Are Cancer Centers Pushing Too Many Trials?

Let’s say a postcard arrives in the mail, a reminder to make an appointment for a mammogram. Either the primary care doctor orders a PSA test to screen a man for prostate cancer, or tells him that because he has smoked for many years, he should be screened for lung cancer.

These patients, trying to become informed customers, can search an online cancer center to learn more about screening, when it is recommended, and for whom.

It may not be the best move. Medical associations and the US Preventive Services Task Force independently publish guidelines on who should be screened for lung, prostate, and breast cancer and how often, among many recommendations. other prevention. But the websites for cancer centers often differ from those recommendations, according to three studies recently published in the journal JAMA Internal Medicine.

The researchers found that some websites discussed the benefits of screening but talked little about the harms and risks. Some made recommendations on when to start screening but mentioned when to stop – important information for older adults.

“If we acknowledge that these sites are important sources of information, we should assume that these sites are important sources of information,” said Dr. Behfar Ehdaie, a urologist at Memorial Sloan Kettering Cancer Center in New York and an author of the study. screening according to guidelines where we can improve. on prostate cancer screening recommendations.

Screening refers to tests for patients with no symptoms or evidence of disease, including prostate-specific antigen testing, mammograms, colonoscopy, and CT scans.

Researchers analyzed more than 600 cancer center websites that provide recommendations for prostate screening and found that more than a quarter recommend that all men be screened. More than 3/4 do not specify an age to stop routine testing.

However, guidelines from both the Preventive Services Task Force and the American Urological Association state that men over the age of 70 should not have routine exams, because, according to Task Force guidelines, ” the potential benefits do not outweigh the expected harms”.

For men aged 55 to 69 years, both groups urged individual decisions after discussion with the clinician about the benefits and harms. However, neither group recommended routine screening for young men at average risk for the disease.

Furthermore, the study reports, 62 percent of cancer center websites do not include information about the potential harm of screening. Because prostate cancer grows slowly, it usually doesn’t cause problems. But detection and treatment can lead to complications from surgery or radiation, including a lower quality of life from loss of control and sexual dysfunction.

Surveys have found similar problems on other cancer screening discussion sites. In a study of 600 breast cancer centers, more than 80 percent of those suggested the starting age and interval for mammogram screening contradicted guidelines. The study did not address whether the websites included information about when to stop.

The Preventive Services Task Force 2016 guidelines, which are currently being updated, recommend yearly routine screening mammograms for women aged 50 to 74 years; it did not find sufficient evidence of benefit and harm for people 75 years of age and older. The American Cancer Society recommends annual or biennial screening for women over 55 at average risk, as long as they have a 10-year life expectancy.

However, lung cancer screening is only recommended for people at high risk because of their smoking history and older age. Here, an analysis of 162 cancer center websites found that about half did not mention potential harms.

“We think it’s important to present a balanced account,” said Dr. Daniel Jonas, a resident physician at Ohio State University School of Medicine and senior author of the study. “It’s fair to say they could do a better job.”

Concerns about overuse and overtreatment of some cancers in older adults have persisted for many years. Dr Mara Schonberg, a healthcare and internal medicine researcher at Beth Israel Deaconess Medical Center in Boston, said: But the benefits of screening can accrue years later; Older patients with other health problems may not live long enough to experience them.

With mammography, for example, harms including false positives, leading to repeat mammograms or biopsies, psychological consequences can continue for months, Dr. Schonberg’s research has shown.

And while most breast cancers diagnosed in women over 70 are very low-risk and may never progress, “nearly all are treated with surgery,” says Dr. Schonberg. say, and sometimes later with radiation therapy and hormonal drugs, all of which can have negative side effects. .

In terms of benefits, the data suggest that 1,000 women aged 50 to 74 would have to have mammograms over nearly 11 years to prevent one breast cancer death.

Why do some cancer center websites ignore possibilities such as false positives, repeat tests, radiation exposure, or consequences of surgery? Why don’t they include information on how many lives are actually saved at specific ages?

“In the US healthcare system, the more procedures you do, the more you get paid for,” says Dr. Alexander Smith, palliative medicine specialist and gerontologist at the University of California, San Francisco. more money. Radiography, required for both lung and breast exams, “is one of the biggest money-generators for health systems,” he notes.

Some websites may be developed by marketers with little input from medical professionals, Dr. Jonas added. Talking about possible risks discourages the patient from clicking the “Make an Appointment” button.

On the other hand, it can be difficult to recommend screening for older patients, even if research shows little benefit.

Dr. Schonberg has developed and tested decision support tools – pamphlets to help women over 75 and their doctors make evidence-based conclusions about mammograms.

To some extent, they work. Older women who receive the pamphlets are more knowledgeable and more able to discuss the benefits and risks with their doctors; they are less inclined to continue screening. But over 18 months, about half of the women who received decision support had a mammogram, as did 60% of those who didn’t.

Schonberg explains it as a habit or a “need for reassurance”. Patients may also overestimate their level of risk; She points out that the average 75-year-old woman has a 2% chance of being diagnosed with breast cancer within 5 years.

Furthermore, screening options involve an issue that some older patients (and doctors) want to avoid: longevity. The American Cancer Society and some medical groups use a 10-year life expectancy, rather than an age limit, as a guide for when older patients can stop screening.

“Prognosis is one of the key factors in decision making,” says Dr. Smith. “Will the patient live long enough to experience the benefits?” It can be an uncomfortable conversation regarding age, health, and mortality.

How do older adults self-inform about cancer screening? In addition to discussing the pros and cons with their doctor – Medicare requires such a visit before performing lung cancer screening – patients can visit the website of the Preventive Services Task Force USA for the latest reviews.

They can also use ePrognosis, an online guide that Dr. Schonberg, Dr. Smith and colleagues at UCSF developed a decade ago. Most visitors are healthcare professionals, but patients can also use the site’s calculators to determine if they are likely to benefit from breast and colon cancer screenings. . They can use questionnaires to help determine their likely lifespan, as well as some decision support.

Of course, patients can also refer to the cancer center’s websites – but keep an eye out for what might be missing.

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