National Cancer Institute NCI Cancer Bulletin: A Trusted Source for Cancer Research News
October 19, 2010 • Volume 7 / Number 20

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Featured Article

Cancer Screening Continues Even after Patients Are Diagnosed with Terminal Cancer

Engraving of a bust of Hippocrates The modern Hippocratic oath warns doctors against overtreatment, which can be broadly defined as medical care that provides no benefit to a patient, either in terms of increased life span or increased quality of life. The benefits of any medical procedure, including cancer screening, must be considered for each individual patient's circumstances. (Hippocrates, engraving by Peter Paul Rubens, 1638. Courtesy of the National Library of Medicine.)

A number of patients with advanced, incurable cancer continue to undergo routine cancer screening tests that are unlikely to provide any medical benefit, reported researchers led by Dr. Camelia Sima from Memorial Sloan-Kettering Cancer Center in the October 13 issue of the Journal of the American Medical Association (JAMA). 

The goal of the study was “to identify a potential opportunity to simultaneously improve care and eliminate wasteful spending in the Medicare program.” Dr. Sima and her colleagues anticipated that a small proportion of patients diagnosed with advanced cancer continue to be screened for cancers other than their primary tumor, despite the fact that they have essentially no chance of benefiting from these procedures. Instead, the researchers found that a “sizeable” proportion of patients with advanced cancer continue to undergo these types of cancer screening tests.

Among 87,736 Medicare recipients age 65 or older who had advanced lung, colorectal, breast, gastroesophageal, or pancreatic cancer listed in NCI’s Surveillance, Epidemiology, and End Results (SEER) tumor registries, almost 9 percent of women received a screening mammogram and 6 percent received a Pap test after diagnosis, 15 percent of men underwent prostate-specific antigen (PSA) screening, and 1.7 percent of all patients underwent endoscopic colorectal cancer screening. These tests were not related to diagnosis or follow-up of the patients’ primary cancer types.

“It takes several years before a clear survival benefit from cancer screening becomes apparent,” explained Dr. Stephen Taplin, chief of NCI’s Applied Cancer Screening Research Branch. “With breast cancer, for example, it takes at least 3 to 5 years after a screening test before fewer women in a screened group die than an unscreened group. That means that a woman needs to have a minimum life expectancy of at least 3 to 5 years to have breast cancer screening affect the length of her life in a meaningful way.” Median survival for the patients in the JAMA study ranged between 4.3 months and 16.2 months, depending on the cancer type, and that is “nowhere near the time needed to benefit from screening for any cancer,” he said.

To understand how the screening rates seen in patients with advanced cancer compared with the screening rates of their peers without cancer, the researchers also looked at the incidence of cancer screening among 87,307 Medicare enrollees without a cancer diagnosis from a random SEER sample who were matched to the cancer patients by age, sex, race, and geographic location. Each control subject had been followed for the same amount of time as the corresponding cancer patient.

In the control group, 22 percent of women underwent mammography during the period studied, 12.5 percent of women received a Pap test, 27.2 percent of men underwent PSA testing, and 4.7 percent of all control subjects underwent endoscopic colorectal cancer screening. The rates of screening among the patients with cancer ranged from 35 percent to 55 percent of the rates observed in the cancer-free control subjects.

In all groups, both higher socioeconomic status and being married were significantly associated with a higher probability of being screened. The strongest predictor of screening in the cancer patients was having undergone screening previously, before a cancer diagnosis.

“The most plausible interpretation of our data is that efforts to foster adherence to screening have led to deeply ingrained habits,” wrote the authors. “Patients and their health care practitioners accustomed to obtaining screening tests at regular intervals continue to do so even when the benefits have been rendered futile in the face of competing risk from advanced cancer…[a] culture of screening on ‘autopilot.'”

Patients and their health care practitioners accustomed to obtaining screening tests at regular intervals continue to do so even when the benefits have been rendered futile in the face of competing risk from advanced cancer…[a] culture of screening on ‘autopilot.’

—Dr. Camelia Sima et al.

This situation is aggravated by the slow proliferation of electronic health records and other “intelligent” technology that would help flag potentially unnecessary care for reconsideration, they continued.

Another contributing factor may be the difficulty, for both patients and physicians, of discussing a poor prognosis and end-of-life issues. “There is substantial evidence that even when physicians recognize that life expectancy is limited, they do not consistently communicate prognosis, and patients may use denial as a coping strategy to face impending loss,” the authors wrote.

But the communication flaws exposed in this paper go beyond end-of-life discussions, explained Dr. Julia Rowland, director of NCI’s Office of Cancer Survivorship. “It highlights the lack of communication between doctors and patients about the risks and benefits of these kinds of procedures. For each individual, you want to tailor your recommendation to the benefit that can be expected,” she explained.

“An important part of the risk-benefit equation is: will a patient have a better or longer life as a result of doing these tests?” said Dr. Rowland. “And the answer in these scenarios, barring rare cases, would be no. In the context of any screening, you have to take into consideration the health and well-being of the individual for whom you’re going to be making the screening referral.”

Some women with metastatic breast cancer can live for more than 5 years after treatment, and these women may benefit from continued screening for other types of cancer, but this is an individual discussion that needs to occur between doctor and patient, said Dr. Rowland.

“We’ve been very successful nationally in promoting routine screening, to both physicians and patients,” she concluded. “However, what we have not been as good at promoting is patient-doctor dialog.”

—Sharon Reynolds

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