Questions Grow Over Usefulness of Some Routine Cancer Tests

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Questions Grow Over Usefulness of Some Routine Cancer Tests

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December 30, 2001

HEALTH

Questions Grow Over Usefulness of Some Routine Cancer Tests

By GINA KOLATA

edical researchers are increasingly questioning one of the most

widely held beliefs in preventive medicine: that screening healthy people for

cancer and catching it early saves lives.

The evidence shows that some screening tests are much more useful

than others, said Dr. Barnett Kramer, the director of the Office of Medical

Applications of Research at the National Institutes of Health.

Some, like Pap tests for cervical cancer and tests for colon cancer,

show clear benefits. But evidence for others, like mammography and a blood test

for early signs of prostate cancer, is less clear, researchers say, and some

experts dispute whether their widespread use actually reduces death rates from

cancer. And some new tests, like spiral CT scans of the lungs, are being

marketed to patients before they have been shown in large, rigorous studies to

benefit anyone.

Tests that detect cancer cannot always discern whether the cancer is

one that will ultimately kill or is an indolent tumor that might never produce

noticeable symptoms.

Even the critics of widespread testing are not necessarily

advocating that people forgo it. But they say people should know what the

demonstrated benefits are, and the risks, because once people know they have a

cancer they usually seek treatment, and the treatments can be debilitating, even

life-threatening.

" This is the `Emperor's New Clothes' of American medicine, " said Dr.

Clifton K. Meador, director of the Meharry-Vanderbilt Alliance, a cooperative

program between the two medical schools in Nashville. Dr. Meador, who has

written on the drawbacks of screening tests, said the general enthusiasm for

screening tests reminded him of what a medical resident once replied when asked

to define a well person: " Someone who has not been completely worked up. "

Such concerns became an issue recently when scientists in Denmark

reported that their analysis of mammography studies had found that the tests did

not lower the overall death rate from breast cancer and that, as a group, women

who had the tests ended up with more surgery, including mastectomies, more

radiation and chemotherapy than women who were not screened. Their analysis is

now being studied and debated, but, many medical experts said, at the very least

it points out that even mammography may produce the same problems as other

screening tests.

Mammographers are not convinced, and they stress the advantages of

finding cancers early. " Early diagnosis translates for many — but not all —

women into lower mortality, " said Dr. Sickles, a professor of radiology

at the University of California at San Francisco. And doubts cast on a test's

effectiveness do not mean that individual people will want to forgo them.

But some researchers studying the issue say they have been

personally sobered by the unforeseen consequences that can arise when seemingly

healthy people sign up for a screening test.

Dr. Swensen, for example, said he began a study of lung

cancer screening three years ago, hoping to find that it could prevent deaths

from lung cancer, the leading cause of cancer death for American men and women.

He screened 1,520 smokers and former smokers with spiral CT lung

scans. As he expected, Dr. Swensen, the chairman of the radiology department at

the Mayo Clinic, found lung cancers — 37 malignant tumors. But he also found

more than 2,800 suspicious lung nodules, hard lumps of cells ranging in size

from a grain of rice to a pea, that required further testing. Sometimes the

testing included chest surgery, which itself carries a 4 percent risk of death.

He found nodules of unknown significance on people's kidneys and

adrenal glands. And he found aneurysms, bulging bubbles on blood vessels. In the

end, Dr. Swensen said, more than 90 percent of the group had something

suspicious on one or more of their scans.

Some ended up with surgery that may have saved their lives. But

many, Dr. Swensen said, suffered needless operations and other medical

procedures for something that may have been innocuous.

It is not even clear yet whether the early diagnosis of lung cancers

helped, Dr. Swensen said. Some of the tumors might have been too slow growing to

be dangerous and others might have already spread by the time he found them.

People who undergo spiral CT lung scans probably " assume that this

could save their lives, " Dr. Swensen said. " That is absolutely, unequivocally

unproven. "

But patients do not usually look at screening tests from that

perspective. " They think they have little to lose, " said Dr. H. Woolf, a

professor of family practice at Virginia Commonwealth University in Fairfax and

a member of the U.S. Preventative Services Task Force, a federally sponsored but

independent group that evaluates evidence for screening tests and publishes

guidelines. " They have little idea of the risk that awaits them. "

Others say the same.

" People think that the early detection of cancer is absolutely and

unequivocally a good thing, " said Dr. J. Stanley, the head of the

radiology department at the University of Alabama at Birmingham. But even when a

test detects cancer, the discovery may not be lifesaving.

For example, Dr. Stanley said, 60 percent to 100 percent of thyroid

glands in people over 60 have cells in them that a pathologist would call

cancer. But, he said, fewer than 1 percent of older people ever develop symptoms

of thyroid cancer.

" I believe in screening, " said Dr. Wolf, associate professor

of general internal medicine at the University of Virginia, who has studied what

people understand about screening. " But I think physicians as well as the public

tend to overblow the risks of cancer. And, more important, we overblow the risk

reduction conferred by screening. "

Dr. Wolf said that he offered women Pap tests and, for those over

50, mammograms. He also offers colon cancer screening tests to men and women

over 50. But he said: " I don't get bent out of shape when people refuse. We can

operate on the margins by offering these cancer screens, but let's be honest

about the expected impact. "

Continued

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