CANCER SCREENING IS LOOSING LUSTER

He observed that, in the United States, CRC screening is being used in many older patients with negligible benefit.

That is a problem with cancer screening in general in the United States, according to a large population-based study alsopublished online August 18 in JAMA Internal Medicine, as reported by Medscape Medical News.

Researchers analyzed data from the National Health Interview Survey and found that more than half of all people 65 years and older who had a life expectancy of less than 9 years had received prostate, breast, cervical, or CRC screening.

Screening in older people with limited life expectancies is in conflict "with several guidelines," writes Dr. Gross.Despite their different perspectives on the current state of screening, Dr. Gross and Dr. Wender agree that screening should only be done in appropriately selected adults.

"It's time to end non-evidence-based screening," said Dr. Wender.

"I agree, we need to screen the right people," said Dr. Gross. But he suggested that this sentiment is at the crux of the murkiness about screening and the related increase in skepticism. "It's not always clear who the right people are," he said.

Tipping Point

Much is at stake in the current era of cancer screening, said Dr. Gross.

"We don't want the pendulum to swing back so far that no one gets screened," he told Medscape Medical News.

He extended the metaphor about balance by saying that the United States is at a "tipping point" with cancer screening — with the "credibility" of the enterprise at risk.

"For years, cancer screening has been oversold," he said, echoing a comment made by Otis Brawley, MD, chief medical officer of the American Cancer Society, in 2009, which caused a firestorm of controversy at that time.

This declaration has become less controversial since a variety of commentators have described screening as being the subject of promotion instead of education.

"We will look back at the past 25 years and see it as a period of irrational exuberance," said Dr. Gross.

Change is possible and necessary, he added.

In his essay, Dr. Gross argues that we will "truly" have a "new era" of screening when healthcare providers are evaluated in part by their "ability to refrain from ordering cancer screening tests for some of their patients."

Such quality measurement would address overscreening, he said. And it might be underway. The National Committee for Quality Assurance has proposed that in 2015, screening for CRC in people 86 years and older and for prostate cancer in men 70 years and older be considered overuse.

Communications are also a key to improving screening. There is "a lot of conversation" surrounding the decision about heart bypass surgery. "I would argue that cancer screening merits the same kind of conversation," said Dr. Gross.

Clinicians should have a "cheat sheet" of the absolute numbers related to screening, including the number of adults needed to screen to prevent 1 cancer-related death, he said. Absolute numbers are more easily comprehended than relative percentages, he noted.

Professional societies also need to develop "rigorous estimates" of benefits and risks for specific screening methods and disseminate them to membership, he added.

"We need patient-centered, outcomes-conscious cancer care," Dr. Gross concluded.

Dr. Gross is a member of the scientific advisory board for FAIR Health, and receives research funding from Medtronic and Johnson & Johnson as part of a clinical trial data-sharing project.