Value of mammograms, PSA tests now debated

A file photo of a mammography patient receiving

A file photo of a mammography patient receiving a screening with the Hologic Selenia Dimension digital mammography machine at NuHealth Nassau University Medical Center. (July 11, 2011) (Credit: Chris Ware)

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It used to be that the decision to get an annual mammogram or PSA test was no more confusing than getting a yearly checkup. Not anymore.

A government-appointed panel two years ago recommended women beginning at age 50, not 40, get mammograms every other year, instead of every year. The recommendation provoked an outcry so great that the government quickly promised the tests would continue to be covered yearly for women 40 and older under The Affordable Care Act, the new federal health care law.

The same panel's recent recommendation on prostate cancer screening has been no less controversial. In October, the U.S. Preventive Services Task Force, a 16-member group of outside primary-care experts, released a draft recommendation that calls for not routinely giving healthy men 50 and older the prostate-specific antigen blood test. Like the mammogram guideline, this drew fire from many doctors and advocacy groups.

The draft has prompted several thousand public comments, the most the task force has received on any draft recommendation since it began posting them this year, a task force spokeswoman said. The final recommendation is due after the first of the year, she said.

The stakes are not small for these recommendations. The way doctors practice, how patients perceive wellness, and whether some tests are routinely covered by insurers are likely to shift, officials and experts say.

Both mammograms and the PSA test have been standard medical practice for decades and heralded as lifesaving. Their widespread use in this country has nearly doubled the chance that a man will be diagnosed with prostate cancer and a woman will be found with breast cancer, according to a 2009 Journal of the American Medical Association article.

But the task force concluded that, based on the available evidence, the screens in some cases do more harm than good: They subject many patients to unnecessary biopsies or to treatments for cancers that ultimately would not harm them.

"We need to be using science to make informed decisions and not just assume that all screening is good," said Dr. Michael LeFevre, professor of family and community medicine at the University of Missouri and co-vice chair of the task force.

Tests called worth the risk

Advocates, while acknowledging that both tests are not perfect, say saving even one life is worth the risk of overtreatment.

Dr. Deepak Kapoor, president of the Bethpage-based Advanced Urology Centers of New York, said he is "appalled" that the government panel would not tell men to get the PSA test and that the new guideline would "undo 20 years of progress."

"There was a time when I could only offer them solace and prayer," said Kapoor, referring to prostate cancer patients he saw decades ago. "Now I can offer them hope and treatment."

Those on both sides agree on one thing: The problem is the lack of definitive data.

"The debate is not where the evidence is clear. It's when the evidence is not clear," said Dr. Carla Keirns, a clinical ethicist in Stony Brook University's Department of Preventive Medicine, who concurs with the task force's more conservative screening guidelines.

There's little debate about the benefit of mammograms for women age 50 to 69. The task force said they reduce deaths by an average of 16.5 percent. But looking at six different statistical models, the task force found that screening women 40 to 49 resulted only in an additional 3 percent reduction in deaths. Screening women every year as opposed to every other year also resulted in twice as many follow-up tests that didn't find a cancer, the task force concluded.

But looking at the same data as the task force, the American College of Obstetricians and Gynecologists came to the opposite conclusion and expanded its guidelines in July, calling for women beginning at age 40 to get annual mammograms -- the same as the American Cancer Society's recommendation.

"If we say we're only saving 3 percent more women, that's 3 percent of women at the peak of their lives," said Dr. Jennifer Griffin, an assistant professor of obstetrics and gynecology at the University of Nebraska Medical Center and co-author of the ACOG guidelines.

As for the PSA test, the task force found even less evidence it had reduced prostate cancer deaths. In its review of five randomized controlled trials, considered the gold standard, it found none showed significantly fewer deaths from prostate cancer among those who got the test compared with those who didn't.

One major American study found a slight increase in prostate cancer deaths among those who had the test. It also found significant side effects from treatments. About 20 percent to 30 percent of men who had surgery to remove their prostate became either impotent, incontinent or both, the task force said.

But groups like the National Alliance of State Prostate Cancer Coalitions dispute the task force findings, saying that prostate cancer deaths are down almost 40 percent since the mid 1990s, which they attribute to screening.

 

Doctor-patient discussions

Smithtown urologist Dr. Richard Schoor said he doesn't routinely give the PSA test and instead talks to his patients about screening's risks and benefits.

"Prostate cancer is a very complex and emotional condition for most men," Schoor said. "There's a lot of money to be made in the diagnosis and treatment of prostate cancer. I won't comment on whether that drives things but I think it's always out there."

Money is also an issue when it comes to what insurers will cover. Although mammography is an exception, the new health care law stipulates that only the costs of tests recommended by the task force will be covered under The Affordable Care Act.

Whether giving a routine annual PSA in an otherwise healthy man will continue to be covered by health insurers is unclear.

"What we think is likely to change is the nature of the discussion between a doctor and patient, and fewer men may opt to get the test," said Susan Pisano, a spokeswoman for the trade group America's Health Insurance Plans. "We expect insurers may continue to cover the test when an individual doctor and patient decides it's the right thing."

For doctors who might miss a prostate cancer because they didn't do a PSA test, there's also the threat of lawsuits, said Dr. Maureen Killackey, chief medical officer of the Eastern Division of the American Cancer Society. "When you talk to physicians, they say, 'Are you crazy? Of course I'm going to order a PSA,' " she said.

Where does this leave patients?

Hank Iori, 64, of Belle Harbor, Queens, a retired educator and consultant, said he gets an annual PSA test and plans to continue to do so. He has had three biopsies as a result -- all negative -- over the past 15 or so years. He'd rather risk the worry and discomfort of a biopsy than not detect a cancer early -- he's had two friends die of the disease. "I think knowing is a good thing," he said.

CANCER SCREENING RECOMMENDATIONS
Proposals for guidelines and new studies have re-kindled debate about the most popular annual cancer screening tests. Below are the various recommendations for average-risk, otherwise healthy people.

Mammogram for breast cancer: The U.S. Preventive Task Force, scientists advising the government, in 2009 said there was little benefit for women to begin routine mammogram screening at 40 years old. Their guidelines said most women could safely wait until 50, and get one every other year until age 74.

The American Cancer Society, the National Cancer Institute and most breast cancer groups continue to advise women to begin annual mammograms at age 40.

PSA blood test for prostate cancer: The U.S. Preventive Task Force issued a draft recommendation that men without symptoms should not get the PSA test for prostate cancer. Prostate cancer groups, survivors and some doctors are trying to get this recommendation reversed. The previous advice is for all men 50 and older to get the PSA blood test annually.


THEIR VIEW ON SCREENINGS

Madison Pauly
Age: 18
Home: Oakdale

Pauly knows she is years away from her first mammogram. But she is within the cervical cancer screening age range and says that she can understand why medical experts would recommend fewer screenings throughout her lifetime.

Fewer medical tests for people of low cancer risk might mean money saved for everyone and better care for those who might be saved from cancer.

“I’m not saying that women shouldn’t get mammograms. All I’m saying is that people should just know there’s another side of the story,” said Pauly, who has been studying medical advances and what she calls “a culture of overtreatment and fear” in the United States.

Growing up on Long Island, she’s heard the stories of cancer survivors and seen the pink-ribbons.

“It’s great that there are the campaigns but there needs to be more education about the potential harms, too,” she said.


Lorelei Galardi
Age: 49
Home: Southampton

Getting a mammogram “isn’t the most comfortable experience, but just a necessary evil,” said Galardi.
Galardi said she was diagnosed with a high-grade form of breast cancer after her first mammogram at 43 years old.
She was reluctant at first to get the test, but caved at the urging of her doctor.
“If I waited until 50, I don’t think I would’ve been alive,” Galardi said, commenting on the controversial advice that some women can safely wait to get mammograms at 50 years old.
She had a mastectomy, a surgery that removed the cancerous breast. It was eventually reconstructed with tissue from her abdomen, a procedure she says still left her “disfigured.”
“I don’t dwell on it but sometimes I think if I had gotten a mammogram earlier, I could’ve just gotten a lump removed,” Galardi said.


Patrick Linehan
Age: 66
Home: Amityville

Linehan got his first PSA screening for prostate cancer at 62. Without a family history or other risk factors for the disease, he wasn’t too worried.

But the screening, a simple blood test in a doctor’s office, showed an elevated number. A biopsy later confirmed he had prostate cancer. He received 45 days of radiation in the winter of 2009 and says he is doing fine now.

“I’m not a doctor, but what I do know about cancer is that you got to get it out before it starts to run around,” Linehan said. “Cancer is very opportunistic.”

Linehan, a financial adviser and grandfather of five, believes the PSA test saved his life. He recognizes that it isn’t perfect but thinks to advise men like him not to get screened would be “penny-wise and pound-foolish.”

“What’s the expense of people who have prostate cancer detected too late and need to be in the hospital?”

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