Mammograms, pap smears and P.S.A. levels, what’s a patient to think?

Each of these procedures has been widely accepted as a means of detecting cancer early and thereby improve ones chances of survival.  The tests themselves are simple to perform and have become an accepted standard of care.  Patients are now being told that the United States Preventative Services Task Force (USPSTF) an independent panel of non-Federal experts in prevention and evidence-based medicine and composed of primary care providers (such as internists, pediatricians, family physicians, gynecologists/obstetricians, nurses, and health behavior specialists) has made changes to their recommendations.

In 2009 USPSTF said that women in their 40s do not appear to benefit from mammograms and women ages 50 to 74 should consider having them every two years instead of yearly. It has also recommended that routine colonoscopy not be done for screening purposes in patients older than 75.  This year it was recommended that pap smears begin at age 21 and be conducted at least every three years and that P.S.A. tests for prostate cancer detection not be performed on a routine basis.

Why the change and what will you do when you see your physician for your next physical exam?  More importantly, what will your physician be recommending when you arrive with your questions?  For starters the tests themselves are not perfect.  Up to 20% of patients with breast cancer may be told their study normal.  Likewise patients may be told they have cancer and when they are worked up with a biopsy they are found not to have breast cancer.  These patients may suffer long-term psychological consequences.  In addition there are certain tumors that will never cause symptoms or shorten a patients life.

For years men have been told to have their P.S.A level checked because prostate cancer is the most common cancer in males with over 30,000 deaths per year.  The recent change by the USPSTF occurred because there is not enough evidence to show that prostate cancer screening saves lives.  The potential benefit to screening is that you might find a tumor early but false positive tests do occur and there are cancers that left untreated may not affect your heath at all.  In addition treatment may have serious side affects.

Where will patients get their information?  A recent study published in the Archives of Internal Medicine found that screening is high even in 80-year olds despite the recommendation that it is not beneficial and may cause harm.  In this study fifty percent of men and women over the age of 75 said they had a test to detect cancer because their doctor recommended it.  Clearly for many patients they may not be receiving the most up to date information with which to make an informed decision.  With physicians having less and less time to spend with each patient we will need to come up with more appropriate means of educating patients regarding these tests.

During the past few years healthcare has become a focal point of discussion with politicians telling us government and insurance companies should not get between a doctor and his patient. While it is true that patients in general trust their physician, the article cited above by Dr. Keith Bellizzi makes it imperative that new educational methods be employed to equip patients with the tools to ask intelligent questions, when tests are recommended, without destroying the doctor patient relationship.  It is clear that the Internet is providing information but answers will need to be tailor made to fit an individual patients situation. Will issues regarding screening be the beginning of a larger dialogue as comparative effectiveness research may eventually call into question procedures and therapies that have been widely accepted in the past but are found to be less effective?  In addition, will we be able to continue to afford therapies that are no more effective but significantly more expensive?

These are issues that will need to be addressed in the healthcare debate.  This is not rationing and one hopes that those who have been against mandates will see that in ordered to provide an affordable healthcare system it is important to makes certain that all patients get the right care at the right time and in the right setting by the appropriate healthcare provider.

Eugene Spiritus is President and Chief Medical Officer of OMyMeds!

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