ACP Issues 'High-Value Cancer Screening' Guidelines

The American College of Physicians offers, for the first time, a way of thinking about whether or not and how much to screen for certain cancers.

Doctors and patients must stop thinking of cancer screening as an annual ritual that should find all cancers in the breast, colon, prostate, cervix, or ovaries. Instead, they should rethink whether certain types of screening in certain age groups is beneficial at all, or whether it will cause more harm and cost than it will help.

That's the thrust of two papers published May 19 in the Annals of Internal Medicine by American College of Physicians guideline experts Timothy Wilt, MD, of the Minneapolis VA Center for Chronic Disease Outcomes Research, and Russell Harris, MD, of the University of North Carolina School of Medicine and others.

"This is the first time that the ACP has come out with specific recommendations about these five cancers," says Harris. "It's also introduces a way of thinking about how we decide whether to screen or not, and how much to screen." He and Wilt are on the ACP's High Value Clinical Guidelines Committee.

Harris adds that the recommendations are expected to lead doctors and payers to think about measuring quality in terms of measuring rates of overdiagnosis.

"We've had these performance measures now [required by various payers to ascertain quality of physician care] that make doctors check the box how many screening exams they've done. But maybe we will start developing performance measures that give you demerits for overscreening. These are in the works and times are changing, gradually."

"When I was in training, the word overdiagnosis never came up," Russell says. "But the more we've learned, we realize that all cancers found are not necessarily the same. One cancer may be grow very rapidly, while another may not be growing at all. It's the middle ones we need to find out about.

"But if you start screening with high intensity, after a while you don't find many cancers in the middle. All you're finding is the slow growing and the fast growing ones."

The committee reviewed guidelines from the U.S. Preventive Services Task Force and several physician specialty groups to produce "high-value advice statements" for each type of cancer screening where there was agreement.

Some sample statements provided for clinicians screening for cancer:

For Breast Cancer

• Discuss benefits and harms of screening mammography with average-risk women between 40-49 and order biennial screening if an informed woman requests it.
• Encourage biennial mammography screening in average-risk women 50-74.
• Do not screen average-risk women younger than 40 or older than 75, or a woman at any age if she has a life expectancy of less than 10 years.

For Cervical Cancer

• Do not screen average-risk women younger than 21
• Start screening average-e risk women at age 21 once every three years with cytology (Pap) tests without human papilloma HPV tests.
• Do not screen average-risk women with cytology more often than once every three years.
• Do not perform HPV testing in average-risk women younger than 30
• Stop screening average-risk women older than 65 who have had three consecutive negative cytology, or two consecutive negative cytology plus HPV tests within 10 years.

Colorectal Cancers

• Encourage fecal occult blood testing (FOBT) or fecal immunochemical tests (FIT) every year, sigmoidoscopy every five years, combined high-sensitivity FOBT or FIT every three years plus sigmoidoscopy every five years, or optical colonoscopy every 10 years in average-risk adults 50-75.
• Do not screen more frequently than recommended in the above four strategies.
• Do not screen in average-risk adults younger than 50 or older than 75 or those with an estimated life expectancy less than 10 years.

For Ovarian Cancer

• Do not screen average-risk women.

For Prostate Cancer

• Have a one-time discussion with average-risk men 50-69 who inquire about a prostate specific antigen screening to inform about limited potential benefits and substantial harms from the PSA
• Do not screen using the PSA test in average-risk men 50-69 who have not had an informed discussion and do not express a clear preference for screening.
• Do not screen using the PSA test in average-risk men younger than 50 or older than 69, or those whose life expectancy is less than 10 years.

Not Like Choosing Wisely
Harris says the ACP is not trying to design recommendations similar to the American Board of Internal Medicine Foundation's Choosing Wisely program.

"Choosing Wisely is about services that one should do less of, or maybe not do at all. But it doesn't talk about the place where you start doing it, how the intensity of doing screening should build, and the point at which you should stop," he says.

"The idea of screening intensity is important," he adds. "It means at what age, or how late in life, do you stop. And how you screen, by which screening tool. In breast cancer, for example, you could use MRI every year, starting at 30 and going to 95, but that would be very intense. The question is, if that's too intense, how intense should you be?

"ACP is looking at the recommendations and saying that starting at 40 is pretty intense, and you should talk with patients before you do that."

The second paper attempts to put screening in context with five screening concepts.

• Clinicians and patients should see it as launching a cascade of events that can lead to benefit or harm.
• They should regard cancers as not all the same, but with varying rates of growth from slow to fast and from asymptomatic to fatal.
• Clinicians and patients should consider other life-threatening health risks when deciding to screen.
• Screening leads to important benefits for some types of cancer, but "significant harms for many, many more" for example, compared with no screening, annual screening mammography for 10 years prevents about two breast cancer deaths for every 1,000 women at 50 years of age.
• Determining the value of screening strategies is complex, but not impossible.