Physicians Push to Increase Awareness of Cancer Overdiagnosis and Overtreatment

Several prominent physicians are pushing to increase physician awareness of cancer overdiagnosis and overtreatment.

In a recent article, 3 oncologists outlined recommendations made at a March 2012 expert meeting convened by the National Cancer Institute to evaluate ways of reducing treatment or intervention for indolent disease (Esserman LJ, et al. JAMA.2013;310:797-798.).

The trio penned the “Viewpoint” article to highlight the fact that conditions such as Barrett’s esophagus, ductal carcinoma in situ (DCIS) in the breast, and stand-alone rising prostate-specific antigen (PSA) are often aggressively treated when the evidence—and at least 2 sets of clinical guidelines—indicates that delayed and/or less frequent screening, coupled with less intervention for findings that are likely to represent indolent conditions, may produce similar outcomes.

“Although no physician has the intention to overtreat or over-diagnose cancer, screening and patient awareness have increased the chance of identifying a spectrum of cancers, some of which are not life-threatening,” the authors cautioned in their paper.

Laura J. Esserman, MD, Director of the Carol Franc Buck Breast Care Center, University of California San Francisco, and lead author, emphasized this message in a telephone interview with Oncology Practice Management. She was reflecting her views as well as those of the 2 other authors, Ian M. Thompson, Jr, MD, Glenda and Gary Woods Distinguished Chair in Genitourinary Oncology at The University of Texas Health Science Center at San Antonio, and Brian J. Reid, MD, PhD, at the Fred Hutchinson Cancer Research Center, Seattle, Washington.

“Words matter—the word cancer strikes fear in people’s hearts, and we want to make sure that we have the ability to make people aware that, for some conditions, less treatment is the right treatment,” said Dr Esserman. “In some cases, there should be a change in words that we use to describe the condition—with the word cancer being reserved for lesions with a reasonable likelihood of lethal progression if left untreated—and in other cases, we have the opportunity to do less screening and treatment, safely.”

Task Force Led the Way
The United States Preventive Services Task Force (USPSTF) was one of the first large American organizations to point out that screening only women at risk for breast cancer—and also once every 2 years rather than annually—is associated with similar outcomes to more frequent screening. It also is associated with reduced biopsy rates, and potentially less overdiagnosis and overtreatment.

The members of the group re­­viewed the evidence to arrive at their 2009 recommendations (Ann Intern Med. 2009;151:716-726). They determined that the harms of routine breast cancer screening before age 50 years and after age 75 years outweigh the benefits. The harms include anxiety and unnecessary biopsies in the face of results that turn out to be false positives, and treatment of conditions that would not become clinically apparent during a woman’s lifetime.

Based on the weight of scientific evidence, they also recommended that routine screening mammography should not be carried out in most women aged 40 to 49 years without a conversation about risk and benefit, except when individual women at higher risk and their physicians agree it would be beneficial.

USPSTF members also recommended that mammography be carried out only every other year in women aged 50 to 74 years. They further recommended against teaching women how to perform breast self-examination.

These recommendations continue to draw strong criticism from groups such as the American College of Radiology.

As a result, physicians have been slow to act on the USPSTF’s message—as shown, for example, by a recently published paper indicating mammography rates did no decrease among women aged 40 years and older between 2008 and 2011 (Pace LE, et al. Cancer. 2013;119:2518-2523).

Nancy Keating, MD, MPH, Associate Professor of Medicine at Brigham and Women’s Hospital, Boston, Massachusetts, led the mammography rates study. She said mammography rates may have dropped somewhat since 2011, but that physicians and patients still need to be warned of the significant dangers of detecting and treating lesions that are not harmful.

“Millions of women have been diagnosed with DCIS, a precancerous lesion that is typically treated aggressively, and now consider themselves to be cancer survivors—when they never even had cancer in the first place,” Dr Keating told Oncology Practice Management. “The USPSTF team didn’t focus on overdiagnosis but rather focused on other harms, such as anxiety. But a lot of patients aren’t that concerned about anxiety—rather, when we say, ‘We may remove your breast for something that may not harm you’—that’s a bigger deal.”

She said the onus is on individual physicians to communicate to patients the benefits and harms of screening in a way that’s clear and understandable. This is one of the other main points brought out by Dr Esserman and her coauthors.

“Physicians, patients, and the general public must recognize that overdiagnosis is common and occurs more frequently with [routine] cancer screening,” particularly with breast, prostate, lung, and thyroid cancers, they state. “Strategies to reduce detection of indolent disease include reducing low-yield diagnostic evaluations appropriately, reducing the frequency of screening exams, focusing screening on high-risk groups, and raising the threshold for recall and biopsy.”

In addition, they call for the creation of observational registries for low-malignant-potential lesions, to help develop the knowledge base and technologies needed to accurately discriminate between dangerous and non–life-threatening lesions.

AUA Following Suit
It is now well known that many of the prostate lesions flagged by increased PSA levels alone are slow- growing and indolent. Because millions of men have been overtested and overtreated when watchful waiting would have sufficed, the American Urological Association (AUA) issued new prostate cancer screening guidelines for asymptomatic, average-risk men earlier this year (http://www.auanet.org/education/guidelines/prostate-cancer-detec tion.cfm).

The organization now recommends against routine PSA testing in average-risk men who are either under age 55 years or over age 70 years. Furthermore, the association recommends that men aged 55 to 69 years should talk to their doctors before deciding whether to undergo PSA testing and, if they opt to go ahead, to have the test every 2 years rather than annually.

“Routine screening has resulted in unnecessary treatment in our country, because diagnosis always leads to treatment, and we need to find a way to reduce that using a more targeted screening approach,” AUA guideline panel chair H. Ballentine Carter, MD, Professor of Urology and Oncology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, told Oncology Practice Management. “We also need to be more circumspect about who does and does not get treated once an anomaly is detected. And I think there’s a paucity of information about whether the new tissue-marker tests are beneficial—we’re trigger-happy in terms of marketing such tests when there’s no absolute proof of benefit.”

Dr Esserman and her colleagues applaud the AUA’s initiative.

“Other groups can follow the process ignited by the leadership in the field of urology for how to delineate and test, and for less-aggressive options for patients with very low-risk lesions,” she said.

ASCO Weighs In
Richard L. Schilsky, MD, Chief Medical Officer of the American Society of Clinical Oncology (ASCO), responded to a request for comment from Oncology Practice Management acknowledging the views on both sides of this issue.

Dr Schilsky said ASCO believes Dr Esserman and her colleagues’ objectives are “laudable” but that patients need to be reassured that early detection is still critically important.

“We do not yet have the ability to say which screen-detected cancers will be indolent, or slow-growing, and which will be aggressive. Until we have better ways of predicting the behavior of these ‘indolent’ tumors, we should continue to treat them as indicated by the results of clinical trials in order to prevent spread, recurrence, or death,” Dr Schilsky noted.

He added that changing the established nomenclature is premature, but that “we urge further research on these issues, and careful analyses and collaboration throughout the oncology community. ASCO welcomes any opportunity to participate in this vitally impor­tant discussion.”

Dr Esserman and her colleagues agree. “Research and evidence are key to quality cancer care. Learning when to do less safely is as impor­tant as learning when and how to do more—that is how we can improve the quality of life of those diagnosed with cancer,” Dr Esserman told Oncology Practice Management. “We don’t want to forego the opportunity to continue to push forward to reduce the physical and mental toll of unnecessary screening and treatment. I think we can all agree that is a laudable goal—and one that is achievable if we work together.”

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