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Screening for Breast and Prostate Cancers — Not Living Up to Its Reputation?

Diagnosis of early breast and prostate cancer has risen with screening, but the number of advanced cancers has not fallen.

Breast and prostate cancer account for more than a quarter of all cancers in the U.S., and the American Cancer Society (ACS) has supported extensive screening programs for both. A new analysis suggests that we rethink screening for breast and prostate cancer. During the last 20 years, after screening was introduced, incidence of breast and prostate cancer rose and never returned to prescreening levels; also, more cases were early cancers. However, the absolute number of advanced breast and prostate cancers that were diagnosed during this period has not fallen as predicted. Thus, whereas colon and cervical cancer screening detects precancerous, treatable conditions (e.g., polyps, cervical intraepithelial neoplasia), prostate and breast cancer screening promotes detection of early cancers, some of which might not be destined to progress or to be lethal. The ACS plans to modify its message in early 2010 to indicate that prostate and breast screening benefits might have been overstated, possibly leading to overtreatment of patients with small cancers (New York Times Oct 10 2009).

Comment: Explaining "small" cancers to patients is difficult, as simply uttering the word "cancer" can invoke intense anxiety. The authors suggest that minimal-risk lesions should not be called "cancer," but rather a term such as "indolent lesions of epithelial origin (IDLE)." Patients who are aware that mortality associated with breast and prostate cancers has fallen during the last 2 decades might attribute the decrease to screening instead of to better treatments. The authors also point out the importance of developing different means (e.g., biomarkers) to determine whether tumors are likely to progress without treatment; in addition, they emphasize the need to put a damper on treatment for minimal-risk disease, to focus on prevention in high-risk patients, and to develop tools for shared decision making in breast and prostate screening. The ACS's planned modification to its previous screening stance is certain to provoke controversy.

— Wendy S. Biggs, MD

Published in Journal Watch Women's Health October 29, 2009

Citation(s):

Esserman L et al. Rethinking screening for breast cancer and prostate cancer. JAMA 2009 Oct 21; 302:1685.

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