By Jennifer Yttri, PhD
The thought of cancer is so frightening that many patients depend on their physicians to make all the decisions about screening, prevention, and treatment. Or they may ask for whatever “new cure” they have heard about. That can result in too many tests or treatments that do more harm than good. Not every test, procedure, or medication is appropriate for every patient, and many are over-used. What is beneficial for one person isn’t worth the risks for another.
The best health decisions can be made when physicians take the time to talk with their patients and patients ask questions rather than just assuming the doctor always knows best.
The ABIM Foundation and Consumer Reports collaborated with specialty medical societies to create lists of “5 Things Physicians and Patients Should Question” as part of a national effort called Choosing Wisely (www.choosingwisely.org). These medical groups represent more than 500,000 physicians. The lists contain evidence-based recommendations made by experts. Here is the list of their recommendations on cancer.
Breast cancer screening
Breast cancer screening is done through mammograms, which are like x-rays. A breast cancer diagnosis involves giving the cancer a stage (0 through 4, with 4 being the most advanced) based on the size of the tumor, how advanced it is, and how likely it is to spread. Other imaging tests, like PET, CT, and bone scans are not recommended for screening early stage breast cancer (stages 0-3), patients newly diagnosed with Ductal Carcinoma In Situ (DCIS), or people without symptoms. This testing does not benefit patients, and false-positives (test results that indicate cancer when no cancer is present) can lead to unnecessary procedures and misdiagnosis. For anyone who has been treated for early-stage breast cancer and is symptom free, mammograms and regular clinical exams are the best ways to check that the cancer has not come back. Advanced imaging tests and tumor marker tests should only be used for patients with later-stage breast cancer.
The first round of cancer therapy works best at reducing or eliminating a tumor. Multiple treatments, including chemotherapy, will not always help get rid of cancer, especially more advanced cancers or tumors that return. After three different treatments, another round is unlikely to improve quality or length of life. It is better to stop therapy and not suffer through the side effects of treatment. (In fact, there is some evidence that patients live longer, with better quality of life, if they stop aggressive treatments earlier.)
Cervical cancer screening
Women over 65 should stop being screened for cervical cancer if they have not previously shown risk for disease. Women under 30 should not have HPV tests to screen for cervical cancer. Women with mild dysplasia or cervical intraepithelial neoplasia (CIN1) for less than two years should not be treated for cervical cancer, as CIN1 is usually caused by a short-term HPV infection and goes away within a year. See below for information about HPV testing. Pap smears should be used to screen for cervical cancer.
Colon cancer screening
For people who are at an average risk for developing colon cancer, tests such as stool tests and sigmoidoscopy can be used instead of colonoscopy to screen for colon cancer. Abnormal results from these tests require follow-up with a colonoscopy. The plasma test named methylated Septin 9 (SEPT9) is an alternative screening test but it is not recommended unless the more conventional tests and colonoscopy are not feasible.
HPV testing is not recommended for low risk infections, such as for HPV associated with genital warts. HPV testing should be used to identify high risk infections in patients with abnormal Pap smears or other clinical symptoms associated with high risk HPV infections.
Ovarian cancer screening
Women at average risk who do not have symptoms should not be screened for ovarian cancer. Screening using ultrasound or blood serum testing might detect early signs of cancer, but ovarian cancer is uncommon in women of average risk without symptoms. An abnormal result that isn’t cancer might require invasive follow-up, and those risks outweigh the benefit of early detection.
Small, simple cysts are common in women and usually won’t affect their health. If one is found, the doctor will schedule an ultrasound to determine if the cyst is benign (not cancer). If the cyst is not cancerous, a follow up ultrasound and surgery is not recommended unless the cyst causes symptoms, like pelvic pain. If the cyst is suspected to be cancerous, a follow up ultrasound is not recommended because the cyst should just be surgically removed. A second ultrasound is only recommended for larger cysts that the doctor could not be sure about.
Palliative care for bone metastasis
Cancers that spread to bones are often very painful. Local radiation is sometimes used to treat patients with one or a few bone metastases, but some doctors question if the increased risk of cancer warrants radiation as treatment for pain. The American Society for Radiation Oncology recommends using one dose of radiation to relieve pain from any bone metastasis. While another dose might be needed in the future, starting with one dose makes sense, since patients with bone cancer have a short life expectancy.
Prostate cancer screening
Men who do not have symptoms generally should not be screened for prostate cancer using a prostate-specific antigen (PSA) test or digital rectal exam as it can lead to treatments that may do more harm than good. Gleason and prostate-specific antigen (PSA) tests are used to measure how aggressive prostate cancer is and how likely it is to spread. Imaging tests can then be performed to identify exactly where cancer has spread. These imaging tests, such as bone scans, PET, and CT, are not recommended for detecting disease in men who are newly diagnosed with low-grade prostate cancer. Imaging tests are expensive, can expose men to high levels of radiation, and are unlikely to provide more information about early prostate cancer. Only men with Gleason scores above 7 and PSA levels above 10 nanograms/mL should consider imaging tests.
Prostate specific antigen (PSA)
High PSA levels may be a sign of prostate cancer. However, having a low PSA level does not prevent prostate cancer nor does it mean there is no cancer. It was thought that antibiotics might lower PSA and protect men from prostate cancer. This has not been proven in clinical tests and is not recommended as an alternative preventive therapy.
Stage 1 non-small cell lung cancer (NSCLC)
Lung cancer is the most common type of cancer to spread to the brain. However, the chance of patients with Stage 1 lung cancer developing brain metastasis is very low. Because of the rate of false positives is much higher than the actual rate of brain metastasis, brain imaging by MRI or CT is not recommended for patients with stage 1 NSCLC unless they have neurologic symptoms.
Radioactive iodine is absorbed by the thyroid and can be used to give doctors a picture of what the thyroid looks like, how it is functioning, and if there are any nodules in the area. Imaging with radioactive iodine is not recommended for determining whether thyroid nodules are benign or cancerous unless the patient is hyperthyroid. Nodules should be biopsied if the thyroid functions normally.