The Cancer Screening Wars

When the U.S. Preventive Services Task Force recommended against prostate-specific antigen-based screening in men of any age this spring, an uproar swiftly followed. Evidence was dissected; cancer survivors and stakeholders lambasted the decision as shortsighted, and still others endorsed the recommendation as a long overdue nod to science.

Similar fallout erupted in November 2009 when the task force recommended against routine screening mammography in women younger than age 50 years. Only this time, critics charged that science had taken a back seat to politics, characterizing the decision as a harbinger of rationing under President Obama’s health care reform.

Less contentious so far are new recommendations that the annual Pap smear screening for cervical cancer should be pushed back to every 3 years and that low-dose lung CT screening be offered to heavy smokers. Time will tell whether the former is accepted in clinical practice and the latter can make the leap from clinical trial strategy to national guideline.

Given the complicated, emotionally charged nature of cancer screening and the political forces still at play, could another maelstrom be far off?

"There are a lot of misconceptions out there, in part because for so many decades, the messages have been so strong, they sometimes leaped ahead of the evidence," Dr. Barnett Kramer, director of the division of cancer prevention at the National Cancer Institute (NCI), Bethesda, Md., said in an interview.

When advocacy groups such as the American Cancer Society (ACS) first formed, strong, simple messages were needed to get Americans even to utter the word cancer out loud.

Over time, cancer screening messages have evolved into sound bites that almost always follow the very strong presumption that early detection means a better chance for survival, said Dr. Kramer, who described this as a serious oversimplification of the principles of screening. By its very nature, a screening test will always advance the date of diagnosis, but this may not benefit the patient.

"Simply saying that screening increases survival doesn’t convey any useful information," he said. "You really need to know what the effect of the screening test is on the risk of dying – that is the mortality rate, and that’s a different calculation from simply measuring the duration of life from the day of diagnosis to death."

Dr. Virginia Moyer, chair of the U.S. Preventive Services Task Force (USPSTF), agreed that some advocacy groups "absolutely oversell the benefits of screening and completely ignore the harms" that screening and medical interventions can cause. The perception among the general public is that if you screen and find something, you have therefore saved a life.

She argued in an interview that scientific groups such as the task force have provided a more balanced message, but admits the scientific community has made its own mistakes.

"Our concept at the time that PSA screening was developed was that if you had cancer in you, it would inevitably grow and kill you if you didn’t do something about it," she said. "That’s what we thought all cancer was about and we just turned out to be wrong. A huge proportion of cancers never do anything and that’s the piece we didn’t know."

Some physicians, however, may still not know. Dr. Moyer pointed out that risk communication experts recently reported that about one half (47%) of U.S. primary care physicians surveyed incorrectly said that finding more cases of cancer in screened vs. unscreened populations, "proves that screening saves lives" (Ann. Intern. Med. 2012;156:340-9).

The Push-Pull of Politics

Dr. Handel Reynolds, breast radiologist with Piedmont Hospital in Atlanta and author of the new book, "The Big Squeeze: A Social and Political History of the Controversial Mammogram," said in an interview that a series of crucial decisions made by health professionals set up screening mammography to be the controversial test it is today.

The first of these came in 1973 when, based on a single trial showing a mortality benefit in women under 50, the ACS and NCI decided to include women as young as 35 years in the National Breast Cancer Detection Demonstration Project (BCDDP), the first large-scale use of mammography as a screening tool involving some 280,000 women over 5 years (J. Natl. Cancer Inst. 1988;80:1540-7).

Just 3 years later, the National Institutes of Health (NIH) convened its first consensus conference to address screening in younger women, even though the BCDDP was not a clinical trial and demonstration projects are typically performed to show that activities with proven efficacy in clinical trials can be done on a large scale.

"1976 was the first time we had this huge blow-up about women under 50, and it has not gone away. In fact, it has become more acrimonious with each subsequent iteration," Dr. Reynolds said.

The most egregious example of political interference occurred in 1997. The NCI had broken with the ACS four years earlier and dropped its recommendation for mammography in women under 50. In 1997, however, the NCI reversed its position after a series of high-profile hearings held by then Sen. Arlen Specter (R-PA.), who chaired the subcommittee controlling funding for the NCI and who openly supported screening for women under 50, Dr. Reynolds said.

"The 1997 episode established the primacy of politics over science in the mammography debate and made it so much easier then for the 2009 controversy to be resolved in a matter of weeks," he contends.

Pap Test Changes Fly Under the Radar

Politics played a huge role in the uproar that surrounded the 2003 cervical cancer guidelines, said Dr. Alan G. Waxman, who recalled being accused of hating his mother because the 2003 guidelines he helped pen urged less frequent screening for cervical cancer.

Although the 2012 cervical screening guidelines essentially retire the annual Pap smear, Dr. Waxman said that he’s not expecting a huge backlash. Things have been relatively quiet since two separate groups released updates this March. The change between guidelines has been incremental, and women trust the science because it hasn’t gone through the permutations and "fluctuating truth" observed with the mammography data.

"With the Pap smear, the science has been pretty much in lockstep," said Dr. Waxman, president of the American Society for Colposcopy and Cervical Pathology, which partnered with the ACS and American Society for Clinical Pathology to release its guidelines in tandem with similar recommendations from the USPSTF.

Money Makes Its Voice Heard

The relative quiet following the changes to cervical cancer screening recommendations may also reflect the numbers. Only about 12,000 new cases of cervical cancer are diagnosed annually, compared with 214,633 new cases of prostate cancer in 2008, the most recent year for which numbers are available. Similarly, mammograms were ordered or provided in 20.3 million physician office visits and 2.3 million hospital outpatient department visits in 2009 alone.

The financial stakes are high in prostate and breast cancer and the rhetoric proportionate.

The American Urological Association expressed outrage after the release of the UPSTF PSA recommendation, warning that it could potentially turn back the clock to a time before PSA testing when "men presented with high-grade, metastatic disease for which there was little or no treatment beyond palliative care."

Dr. Otis Brawley, chief medical officer of the American Cancer Society, defended the USPSTF in a recent commentary, saying that unlike many of their critics, USPSTF members are ideally suited to assess the science objectively because they have no "emotional, ideological, or financial conflicts of interest" and understand the complicated science of screening.

He also expressed hope that the new PSA recommendations will end mass screenings, a "lucrative business" that offers tests outside the physician-patient relationship, often in shopping malls and parking lots with sponsorship from hospitals, medical practices, and even an adult diaper company.

For his part, Dr. Richard Albin, who discovered PSA, has been quoted as saying, "I never dreamed that my discovery 4 decades ago would lead to such a profit-driven public health disaster."

Some urologists have criticized the USPSTF for failing to include urologists on the panel and for the absence of a cost analysis.

"If you’re not saving any lives, then any money you’re spending is wasted, and you don’t need a complicated cost-effectiveness analysis to figure that out," countered Dr. Moyer.

Physicians and patients, however, may need a scorecard to wade through the rhetoric and conflicting data, frequently cherry-picked to argue for or against a particular screening test. In a recent study, 30% of women reported that the 2009 USPSTF mammography guidelines confused more than they helped them understand when to get a mammogram (Am. J. Prev. Med. 2011;40:497-504)

A More Nuanced Conversation

There’s little doubt that the task force’s recent decisions will dramatically reshape mammography and PSA screening in the United States, but the question is by how much.

"Largely what we’ve communicated is all the benefit, but I think the U.S. Preventive Services Task Force is communicating all the harms. And the right place is somewhere in between," Dr. Therese Bartholomew Bevers, medical director of the Cancer Prevention Center at the University of Texas M.D. Anderson Cancer Center in Houston, said in an interview.

What’s important is having a more balanced, nuanced conversation with patients. But is the American public ready for discussions of mortality rates or the changing calculus of risk/benefit ratios of screening as they age?

Nearly half of all American adults – 90 million people – have difficulty understanding and using health information, according to an Institute of Medicine report. In addition, the 2000 census counted 20 million people who speak poor English and 10 million who speak none.

The public is quite intelligent, but that part of the problem is that physicians don’t always know or understand the data. And if even when physicians understand the data, they often do not know how to communicate them in a way their patients can understand, says Dr. Bevers.

"That’s where there is a huge opportunity to create decision-making tools," she says.

With the help of communication experts, Dr. Bevers and her colleagues are developing a computerized tool that reviews the data from the National Lung Screening Trial (NLST) and spells out the benefits and harms of low-dose computed tomography screening for lung cancer in a very simplified fashion, using smiley faces for benefits and frowning faces for risks.

"It really advances my discussion when I walk in the room," said Dr. Bevers, a coinvestigator for the NLST. "I’m not explaining about the 20% mortality reduction, the associated harms. I’m now talking about: ‘What did you think about that?’ ‘What did you think about the harms?’ ‘How did it influence your decision about this?’ It’s a much more advanced discussion, and that’s helpful in a busy practice."

Another tool could then be used to walk patients through the next step of care to give physicians a sense of what concerns their patients most; for example, the risk of dying or that their cancer will return, she said.

The New Kid on the Block

Most experts agree that low-dose CT lung cancer screening is something of an anomaly in the cancer screening wars. Prior nonrandomized trials suggested a benefit with low-dose CT, but practice did not leapfrog the evidence. Only now that the randomized NLST has been completed is the screening machinery gearing up, but with significant questions about cost and high false-positive rates still unanswered (N. Engl. J. Med. 2011;365:395-409)

Moreover, CT lung screening would be an additional service offered to high-risk individuals, rather than the retraction of an entrenched screening practice.

The NCI has developed its own one-page, online NLST study guide for patients and physicians that provides specific data on low-dose CT vs. chest x-ray screening, "take-home" messages, and an educational component directing patients not to smoke.

"We don’t want to oversell the harms and undersell the benefits," said the NCI’s Dr. Kramer. "We don’t want the pendulum to swing completely in the opposite direction, and I think this sheet goes a long way."

In a busy primary care office, no doubt the various new recommendations will shift the conversation with patients, many of whom have been given the simple message for years to come back each year for their annual mammogram or PSA test. Depending on which recommendations their physicians advocate and what patients choose to follow, it will ultimately tip the balance sheet and outcomes data for years to come.

None of the physicians interviewed reported having relevant conflicts of interest.

When the U.S. Preventive Services Task Force recommended against prostate-specific antigen-based screening in men of any age this spring, an uproar swiftly followed. Evidence was dissected; cancer survivors and stakeholders lambasted the decision as shortsighted, and still others endorsed the recommendation as a long overdue nod to science.

Similar fallout erupted in November 2009 when the task force recommended against routine screening mammography in women younger than age 50 years. Only this time, critics charged that science had taken a back seat to politics, characterizing the decision as a harbinger of rationing under President Obama’s health care reform.

Less contentious so far are new recommendations that the annual Pap smear screening for cervical cancer should be pushed back to every 3 years and that low-dose lung CT screening be offered to heavy smokers. Time will tell whether the former is accepted in clinical practice and the latter can make the leap from clinical trial strategy to national guideline.

Given the complicated, emotionally charged nature of cancer screening and the political forces still at play, could another maelstrom be far off?

"There are a lot of misconceptions out there, in part because for so many decades, the messages have been so strong, they sometimes leaped ahead of the evidence," Dr. Barnett Kramer, director of the division of cancer prevention at the National Cancer Institute (NCI), Bethesda, Md., said in an interview.

When advocacy groups such as the American Cancer Society (ACS) first formed, strong, simple messages were needed to get Americans even to utter the word cancer out loud.

Over time, cancer screening messages have evolved into sound bites that almost always follow the very strong presumption that early detection means a better chance for survival, said Dr. Kramer, who described this as a serious oversimplification of the principles of screening. By its very nature, a screening test will always advance the date of diagnosis, but this may not benefit the patient.

"Simply saying that screening increases survival doesn’t convey any useful information," he said. "You really need to know what the effect of the screening test is on the risk of dying – that is the mortality rate, and that’s a different calculation from simply measuring the duration of life from the day of diagnosis to death."

Dr. Virginia Moyer, chair of the U.S. Preventive Services Task Force (USPSTF), agreed that some advocacy groups "absolutely oversell the benefits of screening and completely ignore the harms" that screening and medical interventions can cause. The perception among the general public is that if you screen and find something, you have therefore saved a life.

She argued in an interview that scientific groups such as the task force have provided a more balanced message, but admits the scientific community has made its own mistakes.

"Our concept at the time that PSA screening was developed was that if you had cancer in you, it would inevitably grow and kill you if you didn’t do something about it," she said. "That’s what we thought all cancer was about and we just turned out to be wrong. A huge proportion of cancers never do anything and that’s the piece we didn’t know."

Some physicians, however, may still not know. Dr. Moyer pointed out that risk communication experts recently reported that about one half (47%) of U.S. primary care physicians surveyed incorrectly said that finding more cases of cancer in screened vs. unscreened populations, "proves that screening saves lives" (Ann. Intern. Med. 2012;156:340-9).

The Push-Pull of Politics

Dr. Handel Reynolds, breast radiologist with Piedmont Hospital in Atlanta and author of the new book, "The Big Squeeze: A Social and Political History of the Controversial Mammogram," said in an interview that a series of crucial decisions made by health professionals set up screening mammography to be the controversial test it is today.

The first of these came in 1973 when, based on a single trial showing a mortality benefit in women under 50, the ACS and NCI decided to include women as young as 35 years in the National Breast Cancer Detection Demonstration Project (BCDDP), the first large-scale use of mammography as a screening tool involving some 280,000 women over 5 years (J. Natl. Cancer Inst. 1988;80:1540-7).

Just 3 years later, the National Institutes of Health (NIH) convened its first consensus conference to address screening in younger women, even though the BCDDP was not a clinical trial and demonstration projects are typically performed to show that activities with proven efficacy in clinical trials can be done on a large scale.

"1976 was the first time we had this huge blow-up about women under 50, and it has not gone away. In fact, it has become more acrimonious with each subsequent iteration," Dr. Reynolds said.

The most egregious example of political interference occurred in 1997. The NCI had broken with the ACS four years earlier and dropped its recommendation for mammography in women under 50. In 1997, however, the NCI reversed its position after a series of high-profile hearings held by then Sen. Arlen Specter (R-PA.), who chaired the subcommittee controlling funding for the NCI and who openly supported screening for women under 50, Dr. Reynolds said.

"The 1997 episode established the primacy of politics over science in the mammography debate and made it so much easier then for the 2009 controversy to be resolved in a matter of weeks," he contends.

Pap Test Changes Fly Under the Radar

Politics played a huge role in the uproar that surrounded the 2003 cervical cancer guidelines, said Dr. Alan G. Waxman, who recalled being accused of hating his mother because the 2003 guidelines he helped pen urged less frequent screening for cervical cancer.

Although the 2012 cervical screening guidelines essentially retire the annual Pap smear, Dr. Waxman said that he’s not expecting a huge backlash. Things have been relatively quiet since two separate groups released updates this March. The change between guidelines has been incremental, and women trust the science because it hasn’t gone through the permutations and "fluctuating truth" observed with the mammography data.

"With the Pap smear, the science has been pretty much in lockstep," said Dr. Waxman, president of the American Society for Colposcopy and Cervical Pathology, which partnered with the ACS and American Society for Clinical Pathology to release its guidelines in tandem with similar recommendations from the USPSTF.

Money Makes Its Voice Heard

The relative quiet following the changes to cervical cancer screening recommendations may also reflect the numbers. Only about 12,000 new cases of cervical cancer are diagnosed annually, compared with 214,633 new cases of prostate cancer in 2008, the most recent year for which numbers are available. Similarly, mammograms were ordered or provided in 20.3 million physician office visits and 2.3 million hospital outpatient department visits in 2009 alone.

The financial stakes are high in prostate and breast cancer and the rhetoric proportionate.

The American Urological Association expressed outrage after the release of the UPSTF PSA recommendation, warning that it could potentially turn back the clock to a time before PSA testing when "men presented with high-grade, metastatic disease for which there was little or no treatment beyond palliative care."

Dr. Otis Brawley, chief medical officer of the American Cancer Society, defended the USPSTF in a recent commentary, saying that unlike many of their critics, USPSTF members are ideally suited to assess the science objectively because they have no "emotional, ideological, or financial conflicts of interest" and understand the complicated science of screening.

He also expressed hope that the new PSA recommendations will end mass screenings, a "lucrative business" that offers tests outside the physician-patient relationship, often in shopping malls and parking lots with sponsorship from hospitals, medical practices, and even an adult diaper company.

For his part, Dr. Richard Albin, who discovered PSA, has been quoted as saying, "I never dreamed that my discovery 4 decades ago would lead to such a profit-driven public health disaster."

Some urologists have criticized the USPSTF for failing to include urologists on the panel and for the absence of a cost analysis.

"If you’re not saving any lives, then any money you’re spending is wasted, and you don’t need a complicated cost-effectiveness analysis to figure that out," countered Dr. Moyer.

Physicians and patients, however, may need a scorecard to wade through the rhetoric and conflicting data, frequently cherry-picked to argue for or against a particular screening test. In a recent study, 30% of women reported that the 2009 USPSTF mammography guidelines confused more than they helped them understand when to get a mammogram (Am. J. Prev. Med. 2011;40:497-504)

A More Nuanced Conversation

There’s little doubt that the task force’s recent decisions will dramatically reshape mammography and PSA screening in the United States, but the question is by how much.

"Largely what we’ve communicated is all the benefit, but I think the U.S. Preventive Services Task Force is communicating all the harms. And the right place is somewhere in between," Dr. Therese Bartholomew Bevers, medical director of the Cancer Prevention Center at the University of Texas M.D. Anderson Cancer Center in Houston, said in an interview.

What’s important is having a more balanced, nuanced conversation with patients. But is the American public ready for discussions of mortality rates or the changing calculus of risk/benefit ratios of screening as they age?

Nearly half of all American adults – 90 million people – have difficulty understanding and using health information, according to an Institute of Medicine report. In addition, the 2000 census counted 20 million people who speak poor English and 10 million who speak none.

The public is quite intelligent, but that part of the problem is that physicians don’t always know or understand the data. And if even when physicians understand the data, they often do not know how to communicate them in a way their patients can understand, says Dr. Bevers.

"That’s where there is a huge opportunity to create decision-making tools," she says.

With the help of communication experts, Dr. Bevers and her colleagues are developing a computerized tool that reviews the data from the National Lung Screening Trial (NLST) and spells out the benefits and harms of low-dose computed tomography screening for lung cancer in a very simplified fashion, using smiley faces for benefits and frowning faces for risks.

"It really advances my discussion when I walk in the room," said Dr. Bevers, a coinvestigator for the NLST. "I’m not explaining about the 20% mortality reduction, the associated harms. I’m now talking about: ‘What did you think about that?’ ‘What did you think about the harms?’ ‘How did it influence your decision about this?’ It’s a much more advanced discussion, and that’s helpful in a busy practice."

Another tool could then be used to walk patients through the next step of care to give physicians a sense of what concerns their patients most; for example, the risk of dying or that their cancer will return, she said.

The New Kid on the Block

Most experts agree that low-dose CT lung cancer screening is something of an anomaly in the cancer screening wars. Prior nonrandomized trials suggested a benefit with low-dose CT, but practice did not leapfrog the evidence. Only now that the randomized NLST has been completed is the screening machinery gearing up, but with significant questions about cost and high false-positive rates still unanswered (N. Engl. J. Med. 2011;365:395-409)

Moreover, CT lung screening would be an additional service offered to high-risk individuals, rather than the retraction of an entrenched screening practice.

The NCI has developed its own one-page, online NLST study guide for patients and physicians that provides specific data on low-dose CT vs. chest x-ray screening, "take-home" messages, and an educational component directing patients not to smoke.

"We don’t want to oversell the harms and undersell the benefits," said the NCI’s Dr. Kramer. "We don’t want the pendulum to swing completely in the opposite direction, and I think this sheet goes a long way."

In a busy primary care office, no doubt the various new recommendations will shift the conversation with patients, many of whom have been given the simple message for years to come back each year for their annual mammogram or PSA test. Depending on which recommendations their physicians advocate and what patients choose to follow, it will ultimately tip the balance sheet and outcomes data for years to come.

None of the physicians interviewed reported having relevant conflicts of interest.

When the U.S. Preventive Services Task Force recommended against prostate-specific antigen-based screening in men of any age this spring, an uproar swiftly followed. Evidence was dissected; cancer survivors and stakeholders lambasted the decision as shortsighted, and still others endorsed the recommendation as a long overdue nod to science.

Similar fallout erupted in November 2009 when the task force recommended against routine screening mammography in women younger than age 50 years. Only this time, critics charged that science had taken a back seat to politics, characterizing the decision as a harbinger of rationing under President Obama’s health care reform.

Less contentious so far are new recommendations that the annual Pap smear screening for cervical cancer should be pushed back to every 3 years and that low-dose lung CT screening be offered to heavy smokers. Time will tell whether the former is accepted in clinical practice and the latter can make the leap from clinical trial strategy to national guideline.

Given the complicated, emotionally charged nature of cancer screening and the political forces still at play, could another maelstrom be far off?

"There are a lot of misconceptions out there, in part because for so many decades, the messages have been so strong, they sometimes leaped ahead of the evidence," Dr. Barnett Kramer, director of the division of cancer prevention at the National Cancer Institute (NCI), Bethesda, Md., said in an interview.

When advocacy groups such as the American Cancer Society (ACS) first formed, strong, simple messages were needed to get Americans even to utter the word cancer out loud.

Over time, cancer screening messages have evolved into sound bites that almost always follow the very strong presumption that early detection means a better chance for survival, said Dr. Kramer, who described this as a serious oversimplification of the principles of screening. By its very nature, a screening test will always advance the date of diagnosis, but this may not benefit the patient.

"Simply saying that screening increases survival doesn’t convey any useful information," he said. "You really need to know what the effect of the screening test is on the risk of dying – that is the mortality rate, and that’s a different calculation from simply measuring the duration of life from the day of diagnosis to death."

Dr. Virginia Moyer, chair of the U.S. Preventive Services Task Force (USPSTF), agreed that some advocacy groups "absolutely oversell the benefits of screening and completely ignore the harms" that screening and medical interventions can cause. The perception among the general public is that if you screen and find something, you have therefore saved a life.

She argued in an interview that scientific groups such as the task force have provided a more balanced message, but admits the scientific community has made its own mistakes.

"Our concept at the time that PSA screening was developed was that if you had cancer in you, it would inevitably grow and kill you if you didn’t do something about it," she said. "That’s what we thought all cancer was about and we just turned out to be wrong. A huge proportion of cancers never do anything and that’s the piece we didn’t know."

Some physicians, however, may still not know. Dr. Moyer pointed out that risk communication experts recently reported that about one half (47%) of U.S. primary care physicians surveyed incorrectly said that finding more cases of cancer in screened vs. unscreened populations, "proves that screening saves lives" (Ann. Intern. Med. 2012;156:340-9).

The Push-Pull of Politics

Dr. Handel Reynolds, breast radiologist with Piedmont Hospital in Atlanta and author of the new book, "The Big Squeeze: A Social and Political History of the Controversial Mammogram," said in an interview that a series of crucial decisions made by health professionals set up screening mammography to be the controversial test it is today.

The first of these came in 1973 when, based on a single trial showing a mortality benefit in women under 50, the ACS and NCI decided to include women as young as 35 years in the National Breast Cancer Detection Demonstration Project (BCDDP), the first large-scale use of mammography as a screening tool involving some 280,000 women over 5 years (J. Natl. Cancer Inst. 1988;80:1540-7).

Just 3 years later, the National Institutes of Health (NIH) convened its first consensus conference to address screening in younger women, even though the BCDDP was not a clinical trial and demonstration projects are typically performed to show that activities with proven efficacy in clinical trials can be done on a large scale.

"1976 was the first time we had this huge blow-up about women under 50, and it has not gone away. In fact, it has become more acrimonious with each subsequent iteration," Dr. Reynolds said.

The most egregious example of political interference occurred in 1997. The NCI had broken with the ACS four years earlier and dropped its recommendation for mammography in women under 50. In 1997, however, the NCI reversed its position after a series of high-profile hearings held by then Sen. Arlen Specter (R-PA.), who chaired the subcommittee controlling funding for the NCI and who openly supported screening for women under 50, Dr. Reynolds said.

"The 1997 episode established the primacy of politics over science in the mammography debate and made it so much easier then for the 2009 controversy to be resolved in a matter of weeks," he contends.

Pap Test Changes Fly Under the Radar

Politics played a huge role in the uproar that surrounded the 2003 cervical cancer guidelines, said Dr. Alan G. Waxman, who recalled being accused of hating his mother because the 2003 guidelines he helped pen urged less frequent screening for cervical cancer.

Although the 2012 cervical screening guidelines essentially retire the annual Pap smear, Dr. Waxman said that he’s not expecting a huge backlash. Things have been relatively quiet since two separate groups released updates this March. The change between guidelines has been incremental, and women trust the science because it hasn’t gone through the permutations and "fluctuating truth" observed with the mammography data.

"With the Pap smear, the science has been pretty much in lockstep," said Dr. Waxman, president of the American Society for Colposcopy and Cervical Pathology, which partnered with the ACS and American Society for Clinical Pathology to release its guidelines in tandem with similar recommendations from the USPSTF.

Money Makes Its Voice Heard

The relative quiet following the changes to cervical cancer screening recommendations may also reflect the numbers. Only about 12,000 new cases of cervical cancer are diagnosed annually, compared with 214,633 new cases of prostate cancer in 2008, the most recent year for which numbers are available. Similarly, mammograms were ordered or provided in 20.3 million physician office visits and 2.3 million hospital outpatient department visits in 2009 alone.

The financial stakes are high in prostate and breast cancer and the rhetoric proportionate.

The American Urological Association expressed outrage after the release of the UPSTF PSA recommendation, warning that it could potentially turn back the clock to a time before PSA testing when "men presented with high-grade, metastatic disease for which there was little or no treatment beyond palliative care."

Dr. Otis Brawley, chief medical officer of the American Cancer Society, defended the USPSTF in a recent commentary, saying that unlike many of their critics, USPSTF members are ideally suited to assess the science objectively because they have no "emotional, ideological, or financial conflicts of interest" and understand the complicated science of screening.

He also expressed hope that the new PSA recommendations will end mass screenings, a "lucrative business" that offers tests outside the physician-patient relationship, often in shopping malls and parking lots with sponsorship from hospitals, medical practices, and even an adult diaper company.

For his part, Dr. Richard Albin, who discovered PSA, has been quoted as saying, "I never dreamed that my discovery 4 decades ago would lead to such a profit-driven public health disaster."

Some urologists have criticized the USPSTF for failing to include urologists on the panel and for the absence of a cost analysis.

"If you’re not saving any lives, then any money you’re spending is wasted, and you don’t need a complicated cost-effectiveness analysis to figure that out," countered Dr. Moyer.

Physicians and patients, however, may need a scorecard to wade through the rhetoric and conflicting data, frequently cherry-picked to argue for or against a particular screening test. In a recent study, 30% of women reported that the 2009 USPSTF mammography guidelines confused more than they helped them understand when to get a mammogram (Am. J. Prev. Med. 2011;40:497-504)

A More Nuanced Conversation

There’s little doubt that the task force’s recent decisions will dramatically reshape mammography and PSA screening in the United States, but the question is by how much.

"Largely what we’ve communicated is all the benefit, but I think the U.S. Preventive Services Task Force is communicating all the harms. And the right place is somewhere in between," Dr. Therese Bartholomew Bevers, medical director of the Cancer Prevention Center at the University of Texas M.D. Anderson Cancer Center in Houston, said in an interview.

What’s important is having a more balanced, nuanced conversation with patients. But is the American public ready for discussions of mortality rates or the changing calculus of risk/benefit ratios of screening as they age?

Nearly half of all American adults – 90 million people – have difficulty understanding and using health information, according to an Institute of Medicine report. In addition, the 2000 census counted 20 million people who speak poor English and 10 million who speak none.

The public is quite intelligent, but that part of the problem is that physicians don’t always know or understand the data. And if even when physicians understand the data, they often do not know how to communicate them in a way their patients can understand, says Dr. Bevers.

"That’s where there is a huge opportunity to create decision-making tools," she says.

With the help of communication experts, Dr. Bevers and her colleagues are developing a computerized tool that reviews the data from the National Lung Screening Trial (NLST) and spells out the benefits and harms of low-dose computed tomography screening for lung cancer in a very simplified fashion, using smiley faces for benefits and frowning faces for risks.

"It really advances my discussion when I walk in the room," said Dr. Bevers, a coinvestigator for the NLST. "I’m not explaining about the 20% mortality reduction, the associated harms. I’m now talking about: ‘What did you think about that?’ ‘What did you think about the harms?’ ‘How did it influence your decision about this?’ It’s a much more advanced discussion, and that’s helpful in a busy practice."

Another tool could then be used to walk patients through the next step of care to give physicians a sense of what concerns their patients most; for example, the risk of dying or that their cancer will return, she said.

The New Kid on the Block

Most experts agree that low-dose CT lung cancer screening is something of an anomaly in the cancer screening wars. Prior nonrandomized trials suggested a benefit with low-dose CT, but practice did not leapfrog the evidence. Only now that the randomized NLST has been completed is the screening machinery gearing up, but with significant questions about cost and high false-positive rates still unanswered (N. Engl. J. Med. 2011;365:395-409)

Moreover, CT lung screening would be an additional service offered to high-risk individuals, rather than the retraction of an entrenched screening practice.

The NCI has developed its own one-page, online NLST study guide for patients and physicians that provides specific data on low-dose CT vs. chest x-ray screening, "take-home" messages, and an educational component directing patients not to smoke.

"We don’t want to oversell the harms and undersell the benefits," said the NCI’s Dr. Kramer. "We don’t want the pendulum to swing completely in the opposite direction, and I think this sheet goes a long way."

In a busy primary care office, no doubt the various new recommendations will shift the conversation with patients, many of whom have been given the simple message for years to come back each year for their annual mammogram or PSA test. Depending on which recommendations their physicians advocate and what patients choose to follow, it will ultimately tip the balance sheet and outcomes data for years to come.

None of the physicians interviewed reported having relevant conflicts of interest.