Column: Evolving Cancer Screening Guidelines

June 3, 2015

Michael R Weitekamp[Opinion column written by Dr. Michael R. Weitekamp MD, M.H.A., Chief of Staff, Bermuda Hospitals Board]

The recent public, political and social media backlash against the change in mammogram screening guidelines issued by the United States Preventive Services Taskforce [USPSTF] and adopted within the Standard Health Benefit [SHB - formally known as the Standard Hospital Benefit] for Bermuda is understandable.

Just the word “cancer” may invoke a very personal and visceral reaction of suffering, early death and concern for those we might leave behind.

An identified cancer is tragic enough when worrisome symptoms bring us to the doctor and those symptoms then prompt the testing which leads to the diagnosis.

But imagine you are perfectly healthy, happy, symptom-free and going about your busy, hopefully fulfilled life, when a screening test comes back as “suspicious” and your doctor now recommends some follow-up testing.

Suddenly you are no longer well, you have become a patient.

Even if the screening test turns out to be a false alarm – as many of them will – survey studies have shown that many people suffer heightened and long-lasting psychological symptoms, including anxiety and depression from such encounters with the health system. And as the sensitivity of various screening tests improves – including digital mammography, ultrasound, MRI, certain blood tests, etc. – the risk of both false positives and genuinely abnormal findings – i.e. “true positives” continues to rise – although these ‘true positives’ might not necessarily be life-threatening. We are transforming more and more healthy people into patients.

This might be a good thing if the medical community always knew what to do with what is found and if the natural history of every abnormal finding was fully understood.

Unfortunately, the purported benefits of early screening and early diagnosis are increasingly being called into question. Some very good data and thoughtful scientists interpreting that data have gone so far as to say we are in the midst of an epidemic of “over-diagnosis”.

What is “over-diagnosis”?

It occurs when you are diagnosed with something that was never going to cause you symptoms or shorten your life, and yet once diagnosed, both you and your physicians feel obligated to do something about it.

When universal screening programs target people without symptoms and lead to “over-diagnosis” they are doing more harm than good. In other words, rather than saving lives, they may be shortening some and adversely effecting the quality of many more.

This is why you have seen changes in the screening guidelines of most advanced jurisdictions and almost invariably these changes are to less aggressive screening for the reasons mentioned above.

Sticking just with mammogram screening for the moment, the official public guidelines in the US have been for every other year screening in women of average risk, beginning at age 40 through age 74 since 2009. Just this year the US is proposing changing the age to commence screening for average risk women to 50 years.

The United Kingdom, Australia and Canada already recommend screening only every 2-3 years. Sweden is on the verge of recommending the elimination entirely of routine, population-based screening for average risk women by mammography due to the failure of studies to demonstrate improved outcomes and due to the demonstrable harm that can be attributed to excessive screening.

It is patent nonsense to suggest that all these professionals and public health authorities are ignorant of the truth and insensitive to the needs of the average person. They are basing decisions on the best outcome data available.

Even a widely held assumption as fundamental as “early and frequent mammograms save lives” has been called into question for a number of reasons.

First, even the most optimistic estimates, based on studies of over one half million women over many years and many jurisdictions show that you must screen over 2000 average risk women for at least 10 years to potentially demonstrate one life saved by screening. Yet, over those 10 years nearly half of the women will be subjected to the harm of a false alarm requiring additional testing, perhaps a biopsy and all the attendant psychological issues mentioned earlier.

Now we also are beginning to understand that some are being “over-diagnosed” in the sense that some of the “cancers” being discovered are not inherently aggressive and may never have caused symptoms or death if left “undiscovered.” Yet, due to lingering uncertainty, these patients often undergo surgery and radiation therapy, each with its own immediate and delayed risk elements. Indeed, the breast cancer-specific death rates are showing slow and steady improvement over recent decades in many parts of the world. However, research models cannot and do not attribute this phenomenon to more screening, but to the fact that treatments have improved for established breast cancers, that fewer women are prescribed the hormone estrogen at the time of menopause and that many of these early “cancers” being found and perhaps never destined to shorten someone’s life are now treated, thus making the statistics appear better than they actually are.

I don’t harbor any delusion that an opinion piece such as this will change the minds of anyone with strongly held beliefs, personal anecdotes or vested interest in the status quo. These are complicated questions and to quote H.L.Mencken, “for every complex problem there is an answer that is clear, simple and wrong.” However, I do believe that those who express strong opinions are obligated to provide supporting data. I spent the first 36 years of my medical career in an academic setting and we had a saying that I am quite fond of recalling at times such as these…. “In God We Trust…everyone else must bring data.”

So, guideline recommendations have changed for many diseases and they are likely to change with even greater frequency in the future as we learn more and more about the natural biology and history of certain cancers and more about the unique genetic predispositions of segments of a population. It is very important to realize that population screening guidelines are directed at primary care providers and at individuals at average risk and without symptoms. Such guidelines are not meant to dictate every circumstance and nuance of clinical reasoning and risk. When in doubt, I would encourage anyone to speak with their physician and to be willing to ask question and to educate themselves. Please remember, above all else, that your long-term health and wellbeing depends so much more on your day-to-day choices regarding how you eat, sleep, drive, move, smile and socialize than on any medical test that you might choose to consent to.

For those interested in additional reading that touches on this issue and much more in an informative and entertaining fashion I highly recommend the book “Overdiagnosed: Making People Sick in the Pursuit of Health” by Drs H. Gilbert Welch and Lisa Schwartz.

For anyone interested in finding more information on any number of health issues that are framed in terms of the number of persons needed to treat [or screen] to help one person, contrasted with the number needed to “harm” by the same intervention, simply try out the web-site entitled TheNNT.com. This site is run by a group of physicians who developed a rating system to evaluate therapies or diagnostic interventions for patients based on potential harms and the desired outcomes….very informative and a great resource for truly informed consent and shared decision making with patients.

- Dr. Michael R. Weitekamp

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Comments (22)

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  1. watching says:

    OBA is pulling out all the stops on trying to convince Bermudians that later testing is better for the population.
    It is really sad.

    • Spectator says:

      Maybe you should open your mind and listen to our medical experts. Women have been told for years to have mammograms every year, with good reason, but the science and the practice of medicine has changed. There was a time when taking hormone replacement therapy after menopause was uniformly recommended by doctors because they thought it protected the heart as well as reducing symptoms of menopause; now, after decades of experience with HRT and studies with millions of patients, they have changed the HRT guidelines. Same thing with mammograms. The science is changing as more evidence has been collected.

    • Bettty says:

      This is about Women’s Rights to have their screening yearly. The OBA seems to be making it a political one only and failing once gain to listen to the needs of women. Yearly Screening at 40 is a Right.

      It is very important that folks……do not support this bill…..it takes away women’s rights to screening.

      Please Hang your Bra this Thursday on the Cabinet grounds at 6pm to support screening at age 40.

      Our Lives Do Matter

      • Rhonnie aka BlueFamiliar says:

        ~points to self~
        Woman not having rights taken away by this legislation. And understands that because I keep myself informed, talk to my GP and read the things presented.

        If I need to be screened yearly due to risk level, no problem.
        If I want to be screened yearly and my GP agrees, no problem.
        If I want to be screened yearly and my GP doesn’t agree, I can find a new GP, no problem.

      • Zevon says:

        It’s not about women’s rights. It’s about medical outcomes, and what is best for the patient.

    • Sara says:

      Stop it you idiot just stop the bull***. These are the guidelines being implemented all over the world. This has nothing to do with politics. Get a life!

      • Lauren furbert says:

        Just asking ..why has this even become an issue to be legislated? No other medical treatment is! It became political when cabinet got involved. The issues you and many. Others are overlooking is the the genetic pool we have here. It exist no where else we really are another world. Why are we not looking at the research of the partners group by dr. Kevin Hughes. As it pertains to Bermuda!

        • Spectator says:

          It is legislated because it is a small portion of a larger bill that deals with setting the Standard Health Benefit, which has always been established by the Government every year. It used to be called the Standard Hospital Benefit, and it defines what it covered (or not) by the Standard Premium Rate. Having said all that, healthcare financing is complicated. If you read the Minister of Health’s original statement to the House two weeks ago, she explains it.

    • Casual Observer says:

      Can you refute any of his statements?

      Or are you and the keyboard warriors more qualified than this gentleman and the numerous other medical professionals within the jurisdictions he noted in his piece?

    • jt says:

      Dr. Watching, I presume?

  2. rhonda says:

    It makes no sense hearing from the choir, as the saying goes. If this is about health why does these changes only affect the under insured and the uninsured. Certainly something so detrimental to a woman’s health, should apply across the board to all.

  3. um um says:

    Thank you for an informative reasoned dissertation on the topic.

    There are many who will be relieved, and happy to avoid an unnecessary, uncomfortable “screenings”.

    Having had a “scare” with a “safe” outcome, I can only say that self examination, in the case of breast cancer, is essential. The routine test came at the wrong time.

    … and Please, can we stop making everything political and become “Team Bermuda” to work through these difficult times? We are already seeing significant increases in health insurance premiums as a result of the increased costs of running the new hospital wing. We cannot change the debt incurred, (and those who need the hospital are enjoying the benefits of nicer surroundings), but we must work together to reduce it.

  4. Alvin Williams says:

    One more issue that proves that the disconnect of this government from the people of Bermuda grows wider by the day.

    • jt says:

      And here we all thought you were a mail man, when in fact you’ve been a closet Oncologist all these years.

  5. Back-in-the-day-girl says:

    Quote “Now we also are beginning to understand that some are being “over-diagnosed” in the sense that some of the “cancers” being discovered are not inherently aggressive and may never have caused symptoms or death if left “undiscovered.” unquote.

    I don’t know about the next person, but I do not wish to have anything cancerous inside of me regardless of the type, just to save the insurance companies a buck. ‘What you don’t know won’t hurt you’ just does not sit well with me in this case.

    • de fence says:

      It’s not to save the insurance company money, it’s to save YOU money.
      If there are excessive test done of course it affects the insurance premium we all pay.

  6. Bettty says:

    Stop it OBA. Will the real OBA Women MPs stand up for Women? Or will they toe the party line. This issue is about women’s lives, take off your political hats and stand firm. This is an issue worth fighting for, the Rights of all women to be screened every year beginning at age 40.

    Please stop with taking away the rights of women.

  7. Incognito says:

    So what are Bermudas STATS? Surely with such a tiny population we can track how many have had false positives and at what age.

    I’d rather a needle in my breast to confirm non malignancy than no needle and unknowingly have cancer.

    Betty, along with bra’s on cabinet grounds, do you know if there will be a rally? I signed the petition but I don’t feel like that’s enough.

  8. First do no Harm says:

    It is patent nonsense to suggest…
    This man is disrespectful…He does not need to be rude and begin to insult the intelligence of our people. We are fearful because we know that private financial interest are often at the bottom of changes in practices and policies. Don’t get rude and disrespect our people because we are not playing to the tune of your puppet master. You may be correct but the way in which you have communicated is not patient sensitive, respectful or service oriented. You need to go back to your academic environment and I don’t think you really trust God either!

    • jt says:

      Rude? You’re doing a fine job of it.
      Explain to us how the doctor is being rude please.

      • Double D says:

        Because his opinion isn’t the same as theirs.

        That’s just rude to some.

  9. Legal Eagle says:

    Dear Posters: First read ‘Ronnie’s post above-+ ‘jt’s posts afterwards! Says it all!!!!!