it.

Dr. L. L. Tad Davis
Obstetrician/gynecologist, Brookside Women's Medical Center, Austin, Tex.
The idea that breast self-examination is not worthwhile really defies logic. I've been in practice about 25 years, and I have had a number of patients who have found things themselves. In fact, I've had more people find what turns out to be breast cancer on themselves than I or other physicians have found during exams.

I still advise patients, `Get used to your own breasts, and if something changes in them, tell us.' I don't see the expense in it. And I definitely don't see any harm in it.

I think everyone agrees that a mammogram is indicated over the age of 50. I suggest mammograms every year starting at 40. If you're setting national policy, it may not seem worth the money. But if you're a patient, an annual mammogram may seem well worth the money.

Dr. Meg Durbin
Internist and pediatrician, Palo Alto (Calif.) Medical Foundation
We've known for a long time that there's no data to suggest that self breast-exam helps people live longer.

But it's heresy to say that out loud. I said it at a conference of women, and I nearly got thrown out of the room.

Having said that, there are also studies showing that 50 percent of women find their own breast cancers. So it's a great dilemma.

I don't discourage it, but I don't know that I encourage it as much as I should. Part of it is the exhaustion that comes with going over this with every single woman.

If I knew for sure that breast self-exam was known to decrease morbidity and mortality, I would probably more enthusiastically recommend it.

The data supports the idea of women over 50 having mammograms every one or two years. For women in their 40's, we say, let's talk about it. If she doesn't object, I would err on the side of doing annual mammograms.

I believe that the false positive issue is not that huge.

And though breast cancers are uncommon in women in their 40's, they are also more aggressive. You have a thicker haystack with fewer needles in it, but when you find one, it is sharp.

For men at the age when prostate screening is recommended, we say, Mr. Jones, you're now 50, and it's time to talk about the P.S.A. Read this handout, and if you want the test, call me and I'll order it.

There is very little data supporting the utility of P.S.A. tests.

The digital rectal exam has never been proven to improve morbidity or mortality either. So I think it's a matter of, maybe not quite wishful thinking, but hope that these tests will be helpful.

Again, for African-American men, we have no proof that the screening affects their mortality and morbidity. But we don't have anything else to offer.

Dr. Mark H. Ebell
Family physician, editor of The Journal of Family Practice, Athens, Ga.
I don't think teaching breast self-examination is a good use of the limited time I have with my patients. It's one of the those things where it seems like a good idea, it makes perfect sense, but it doesn't work.

I do continue to recommend mammography, starting at age 40. But if we have a patient who's at very low risk for breast cancer, based on her family history and health history, then I think it's reasonable to wait until age 50.

The biggest challenge is getting women in their 60's and early 70's to be screened, because that's where there's the clearest evidence of benefit, and you tend to have lower rates of screening.

Prostate cancer is different. It's often an indolent, slow-growing cancer, and most men who have it die with it and not of it.

There are certainly some men for whom prostate cancer is a devastating illness, and it shortens the quality and length of their life. There are also some men who are harmed by having been screened.

If you take somebody who's an otherwise healthy, happy 55-year-old or 60-year-old, and you find that they have a small area of prostate cancer, you pull out their prostate gland surgically. If in doing so, you make them impotent or incontinent or both, you've harmed their quality of life, and it may be that that cancer never would have shortened their life.

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It would have grown slowly and they would have had a heart attack at 75.

I begin with a discussion with each patient. But I normally start screening at age 50. Once someone has had two normal P.S.A.'s in a row, I'll get them every other year, because there's some pretty good evidence that that is as good at detecting cancer as doing it every year. You save money and you save worry.

John Tyson
Rancher, Virginia City, Nev.
Had I not gone in for a P.S.A. test, I wouldn't be here right now. I was diagnosed with prostate cancer seven years ago, almost right on my 50th birthday, when I went in for a regular checkup.

My P.S.A. number was 7.5. They did another one, and it came back 6.5

I chose to have a radical prostatectomy because I was young, my cancer was growing fast, and it was my best chance of survival.

As far as I'm concerned I'm 100 percent cured.

They found the cancer when it was so small; it was confined to the prostate. And I'm very happy to tell you that I've had no side effects.

Everything works. I have much to be grateful for.

Dr. John W. Coleman
Urologist, New York City
I'm recommending that my patients have a P.S.A. test when they're about 50 years old, unless they have a family history. Then it's earlier. It's basically the only test you've got. And if you do it on a yearly basis and someone is running with reasonably steady levels, and suddenly their P.S.A. jumps, it's your one opportunity to investigate before the tumor can spread.

Seventy-five percent of the time, the biopsies are coming back nonmalignant. The P.S.A. gives you a lot of false positives.

The problem is most of my patients want to know why they shouldn't be tested once every six months. I try to discourage that. Prostate cancer is not a fast-spreading tumor. I'm comfortable with once a year. Sometimes, if you tell patients to have a P.S.A. only once a year, they feel you're ignoring them. If you told someone to come back in two years, it's almost like you don't want them in your practice.

This has changed. When they started doing P.S.A. tests 10 to 12 years ago, you had a deuce of a time getting anybody to go and get a blood test. Then pharmaceutical companies began advertising it. Gradually, it took on a life of its own.

I have one fellow who is a prominent lawyer. He's had prostate cancer, but now his number is absolutely perfect. It's 0.1. But it's taken me three years to talk him out of having a monthly P.S.A.

Ronald Graham
Activities coordinator, Detroit Recreation Department
I have faith in the P.S.A. test. I'm 49, and I've had two P.S.A.'s, and both have been low. I'll have another one soon and when I'm 50, I'll start having them every year.

The risk is much higher for African-American men. It has hit close to home for me. My dad had prostate cancer, though he didn't die of it, and also several of my golfing friends. When you're 45 years old, that's when your risk is high, and that's when you have to start having the P.S.A. test.

I do outreach work on prostate cancer in the community, speaking to different churches and community groups, and just trying to bring awareness to my friends. When I tell people they need the test, they react with shock — not so much for the blood part but the exam. A male is sometimes embarrassed to have someone examine them. But I tell them, you should think about the statistics. They show that almost twice as many African-Americans as whites die from prostate cancer.

Christine Norton
Breast cancer survivor, English teacher, field coordinator for the National Breast Cancer Coalition, Cottage Grove, Minn.
I myself trusted mammography. From the time I was 40 I had a yearly mammogram. But when I was 43, I found a lump when I was taking off my bra.

It didn't show up on my mammograms, so I was told not to worry about it. Finally, the surgeon did a biopsy, and it was cancer. I was in the group of 15 to 20 percent whose tumors don't show up on mammograms.

We're not ready to get rid of mammograms now, because we have nothing to replace them with. But I think folks need to understand that for every five people who have a surgical biopsy, there are four who had it needlessly.

Some of those women think: "I'm just so happy it's over with, that's fine. I don't care that I went in for a $2,000 or $2,500 biopsy, and I was scared out of my mind." But we're putting a lot of women and a lot of families through this incredible worry.

People need to become activists and press for something that's better than mammography.