Has your primary care physician talked to you about being screened for cancer? For most of us the answer is a resounding yes, since to avoid messaging about screening colonoscopy, for example, would likely require being deaf, dumb and blind, as well as residence in a cave in the Ozarks, perhaps. So virtually all of us are exposed to messaging about cancer screening of various types, raising the likelihood that if our doctors don't mention it to us we will probably mention it to them. But as Rick and I talk about on PodMed this week, do physicians reveal the potential harms of screening, including the probability of overdiagnosis and subsequent overtreatment? That's the substance of a research letter in JAMA Internal Medicine this week, and to that, the answer is a resounding no.
Researchers engaged 317 men and women ranging in age from 50 to 69 years from across the US in an online survey querying their exposure to screening programs. Clearly this is an age range where such exposure is likely to be high. No one included in the survey had had cancer. Approximately 20% of the sample had undergone one screening, 36% two screenings, 27% three, and 17% none. Mammography was reported most often by women, and PSA testing or colonoscopy most common among men. Most damning, only 9.5% reported that their physician had apprised them of the risks of overdiagnosis and overtreatment when discussing screening tests with them, while 80% expressed a desire to be told of such risks prior to having screening.
Also concerning was the fact that among the very small number who reported being informed by their physician of these risks, the quantification of the risk was incorrect based on current literature. When confronted with the number of people who would be overdiagnosed in order to save one life, 69% of participants indicated that if that ratio was greater than or equal to 10:1 they would not undertake screening. The authors reveal that these are the ratios associated right now with both mammography and PSA testing.
Hmmm. So what is a caring physician to do? Clearly, being informed on current statistics regarding the harms and benefits of cancer screening must underpin any recommendations. Admittedly, these are moving targets but also easily accessible, and it behooves providers to know them. As medicine moves increasingly toward not just involving patients in their own caretaking decisions but holding them responsible for doing so, clear and current information must be provided. The authors cite another study regarding physician awareness of current risks of overdiagnosis for mammography and PSA testing, and only about 34% and 43%, respectively, knew the correct numbers.
Patients too must attempt to become informed before undertaking screening, just as many investigate other aspects of healthcare. As I am so fond of saying, no one is more vested in your health than you are.
Other topics this week include contamination of breast milk purchased via the web in Pediatrics, the disturbing increasing burden of stroke worldwide in the Lancet, and the impact of counseling and HIV testing in JAMA. Until next week, y'all live well.