prostate cancer screening

As cancer surgeons, we witness the fear and anxiety that we create when we tell patients they may have cancer. This fear is understandable, since cancer can be a deadly disease. Options for therapy and treatments can be overwhelming emotionally and physically demanding. We want to use every tool at our disposal to minimize the impact of cancer and maximize the chances of a good result. Cancer screening is a tool like this, but it needs to be used with caution, and the results should be interpreted with caution.

We recently posted a review (JAMA October 21, 2009), the current impact of screening for breast cancer and prostate cancer and found significant room for improvement. Consideration has led to an increase of cancers detected, many of which are not life threatening, and we have not been as successful as hoped in preventing cancer in advanced stages. We are not proposing that we stop screening all we are saying we can and must do better.

The screening is complex because cancer is complex. Not all cancers of the breast cancers or prostate behave the same, and as a result, some people benefit more than others to control. Detection is more effective for moderate to slow-growing tumors or removal of a precancerous condition prevents the disease, such as cervical cancer and colon cancer. For fast-growing or very aggressive tumors, the traditional selection may not be able to help, as these types of tumors have a significant risk, even when they are small and seem curable. For slow-growing tumors, early detection will not make much or any difference.

Therefore breast cancer and prostate cancer, we have substantially increased the risk of being diagnosed with a slow-growing tumor could never have come to the attention in the absence of control, leading people to think they have cancer when no murderer do. In this situation, we may be doing damage and creating anxiety, which often leads to more aggressive treatment options. The more (public and doctors) are aware of the limitations of mammography and PSA testing, the better we can adapt the recommendations of detection, the use of detection results in a prudent manner and provide appropriate options for our patients.

Importantly, proposes a strategy for moving forward. First, we must focus on understanding who is at risk for developing more aggressive cancers and testing of new drugs aimed at improving the treatment and prevention. We must also be aware that the more aggressive cancers can appear as lumps or elevated PSA between normal screens, and not ignore symptoms just because there has been a recent normal screening test.

Second, we must use the tools available (and develop new ones) to determine the aggressiveness of the cancers at diagnosis. This will help patients and doctors have conversations weighing the risks and benefits of interventions, and lead to new tests designed to help secure some patients give up treatment.

Third, we must think about prevention. Our concept of screening should include the use of tools to identify what is the risk that a person has of developing cancer. For prostate cancer, online tools such as Calculator prostate cancer risk, not only predicts the risk of cancer, but the risk to high-grade disease. When high-prevention interventions, such as finasteride should be discussed not only the PSA screening. For breast cancer there are a number of risk models that we use today to help patients and physicians think about the options available medical and surgical prevention and a more intensive and frequent surveillance for those at highest risk.

We may also use risk assessment tools to identify individuals unlikely to benefit from screening, they must avoid detection. In women older than 70, for example, there is no evidence that mammography saves lives, as most of these women often develop less aggressive tumors or inactive. Our advice to women in this age group is to continue to do breast exams, and to seek medical attention if you find a lump. Men and their physicians can use the calculator prostate cancer risk to inform their decision about whether to get a PSA test as well.

Finally, we need a concerted national effort to invest in long-term large-scale studies and demonstration projects to accelerate the pace of learning for the detection and prevention. We all will welcome the day of detection and treatment options are more personalized and effective and less women and men face the phrase "may have cancer."

Dealing with the complexities of honesty detection will lead to more choice for our patients and make tomorrow better care than it is today.

Laura Esserman MD, is professor of surgery and radiology at UCSF. Ian Thompson, MD, is professor of urology at the University of Texas Health Science Center at San Antonio.