Overscreening of breast/prostate cancer?

[Guest guest]

ABC News

Oct 21, 2009

A firestorm of controversy erupted today when a top official with the

American Cancer Society let slip that the benefits of breast cancer and

prostate cancer screening may have been oversold.

A new article contradicts previous findings on prostate and breast cancer

tests.

The epicenter of the controversy is statement by Dr. Otis Brawley, chief

medical officer of the ACS. Brawley made the statement in an interview with

the New York Times about a Journal of the American Medical Association

analysis of breast and prostate cancer screening, which raised questions

about claims that screening saves lives.

Brawley said the questions raised in the journal article were legitimate,

and he said the ACS was in the process of reworking its message on breast

and prostate cancer screening. According to the Times report, he said the

benefits of screening had been " exaggerated. "

When ABC News contacted the ACS for an interview with Brawley, it was told

that he was attending a family funeral and was not available for comment.

The ACS did, however, release a prepared statement under Brawley's name:

" While the advantages of screening for some cancers have been overstated,

there are advantages, especially in the case of breast, colon and cervical

cancers. Mammography is effective ­ mammograms work and women should

continue get them... The American Cancer Society stands by its

recommendation that women age 40 and over should receive annual mammography,

and women at high risk should talk with their doctors about when screening

should begin based on their family history. "

Brawley also addressed prostate cancer screening in his statement.

" Since 1997 the American Cancer Society has recommended that men talk to

their doctor and make an informed decision about whether or not prostate

cancer early detection testing is right for them. This recommendation also

still stands. "

It's not known if the clarifying statement from ACS will calm the situation,

but it is clear that such a statement may have been needed.

" [Prostate cancer] screening and treatment of prostate cancer has been

widely accepted in the United States and many other countries because it

really works, " said Dr. Catalona, director of the Clinical Prostate

Cancer Program at Northwestern Memorial Hospital in Chicago. " In the U.S.

there has been an 85 percent decrease in the percentage of prostate cancer

cases that present with advanced-stage disease and a 40 percent reduction in

the age-specific prostate cancer mortality rate during the PSA screening

era... I continue to recommend PSA screening to my patients. "

And when asked to comment on Brawley's published statements in the Times,

Dr. Larry Norton, deputy physician-in-chief for Breast Cancer Programs at

Memorial Sloan-Kettering Cancer Center in New York said Brawley and the ACS

were sending the wrong message. While he agreed that mammography is far from

a perfect screening tool, Norton told ABC News, " The simple fact is that if

a woman wants to reduce her chances of dying of breast cancer, she should

choose mammography. "

But Dr. Love, president and medical director of the Dr. Love

Research Foundation, says it's not that simple. Love, who is attempting to

recruit 1 million women for a trial that she hopes will once and for all

nail down the real cause of breast cancer and help lead the way to a way to

prevent the disease, said the real issue is that the current screening tool

­ imaging -- is not up to the task.

" This recent paper points out the fact that we need to go beyond screening

for cancers that are already there, to finding the cause and prevention of

breast cancer once and for all, " Love said. " Not all cancers are alike. We

have focused on the risk factors, chemoprevention, and screening for the

'good cancers' that are hormonally sensitive, and generally postmenopausal,

and have not done as much for the more aggressive premenopausal cancers. "

The correct conclusion is that the current screening techniques are

inadequate, " said Dr. Mauro Ferrari of the University of Texas Medical

School at Houston. " PSA tests and mammograms are indeed obsolete. "

But even it the screening tools are inadequate, Ferrari faulted Brawley for

going public with his concerns.

" The conclusion from the new data that screening is less important than

previously thought is a grotesque and ill-informed logical error, which has

very grave implications for health care policy and the lives and deaths of

all Americans, " Ferrari said.

Meanwhile, Fran Visco, president of the National Breast Cancer Coalition,

appeared to be in agreement with Brawley's thoughts as they appeared in the

Times article.

" The National Breast Cancer Coalition has said for over a decade that

mammography has serious limitations, has not been shown to reduce mortality

in women under 50 and should be a personal decision, not a public health

message, " Visco said. " The American Cancer Society largely helped create the

public's unwarranted obsession with screening, they will have to work very

hard to help fix the current situation which, again, they caused.

" It is long overdue that we recognize that we should not be pushing for more

mammography, should accept that breast self examinations do not save lives

and can result in harm and, rather than try to expand screening into younger

and younger ages, we should focus on figuring out which breast cancers will

be harmful and how to deal with those, " she added.

Dr. Ganz, director of cancer prevention and control research at

UCLA's Jonsson Comprehensive Cancer Center, agreed that the medical

community should take a hard look at breast cancer screenings.

" [M]aybe we shouldn't start screening women until they're post-menopausal, "

she said. " Most of the non-serious pre-cancers and very early, small cancers

would probably disappear as hormone levels drop... I think there are too

many women with pre-cancers and very early cancers that are being

overtreated. "

Brawley is, however, not without his supporters. Dr. , a breast

cancer expert from the University of Michigan, said, " I thought Otis

Brawley's comments were very courageous and thoughtful. "

Moreover, pointed out that this " is a sea-change for ACS, which has

always promoted screening, with or without supporting data. Otis has induced

a new culture into ACS, and he will take heat for it -- so he needs to be

quoted accurately and his intent -- to induce evidence-based medicine into

ACS guidelines -- needs to be understood, without seriously diluting the

beneficial effects that screening does have. "