Cancer screening comes down to personal preferences

I have been thinking a lot about cancer screening tests. It seems that there has been a constant stream of articles about screening in both the lay press and professional journals – as well as the inevitable stories in the lay press about the reports in professional journals – but this is more personal. I have had two recent experiences that I can’t get out of my mind.

A few weeks ago my wife and I went to Boston for a bittersweet reunion with a tight-knit group of my former medical school classmates. It was a bit of a last minute thing, triggered by a classmate’s business trip to Boston and our learning that one of “the gang” had advanced metastatic prostate cancer. Ironically, the one with prostate cancer is an oncologist. Amidst the merriment of our first hour together, between updates on our careers and stories of our kids, he addressed the “elephant in the room” by speaking frankly about his condition and prognosis. I won’t share details, but he did mention in passing that the problem with screening is that it “sometimes finds the small ones and sometimes misses the bad ones,” which I took to mean that whatever screening he had had, it failed to find his disease at a more treatable stage.

The comment probably stood out because of the conversation I had had with another doctor friend a week before. We were out to dinner with our wives, and I mentioned our upcoming trip and how a man our age was dealing with metastatic prostate cancer. I guess I must have said something about my own decision to not have a PSA done when I last saw my internist over the summer, to which he nearly erupted at the table. It was some variation on: “Are you nuts? You just told me that you have a friend with metastatic prostate cancer and you don’t want to get your PSA checked?” It is fair to say that the conversation got a bit strained after that. I tried to go with the “poor specificity of the test leading to unnecessary treatment” line of reasoning, but it was clear that there was an unbridgeable gap in our thinking on the subject, and I wanted to bury the conversation before it ruined everybody’s evening, so we dropped it and moved on to dessert.

I think these two related conversations have stuck with me for a few reasons.

First, I am sad about my old classmate, and of course his illness is an unwelcome reminder of my own mortality. Second, they remind me that it is incredibly difficult to separate the “anecdote” from the “evidence” in our clinical practice, and in our own lives. Third, thinking clearly about the risks and benefits of screening is hard: there is a lot of uncertainty in the evidence.  And finally, even if we could all agree on the facts, there would still be no single right answer about what to do.

Ultimately, decisions about screening, like so many other decisions about testing and treatment, come down to personal preferences — how we value certain states of health, how we feel about risk, and how we approach uncertainty.

Ira Nash is a cardiologist who blogs at Auscultation.

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  • Kristy Sokoloski

    Interesting article. Your 3rd item on the list of reasons that you gave abut the thinking on whether the screenings are beneficial or not backs up my thought about that it is a matter of opinion that these screenings, and even for annual physicals. So much (if not the majority seems) of Medicine is based on opinion. And as the expression says about opinions, “everyone’s got one”.

  • Lisa

    I am not exactly pro mommogram, but I think the science shows that screening women between the ages of 50 to 70, every two years, does reduce the death rate for breast cancer. In addition, I believe younger women should consider being screened if they are at high risk. That does require a discussion with a doctor and an undertanding of their risks, both for developing breast cancer and of being screened.

  • Lisa

    Medicine, as practiced in the US, does not do a good job of giving the general public the information they need to make decisions about cancer screening. People need to understand their risks of developing the disease being screened for and the risks of screening.

    Also, it is hard to make intelligent decisions when the medical lobbies push screening so heavily. Every time a study comes out indicating screening younger women for breast cancer may do more harm than good, the radiologist scream bloody murder.

  • Patient Kit

    First, I’m sorry about your classmate friend. As a recently diagnosed cancer patient, the current conflicting info about various cancer screenings is head spinning.

    A year ago, I was diagnosed with early stage (1a) ovarian cancer. When I tell people this, their first question is almost always: How did your doctor find it early? There is no routine screening for OC, no counterpart to mammograms for breast cancer or Pap smears for cervical cancer, imperfect as those screenings may be.

    That said, my ovarian cyst was found during my annual pelvic exam during my annual well woman visit (another thing that some say is unnecessary). Probably because of my age (mid fifties), my GYN wanted to get a look at the cyst so she ordered a transvaginal ultrasound. The cyst looked “suspicious” so she ordered a CA125 blood test, imperfect as that test is. It came back elevated.

    Long story shortish, I ultimately ended up in the hands of an excellent GYN oncologist, who did my surgery and who I now see every 3 months to monitor for recurrence. At my 6-mo post-surgery visit, he asked me when I last had a Pap smear. I told him a year ago but asked him why I still needed a Pap smear when I no longer had a cervix. He responded “good question!” without any bit of annoyance or condescension. He explained that it is an inexpensive test that can still pick up on abnormal cells. That made sense to me and because I trust him, we did the Pap. He won my trust earlier when he discussed his reasoning for not doing chemo. I told him that I trusted him but that I needed him to make me understand WHY I didn’t need chemo. He took the time to do that calmly and compassionately.

    I continue to want to have an annual mammogram. Evidence-based medicine is fine to a point. But it is not the only thing in play and it has it’s shortcomings. For starters, you can only measure things that are measurable. You can measure deaths but what about quality of life based on individual priorities?

    People, both doctors and patients, wish medicine was more of an exact science than it actually is. But as my very wise GYN ONC has said to me more than once “There are no guarantees.” I agree with the original poster that cancer screenings are a matter of personal preference that should be the subject of discussion and decision between each patient and their doctor.

    • Ira Nash

      Thanks for sharing a personal and moving story. I am struck by the fact that you have what sounds like a great relationship with a physician who listens well and respects your values and preferences. All too often, this is exactly what is missing, and more such “therapeutic” relationships would help patients make better decisions. Better not because they conform with some standard of medical evidence that doesn’t really exist, but better because they are made in light of medical evidence, and reflect patients’ individual values and preferences.

  • Lisa

    If you are referring to the Canadian study that compared mammograms to clinical breast exams, you are correct. But this study was not even mentioned in this article. I suggest you read what the US Preventive Services Task Force says about screening mammograms if want a broader view point.

    One single study does not determine the scientific value of a test or procedure.

  • Sharon

    Thank you for bringing this subject up. You sum it up well in one of your last paragraphs.