American College of Physicians Releases High Value Care Screening Advice for Five Common Cancers
In a very common sense thoughtful article these authors discuss the concept of what makes a screening test high or low value and why. Can they be harmful and lead to more tests and false positives and even therapy for something that is not there? This article walks you through the right thinking intellectual steps on how we all must come together and address these issues- Do all non risk men with an initial negative colonoscopy need one every ten years- can ultra sensitive fecal occult blood testing be as good? Why are we doing Pap smears in women without a cervix. Why do we so frequently scare the bejesus out of older white males with a slightly elevated PSA thinking they must have prostate cancer- biopsies are no joke, neither is overtreatment as the majority of elderly white males will have usually early and non consequential prostate cancer if you looked hard enough and sadly many have looked and it is not comfortable or necessary. Now, an African American male or one with a positive family history with an elevated PSA, well its a different disease in them. The point is to THINK through what is screening what is high value and what is not. This group published in the Annals the five cancers they think there is data to support screening but in each case, colon, cervical, ovarian , breast, prostate . The devil is in the details of assessing PRE TEST risk to direct any screening and what type of screening Dr Ryan
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– John Smith, MD
–>In a paper published in Annals of Internal Medicine1, the American College of Physicians (ACP) issued advice for screening average risk adults without symptoms for five common cancers: breast, colorectal, ovarian, prostate, and cervical. In a companion piece also published in Annals2, ACP outlined a framework for thinking about the value of varying intensities of cancer screening.
“ACP hopes for smarter screening by informing people about the benefits and harms of screening, and encouraging them to get screened at the right time, at the right interval, with the right test,” said Wayne J. Riley, MD, MPH, MBA, President, ACP. “Many people have a lack of understanding about the trade-offs of screening. Study after study has consistently shown that patients and many physicians overestimate the benefits and are unaware of and/or downplay the potential harms of cancer screening.”
Synthesis of Guidelines
In “Screening for Cancer,” ACP reviewed clinical guidelines and evidence synthesis issued by the United States Preventive Services Task Force, the American Academy of Family Physicians, the American Cancer Society, the American Congress of Obstetrics and Gynecology, the American Gastroenterological Association, the American Urological Association, and ACP.
“We found much common agreement on high value care screening among different organizations,” said Tanveer Mir, MD, MACP, Chair of ACP’s Board of Regents and a member of ACP’s High Value Care Task Force, which developed the papers. “Our advice puts that agreement together in one convenient place for physicians and patients. Many major physician organizations are seeking to implement strategies that best optimize the known benefits and harms of cancer screenings.”
Various screening strategies exist for each of the cancers highlighted in the paper. High intensity screening strategies (screening broader populations, more frequently, and/or with more sensitive screening tests) are not necessarily high value care. ACP defines high value care as the delivery of services providing benefits that make their harms and costs worthwhile. ACP encourages physicians to implement a health care strategy that focuses on tests or treatments that improve health, avoid harms, and eliminate wasteful practices.
Screening average risk adults ages 50 to 75 for colorectal cancer with high sensitivity fecal occult blood testing every year is an example of high value care. Screening women without a cervix for cervical cancer is an example of low value care.
“The largest harm that can result from overly intense screening is overdiagnosis and overtreatment,” Dr. Riley said. “The more sensitive the test we use or lower the threshold we establish for an abnormality, the more abnormalities we find—many of which will never lead to health problems. But because doctors cannot know which of these would or would not cause problems, we tend to treat them. Treatment for cell and tissue abnormalities that will likely not cause health problems cannot provide benefits.”
Prostate cancer, for example, detected with the prostate-specific antigen (PSA) test, never becomes clinically significant in a patient’s lifetime in a considerable proportion of men. Screening using the PSA test in average-risk men under the age of 50 years, or over the age of 69 years, can open the door to more testing and treatment that might actually be harmful. If cancer is diagnosed, it will often be treated with surgery or radiation, which increases the risk for loss of sexual function and loss of control of urination compared to no surgery. This does not apply to those men considered to be in high-risk groups, such as African American men or those with a strong family history of prostate cancer.
Causes of Overscreening
In “A Value Framework for Cancer Screening,” ACP speculates about pressures that encourage overly intensive low value screening. The paper lists and discusses five general concepts:
1) Screening is a cascade of events, rather than a single test.
2) Cancers are heterogeneous. Optimal intensity screening strategies seek to find that subset of abnormalities that has the greatest probability of progressing to cause health problems, and that is more treatable at an early, asymptomatic stage.
3) Individuals are heterogeneous. Optimal intensity screening strategies focus on people with sufficient risk of having a potentially fatal cancer who also have low competing health risks from other causes.
4) Although screening leads to important benefits for some cancers and some people, it can also lead to significant harms to many more people than those receiving benefits.
5) Determining the value of screening strategies is complex, but not impossible.
About the High Value Care Initiative
ACP’s High Value Care Initiative is designed to help doctors and patients understand the benefits, harms, and costs of tests and treatment options for common clinical issues so they can pursue care together that improves health, avoids harms, and eliminates wasteful practices. ACP defines High Value Care as the delivery of services providing benefits that make their harms and costs worthwhile. ACP’s High Value Care Task Force papers focus on value by evaluating the benefits, harms, and costs of a test or intervention. ■
1. Wilt TJ, Harris RP, Qaseem A: Screening for cancer: Advice for high-value care from the American College of Physicians. Ann Intern Med 162(10): 718-725, 2015.
2. Harris RP, Wilt TJ, Qaseem A: A value framework for cancer screening: Advice for high-value care from the American College of Physicians. Ann Intern Med 162(10): 712-717, 2015.