Cancer Screening Controversies: Weighing the Pros and Cons

CANCER SCREENING; LOOKING FOR THE “RIGHT” ANSWER
Cancer Screening; Looking for the “Right” Answer
Glenn Solomon

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Outline
1. Introduction
This section introduces cancer screening as a controversial issue from the early years to the
contemporary era. Evidence of screening methods applied in the current era is presented,
together with the basis of these techniques. In addition, there is a brief discussion of the ACS
guidelines and the process of screening, with the focus on breast, prostate, and colon cancer
screening.
2. Research Background
In this section, there is an in-depth analysis of new approaches employed in cancer screening in
the contemporary era. The approaches discussed are PSA, breast cancer, pap smears, and colon
cancer. The applications of the screening of these cancers are discussed to give a clear picture of
what they entail.
3. Primary Methods Used to make Recommendations
In this section, there are different methods of recommendations in screening of women and men.
The women’s screening focuses on cervical and breast cancer while prostate cancer is primary to
men’s screening.
4. Specific Modalities and Data Collection Methods
Under this section is the information that entails the retrospective and prospective analyses in
cancer screening. Population is used as the main interest in which efforts to reduce cancer
predominance are input. Public health and efficacy in screening programs are discussed as
determinants for assessment of long-term efficiency.

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5. Differentiation between Successful v. Unsuccessful Cancer Screening
The focus of this section is the effectiveness of both prostate and breast cancer screening through
review of the appropriate literature.
6. Change of Cancer Screening Recommendations/Guidelines over the Years
While there are continued efforts in discovering ways to improve the existing approaches of
cancer screening, there have been changes made on the recommendations for performance of the
screening. The focuses of this section are new guidelines recommended for screening of colon,
breast and prostate cancers.
7. Current Controversies
The existing controversies in breast, colon and prostate cancer exist among different medical
institutes regarding different modalities.
8. The Effect of Technology on the Cancer Screening Landscape
This section discusses how the development of technology has influenced the process of cancer
screening in the contemporary era. Breast, colon and prostate cancer are discussed specifically in
a bid to highlight how technology has affected each form of screening of the type of cancer.
9. Current Status of Cancer Screening according to the Experts
The status of cancer screening is discussed, with reference to the relevant bodies that are
responsible in making recommendations. These include ACS, USPSTF, and the NCI.

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Table of Contents
Outline.............................................................................................................................................2
Table of Contents.............................................................................................................................4
Introduction......................................................................................................................................6
Research Background......................................................................................................................8
New Approaches to Cancer Screening.........................................................................................8
PSA...........................................................................................................................................9
Breast Cancer...........................................................................................................................9
Pap Smears.............................................................................................................................10
Colon Cancer..........................................................................................................................10
Primary Methods Used to make Recommendations......................................................................11
Cancer Screening Methods for Women.....................................................................................11
Cancer Screening Methods for Men..........................................................................................11
Specific Modalities and Data Collection Methods for Retrospective Analyses............................12
Prospective Analyses Currently Underway ..................................................................................13
Differentiation between Successful v. Unsuccessful Cancer Screening.......................................14
Mammography...........................................................................................................................14
Reasons why Mammograms are not 100% Effective................................................................15
False-negative Results...........................................................................................................15
False-positive Results............................................................................................................16
Overtreatment and Over-diagnosis........................................................................................16
Exposure to Radiation...........................................................................................................16
Prostate Cancer Screening.........................................................................................................17

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Reasons why PSAs are not 100% Effective...............................................................................18
Change of Cancer Screening Recommendations/Guidelines over the Years................................19
Breast Cancer.............................................................................................................................19
Prostate Cancer..........................................................................................................................20
Colon Cancer .........................................................................................................................21
Current Controversies....................................................................................................................22
Breast Cancer ............................................................................................................................22
Colorectal Cancer.......................................................................................................................23
Prostate Cancer..........................................................................................................................24
The Effect of Technology on the Cancer Screening Landscape....................................................26
A.Technology in Breast Cancer Screening................................................................................26
B.Technology in Colorectal Cancer Screening..........................................................................27
C.Technology in Prostate Cancer Screening..............................................................................28
Current Status of Cancer Screening according to the Experts.......................................................29
The USPSTF as Primary Decision Driver.................................................................................33
References......................................................................................................................................36

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Introduction
Screening presents as a controversial issue. Even with people being continually
diagnosed with cancer during a certain phase of their lifetime, it is expected that the community
has become more startled.1
Screening cancer among the healthy population appears to be an
apparent solution especially among the Western states. Cancer occurs as the second foremost
death cause in the US. Approximately one-half of women and one-half of men in the United
States develop cancer at some stage in their lifetimes. Currently, millions of individuals have had
cancer or are living with it.2
Some of the oldest evidence of the existence of cancer is identified
among ancient manuscripts, human mummies found in ancient Egypt, and fossilized bone
tumors.
Screening refers to exams and tests applied to identify cancer as well as people without
any cancer symptoms. The primary screening cancer test to be applied broadly was the Pap test.
It was identified by George Papanicolaou who recognized it as a research technique for
comprehending the women menstrual cycle. Papanicolaou identified its latency in recognizing
cervical cancer prematurely and published his results in 1923. This led to further investigation by
the American Cancer Society (ACS) and its authentication led to extensive use. This resulted in a
70% cancer death rate decrease in the US.3
Mammography techniques were discovered in the
late 1960s while the ACS first recommended them in 1976. Current ACS guidelines comprise
techniques for early identification of cancers of the prostate, endometrium, rectum, colon, breast
1
Kramer, B. S. (2004). The science of early detection. UrolOncol , 22 (4), 344-347.
2
Ibid, 345
3
American Cancer Society. (2013). Cancer Facts and Figures. Atlanta, Georgia.

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and cervix. Cancer-related health check was also developed relating with an individual’s gender,
age and may comprise of cancers of the ovaries, testes, lymph nodes, skin, mouth and thyroid.
Over the years, prostate cancer has become one of the most often diagnosed cancers. In
addition, it is the second foremost cancer death cause among men globally. The evolution of
cancer screening has resulted in the Prostate-specific antigen (PSA) assays and digital rectal
examination in asymptomatic men.4
In addition, the focus has also shifted to application of levels
of serum PSA for the early identification of prostate cancer. The PSA level measurement has
been applied as a prostate cancer-screening tool from the mid-1980s. Contemporary, first-line
prostate cancer screening includes ascertaining serum levels of PSA and annual DRE.
Screening and prevention of cancer has evolved over the past four decades. Cancer
prevention encompasses anti-oxidant and/or nutrients therapy, pharmaceutical agents and
surgery. Numerous recommendations have been set to ensure prevention of particular cancers
comprising of melanoma, cervical, prostate, colon and breast cancer.5
All healthcare
professionals ought to be knowledgeable about the modern screening algorithms and prevention
approaches to make the public aware regarding the potential effect of cancer screening on
mortality rates of cancer. While the most common cancers such as breast, prostate and cervical
cancers have algorithms for cancer screening, other cancers that are less common lack standard
or defined screening recommendations. Nevertheless, the guidelines created by ACS support
individuals to go through periodic cancer screenings through their physicians. The assessment
and screening ought to comprise the evaluation of the skin, oral cavity, lymph nodes, ovaries,
testicles and thyroid as appropriate.
4
Harris et al. (2001). Current methods of the US Preventive Services Task Force: a review of the
process. Am J Prev Med , 20, 21-35.
5

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Additionally, the physician ought to discuss self-examination methods for skin, testicular
and breast cancers. Counseling that is health related can evaluate significant prevention and
screening concerns for instance, physical activity, sun exposure, diet and smoking cessation
among others.6
Public health campaigns have been instituted by the Centers for Disease Control,
other governmental agencies, and private concerns such as those from groups as diverse as
professional athletic associations to individual stage and Hollywood actors. Their vocal and
monetary support has played increasingly effective roles in “getting” the message out to the
public.
Research Background
New Approaches to Cancer Screening
During the 1990s, there was establishment of the National Breast and Cervical Cancer
Early Detection Program (NBCCEDP) to enhance cervical and breast cancer screening
particularly among under-insured, uninsured and low-income women. Twenty years following
this implementation, NBCCEDP possesses considerable infrastructure across the states and
efficient structures to reach undeserved public and assure appropriate follow-up and treatment.
Health care reform created by the ACA (Affordable Care Act) will augment cervical and breast
cancer screening services directed at several underserved and low-income women through
elimination of cost-sharing along with expanded insurance coverage.7
However there are still
expected challenges towards these new directions, such as language barriers, inconvenient
6
Ibid, 347
7
Irwig, L., Houssami, N., & Armstrong, B., et al. (2006). Evaluating new screening tests for
breast cancer. BMJ, 332 (7543): 678-9

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durations to access services, lack of recommendations from providers, self-efficacy or
constrained health literacy, and geographic isolation.
There are four principal ideas in cancer care progress; 1) novel advances to screening in
order to better comprehend the significance of causative agents, 2) new technologies, 3) targeted
therapies and 4) enhanced advances to making an improved life quality available.8
PSA
The Annals of Internal Medicine published new recommendations from the US
Preventative Services Task Force. The information showed that PSA should cease to be a routine
examination for detecting latency of prostate cancer. The Task Force summary has stated that
PSA-based screening outcomes results in little or no change in the development of prostate
cancer and is linked to damages associated with subsequent screening and treatments where they
may not be necessary.9
It was outlined that PSA possesses definite restrictions. If there are any
advantages derived from it, they should’ve been evident by now.
Breast Cancer
It has been recommended that women aged between 40-49 years not take part in routine
mammograms assuming that they did not possess any exact risk factors- for instance a family
history. Following this statement by the US Preventative Services Task Force, the justification
was raised that the screened patient number in order to detect a single cancer was too low to be
significant.10
In the same case, the possibilities of achieving false positives were elevated and the
8
Ibid, 679
9
Weiss, N. S., & Lazovich, D. (1996). Case-control studies of screening efficacy: the use of
persons newly diagnosed with cancer who later sustain an unfavorable outcome. American
Journal of Epidemiology, 143 (4): 319-22
10
Ibid, 320

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ensuing anxiety and biopsies all weighed together. The suggestion was that there were unclear
data for women who were above 70 years in relation to the practicality of routine mammograms.
Lastly it was stated that normal mammograms should be followed by subsequent performance of
more mammograms annually.
Pap Smears
Women who have gone through several negative Pap smears while staying in a sexual
relationship that is monogamous could change to screening annually for cervical cancer.11
Additionally, women aged above 70 years and have gone through several negative pap smears
could skip additional exams. Currently, there exists evidence showing that CT scanning in low
dose for individuals with high risk can identify premature lung cancer. This means that the
cancer can be detected prior to its advancement to ensure that the option of surgery for its
treatment does not exist alone.12
Suggestive evidence regarding this approach exists and shows
that lower CT screening dose is more practical.
Colon Cancer
In the current era, the colon cancer ‘gold standard’ has become colonoscopy. This exam
enables the visualization of the whole colon for each patient, starting from the cecum and ending
in the anus. Because the majority of cancers emerge from polyps, it is possible to remove them
either prior to the development of cancer or at a premature state. The exam is recommended even
though not all people are able to have it performed due to cost. Virtual colonoscopy performed
11
Croswell, J. M., Kramer, B. S., Kreimer, A. R., et al. (2009). Cumulative incidence of false
positive results in repeated, multimodal cancer screening. Ann Fam Med, 7 (3): 212-22
12

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with the use of CT scanning presents as efficient but it needs a dissuader, and colon purge. Also,
if the test proves positive for polyps, a full and complete polypectomy would be necessary
thereby adding to costs. Lastly, Medicare does not cover the test.
Primary Methods Used to make Recommendations
Cancer Screening Methods for Women
The two major cancers that are widespread among the female population are cervical and
breast cancers. In breast cancer, recommendations are made based on a mammogram.13
This
presents as a breast tissue x-ray that is capable of identifying cancer, years prior to tumor
presentation and recognition. The health care provider makes assessments through a clinical
breast exam, and then makes recommendations for the subsequent steps that should be followed
by a patient. Health physicians also recommend the frequency of breast examinations with
relevance to the ages of women. On the other hand, Pap tests are used to provide
recommendations for cervical cancer in women. This test is simple, and involves the collection
of cells in and around the cervix. The test can be performed in a short duration. It is
recommended that the test should start within three years following sexual activity of a woman.
There should be performance of a test each year until there is a determination of a different
screening plan for the patient.14
Cancer Screening Methods for Men
The number one cancer identified in men is prostate cancer. The screening approaches
are comprised of transrectal ultrasound, PSA blood test and digital rectal exam. The performance
13
Friedman, D. R., & Dubin, N. (1991). Case-control evaluation of breast cancer screening
efficacy. American Journal of Epidemiology, 133 (10): 974-84
14
Ibid, 975

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of a digital rectal exam involves insertion of a lubricated and gloved finger into the individual’s
rectum to inspect hard areas and bumps that may be present in the prostate gland. The PSA test
presents as a blood exam capable of revealing abnormally increased PSA levels, signifying
prostate cancer. The third method is the Transrectal ultrasound, which applies sound waves to
create a prostate image on the video screen. A combination of the three tests can make a basis for
recommendations from a health care provider.15
Specific Modalities and Data Collection Methods for Retrospective Analyses
A large amount of evidence for production on the long-standing efficiency of new
screening and modified modalities with relevance to decrease in the invasive disease incidence
emerges from an examination of the outcomes of classified population-based plans. Screening
modality modifications performed in the subsisting screening agendas hence, need to be initiated
in a move that will aid rigorous assessment of long-term efficiency. Two principal determinants
of efficacy of screening programs conducted by the public health are high and wide exposure of
the intended population as well as the value of the absolute screening episode. These are
comprised of the initial screening exam and the subsequent examinations from positive
individuals.
Research is required on 1) techniques to enhance coverage particularly among
disadvantaged populations and (2) for carrying on quality assurance, despite of the operating
screening modality.16
Once there is implementation of an organized structure, there should be
discouragement of unscheduled or opportunistic screening. A limitation that affects data
15
Harris et al. (2001). Current methods of the US Preventive Services Task Force: a review of
the process. Am J Prev Med , 20, 21-35.
16

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collection regarding cancer screening is patient perception issues concerning the type of
screening, which in the least is responsible for non-adherence of patients to recommended
testing. Intraprocedural, periprocedural and patient-based factors may constrain cancer screening
and therefore, present as a modality.
Prospective Analyses Currently Underway
Novel developments directed at cancer screening technology are examinable in cross-
sectional or short-term studies through surrogate efficacy markers such as specificity and
sensitivity for a histological examination.17
This is matched up with screening examinations
identified to decrease the incidence of cervical cancer. An example of this for instance is high-
quality conservative clinical cytology. Such short-term study design is most efficacious if the
same individuals go through both the established and new tests. The adoption of prospective
novel cancer screening modalities especially in a program based on the population ought to be
compared to the cost of the local environment, facilities and expertise. These comprise the
capacity of screen-detected lesion management and initial screening test. Internationally,
countries with constrained resources have created solutions that lie within the healthcare policy
frameworks of those societies as well as those of international organizations.18
Conversely, screening ought to be always initiated following an informed strategic
evaluation inside the national and international context relating with the cancer control agenda,
and only after essential facilities and resources are developed. These should then allow for high-
17
Welch, H. G., & Albertsen, P. C. (2009). Prostate cancer diagnosis and treatment after the
introduction of prostate-specific antigen screening: 1986-2005. Journal of National Cancer
Institute, 101:1325-9.
18

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quality screening, effective management and diagnosis of detected abnormalities in the
population. On the other hand, there have been developments created as a direct result of certain
clinical studies. One such trial is the Prostate Cancer Intervention versus Observation Trial
(PIVOT).19
On the basis of results from the PIVOT study, there have been significant statements
specific to the necessity for advanced methods of screening cancer while also comprehending the
disease. In addition, the PIVOT offers confirmation for the continued ventures on technology,
intended to create methods that address the underlying problems in the onset and progress of
cancer.
Differentiation between Successful v. Unsuccessful Cancer Screening
The focus of this section is the effectiveness of both prostate and breast cancer screening
through review of the appropriate literature.
Mammography
Mammography is the number one technique applied in breast cancer screening during the
early phases, when treatment presents as more efficacious and breast cancer cure is possible.
Several studies have revealed that untimely detection increases treatment options while saving
lives.20
Steady reductions in women’s mortality with breast cancer since the 1990 era have been
linked to an incorporation of treatment improvements and early detection. Mammography has
been identified as a very precise screening tool for women who have increased and average risk.
Identifying cancer at an early phase does not always decrease a woman’s chance of dying from
breast cancer. Although mammograms serve to identify malignant tumors incapable of being felt
through palpation, taking care of a tiny tumor does not assure a relationship of reduced mortality
19
Ibid, 320
20
Ibid, 322

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or treatment. Aggressive or fast-growing cancers may have at times metastasized to other body
parts prior to its detection.
While a woman may be suffering from breast cancer as well as other terminal illnesses, a
mammogram does not aid in prolonging life in such a case. On average, the technique will
identify approximately 80-90% of breast cancers devoid of symptoms.21
All apprehensive
abnormalities must then be biopsied to achieve a receptor-position. Withdrawal of supplementary
lymph nodes then becomes unnecessary.
Reasons why Mammograms are not 100% Effective
False-negative Results
Occurrence of false-negative outcomes in mammograms show normalcy even when there
is presence of breast cancer. Generally, screening mammograms overlook approximately 20% of
breast cancers, which may be present during the screening period. The main reason for false-
negative outcomes is attributed to the elevated breast thickness.22
Breasts hold both fatty and
thick tissue (connective and glandular tissue, together referred to as fibroglandular tissue). Fatty
tissues are revealed as dark when a mammogram is performed whereby fibroglandular tissue is
viewed as white in color. Since fibroglandular tumors and tissue have analogous density, it is
harder to detect tumors in women with thicker breasts.
21
22
Ibid, 975

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False-positive Results
These forms of results are seen when there are abnormalities viewed on mammograms by
radiologists, but there is no actual presence of cancer.23
All unusual mammograms must be
transcribed with supplementary testing (biopsy, ultrasound, diagnostic mammograms) to
ascertain the presence of cancer. These results are widespread among younger women or those
who have had breast biopsies conducted before. Furthermore, they are seen in women who have
a family history of the disease or are being administered estrogen therapy.
Overtreatment and Over-diagnosis
Screening mammograms can lead to identification of ductal carcinoma cases in situ or
cancers that should be managed.24
Nevertheless, the techniques can also identify different ductal
carcinoma (DCIS) and cancer cases that will never result in symptoms or pose danger to the life
of a woman. This results in breast cancer “overdiagnosis”. Management of these latter DCIS
cases and cancers is not necessary and results in ‘overtreatment’. This then leads to unnecessary
exposure of harmful effects to women particularly those linked to cancer therapy.
Exposure to Radiation
Mammograms need very tiny radiation doses. The risk of adverse effects due to exposure
to radiation is exceedingly low, although frequent x-rays have a latency which may lead to
cancer. It has been identified however, that mammography benefits outweigh probable harm
from the exposure.
23
Ibid, 977
24
Black, W. C. (2000). Overdiagnosis: An under recognized cause of confusion and harm in
cancer screening. Journal of National Cancer Institute. 92 (16): 1280-2.

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Prostate Cancer Screening
This type of cancer presents as one of the most widely screened non-skin cancers in men
with an approximately 15.9% lifetime diagnosis risk.25
The majority of prostate cancer cases
have a superlative prognosis devoid of treatment, although some are aggressive. Contemporary
suggestions for screening of prostate cancer integrate the serum PSA level measurement; other
techniques like ultrasonography or digital rectal examination may be included. Convincing proof
reveals that programs of PSA-based screening lead to identification of several prostate cancers
without symptoms. In addition, there is compelling proof that a considerable number of men who
are diagnosed with asymptomatic cancer identified through PSA screening possess a tumor that
is likely to cease progress, or progress in a gradual manner that it can remain in the man’s
lifetime without symptoms.
The principal objective of screening of prostate cancer is to decrease deaths owing to
prostate cancer. Therefore, the overall goal is to enhance the length of life for the patient. An
extra significant result would be decrease in the growth of metastatic disease with presence of
symptoms.26
Men with cancer that is detected through PSA screening can possibly fall into one
out of three classes. They include men whose cancer will lead to death regardless of early
screening and treatment. The next class is men who are expected to have good results in the
absence of screening. The last class is men whose untimely screening and treatment enhances
their survival. Only randomized attempts for PSA screening permit a correct approximate of the
patient number who belong to the latter class.27
Compelling proof reveals that the patient number
25
Ibid, 1280
26
27
Ibid, 213

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evading death through prostate cancer due to PSA screening following ten to fourteen years
appears to be very small. As a sidelight to this main issue is the fact that most data are accrued
via post-mortem autopsies. Men tend to die from other causes than prostate cancer. The prostate
Reasons why PSAs are not 100% Effective
The United States Preventative Task Force on Prostate Cancer has revealed compelling
proof that the use of PSA in prostate cancer screening generates false-positive outcomes; an
estimated 80% of PSA test outcomes that are positive are usually false positive particularly in
cases where cutoffs are fringed by 2.5 and 4.0 μg/L utilized. In addition, there is sufficient proof
that false positive results of PSA in prostate cancer screening are linked to negative
psychological impacts comprising persistent worry and anxiety regarding the disease.
Men who are given false-positive PSA test outcomes are more likely to go through
supplementary testing comprising a single or multiple biopsies in the subsequent year.28
This
occurs in comparison to men who hold negative test outcomes. Novel evidence obtained from
randomized clinical trials of cancer that is detected through screening indicates that about one-
third of the men in the population who have been examined through prostate biopsy experience
transient urinary difficulties, infection, bleeding, fever, and pain. In addition, they may face other
concerns that need check-up from a physician in cases where they regard it as a major or
moderate problem. Among these men, one-percent requires hospitalization and they then must
have constant follow-ups.29
The ACS proposes that from 50 years of age and older, the men with
a standard prostate cancer risk and a 10-year life expectancy receive information regarding
28
29

19
possible advantages of not having a PSA. They should also be given identified restrictions of
testing for premature prostate cancer screening and have a chance to create a consented decision
regarding testing.
Change of Cancer Screening Recommendations/Guidelines over the Years
While there are continued efforts in discovering ways to improve the existing approaches
of cancer screening, there have been changes made on the recommendations for performance of
the screening. The focus of this section is new guidelines recommended for screening of colon,
breast and prostate cancers.
Breast Cancer
The novel guidelines provided by USPSTF, which revise those that were apprised in
2002, propose changing the interval of breast cancer screening from one to two years.30
They
also recommend that for women between the ages 40- 49 years showing high breast cancer risks,
they should consult their physicians regarding the favorable time to start standard, biennial
screening mammography. Furthermore, mammography and physical breast examination can help
to identify presymptomatic breast cancer. Since there is inadequate proof to ascertain the harms
and benefits of mammography in women above 75 years, the revised recommendations suggest
discontinuing screening at approximately 74 years of age.
Since USPSTF identified sufficient proof that educating on self-examination does not
lead to reduction in mortality rates from breast cancer, it proposes against self-examination
30

20
education.31
Up to date evidence is inadequate to ascertain additional harms and benefits or either
film mammography vs. MRI or digital mammography as breast cancer modalities for screening.
Prostate Cancer
According to the new guidelines for prostate cancer screening from the USPSTF, it is not
recommended to screen men below 40 years of age. In addition, it is not recommended to
conduct routine prostate cancer screening among men between 40-54 years of age. For men
falling between 55-69 years of age, the choice to go through PSA screening entails identifying
the advantages of preventing mortality resultant from prostate cancer in one out of every 1,000
men who have gone through screening over ten years against the recognized potential harms.
These are the disadvantages that are linked to treatment and screening. Because of this, mutual
decision-making regarding the test is suggested for men between 55-69 years and are thinking
about PSA screening and going forward because of the patient’s preferences and values.32
To decrease the harms associated with screening, there is preference of a routine
screening intermission of two or more years over screening annually in men who have taken part
in mutual decision-making and made a choice on screening. When matched with screening
annually, it is anticipated that screening intermissions of two years are capable of protecting the
greater part of the advantages and decrease false-positives and overdiagnosis cases. Routine
screening of PSA is not advised in men above 70 years or any man who does not have a life
31
Barton, M. B., Harris, R., & Fletcher, S.W. (1999). The rational clinical examination. Does
this patient have breast cancer? The screening clinical breast examination: should it be done?
How? JAMA. 282.1270-80
32

21
expectancy of above 15 years.33
There is a common agreement of a reduction in the number of
mortality cases that emerge from early detection through PSA screening.
Colon Cancer
The new recommendations for colorectal cancer put more emphasis on the risk of an
individual. People who possess an average threat of colorectal cancer must get screened
beginning at 50 years while those people who have an increased risk (for instance those with a
family or personal history or inflammatory bowel disease) must start being screened before or at
40 years. This is in agreement with the revised guidelines from the USPSTF.34
In creating new
recommendations, there was investigation of the quality of existing guidelines on colorectal
cancer screening from numerous medical institutes to create a “take home message”. This was
intended to be an aid to both patients and physicians on making useful decisions through
discussion between the two parties. The ability of tolerance of these tests to the patients presents
as a means of ensuring that the disadvantages do not outweigh the benefits.
Each test has its harms and benefits. The risk of colon puncture and bleeding may present
as elevated in particular patients who go through invasive procedures such as flexible
sigmoidoscopy and optical colonoscopy. On the other hand, patients at high risk should go
through an optical colonoscopy, presenting as the most sensitive exam and the single most
suggested test that checks through the entire colon. Even though other recommendations have
embraced the significance of individual risk determination, not all have gripped it. Therefore, it
33
34

22
is advisable to identify individuals who are at average risk and make a suggestion for them. In
addition, there is need to consider patients at high risk and propose a different recommendation
for them.35
Patients with relatives who are first degree (such as children, siblings or parents) who
had a colorectal cancer diagnosis are at an augmented risk and must begin being screened at 40
years. Alternatively, they can get screened ten years prior to the specific age, which signifies the
diagnosis of their relatives according to the recommendations.
Current Controversies
The existing controversies in breast, colon and prostate cancer exist among different
medical institutes regarding different modalities.
Breast Cancer
Modalities: performance of mammography with or devoid of clinical breast test
Contemporary controversies: Whether to provide breast cancer screening to women between 40-
49 years of age36
Initiate:
Average risk – mammography routine screening should be provided to women aged
between 50-74 years. For women between ages 40 to 49, there are two nationally distinguished
guidelines:
 The NCCN (National Comprehensive Cancer Network) and the ACS recommend
starting breast cancer screening at 40 years of age for women with average risk.
35
36
Ibid, 20

23
 The USPSTF proposes that starting screening prior to 50 years of age among
women ought to be an individual choice that considers the patient context. This
decision is based on discussions of the specific harms and benefits and the values
of the patient. For women between 40 to 49 years of age, using mutual decision
making comprising of the discussion regarding potential advantages and harms
with the doctor should help in mammography screening.37
Increased risk: Women at a high breast cancer risk may gain from earlier screening as
well as dialogue regarding the strategies for reduction of risk.
Frequency – For women at average risk, NCNN and ACS proposes screening annually while
USPSTF proposes screening after each two years.
Terminate – Consider going forward with screening above 74 years of age.
Colorectal Cancer
Modalities: suggested modalities comprise: flexible sigmoidoscopy, fecal occult-blood testing
(consisting of fecal immune-histochemical examination), or colonoscopy (screening with digital
rectal exam does not present as an effective method for colorectal cancer).
Contemporary controversies: Novel technologies for instance, stool generic testing and virtual
colonoscopy (CT colonography) are not completely recommended or validated for patients with
average risk38
Initiate: for patients devoid of symptoms
Average risk: Screening ought to start at 50 years of age
37
Linda, L., Humphrey, MD, MPH., Mark, Helfand, MD, MS., Benjamin, K.S., Chan, MS.,
Steven, H., & Woolf, MD, MPH. (2009). Breast Cancer Screening- United States Preventive
Services Task Force update.
38

24
Increased risk: Individuals at high risk of developing colorectal cancer need to go
through screening that is more forceful. The ideal age to start screening differs with the
increased risk nature.
Frequency
Average risk: The following should be applied in screening. The screening frequency has
not been completely assessed in clinical trials performed.39
 Fecal occult blood exams with high sensitivity (immunohistochemical test or FOBT)
each year
 Flexible sigmoidoscopy each 5 years inclusive of high FOBT sensitivity each three years
 Performance of colonoscopy each ten years
High risk: the frequency of screening differs with the increased risk nature
Terminate- contemporary recommendations propose discontinuation of colorectal screening at
75 years of age. Earlier extinction may be considered because of shortened life expectancy and
co-morbidities.
Prostate Cancer
Modalities: Digital rectal examination (DRE) and prostate-specific antigen (PSA)
Contemporary controversies: Recommendations from USPSTF are against screening with PSA
for men at average risk and at all ages since the small possible gain does not overshadow the
considerable probable harm. The American Cancer Society proposes discussing the step of
screening at 50 years of age for men whose risk is average.40
On the other hand, the American
Society of Clinical Oncology proposes that for men who have above 10 years of additional life
39
Ibid, 23
40
Ibid, 24

25
expectancy, mutual decision-making take place between physician and patient since individuals’
are likely to value particular advantages over some drawbacks. These disparities of thought
present a conundrum for the ‘average’ physician. Does any physician want to engage with a
patient about screening with a test that averages approximately $35.00 to perform? Most will say
no to that question.
Initiate: If screening of prostate cancer is considered, there should be performance of an
informed and careful decision-making prior to the screening. In addition, clinicians ought to
share choice making with the patients, giving enough information regarding the potential
benefits, risks, uncertainties of prostate cancer screening.41
Average risk: For patients between 50 to 74 ages with less than a 10-year life expectancy,
clinicians may prefer not to initiate testing or may initiate a mutual decision-making
dialogue regarding patient routine screening. In addition, when there is a request for PSA
screening by individual patient, clinicians ought to instigate a mutual dialogue that can
influence the final decision. Again, will they? After all, it took decades to convince men
to advocate for this screening exam as part of a routine checkup for them.
High Risk: For men of African-American descent with a family record of prostate cancer,
there is a need to offer this information and to initiate talking about screening of PSA
beginning at 40 years of age.
Frequency: If PSA screening is performed annually or in each of four consecutive years, this
leads to analogous rates of prostate cancer detection.
41

26
Terminate – Again, the ACS recommends that if the procedure is performed, there should be
discontinuation at 75 years of ages or when there is a less than 10 years life expectancy because
of health status and age.42
The Effect of Technology on the Cancer Screening Landscape
Novel technologies applied in cancer screening are turning out to be a widespread
development. However, no novel technologies so far have unambiguous proof showing either
accurate or reliable detection rates among the general population. Clear evidence also exists that
application of these novel technologies decreases the rates of mortality for patients with cancer.
Little coordinated information provided regarding the possible harms linked with the novel
screening technologies is available. Overtreatment and over-diagnosis is an issue with any
process of cancer screening.43
Until there is stronger and clearer evidence, the ACS does not
advocate the application of any technology for cancer screening other than those available
currently as an element of the programs from the National Screening Unit.
A. Technology in Breast Cancer Screening
The recommendations proposed by different medical institutes advocate that specific
technologies exist for the risk groups in cancer screening. Film or digital mammography is given
for women with average risks while digital supplementation through ultrasound in women with
intermediate risk is used. Furthermore, MRI for digital supplementation is used for women with
high risk. Diversities observed in technologies are associated to differences that have come up
regarding breast tumor and density characteristics in women with higher risk.44
When specific
42
American Cancer Society. (2013). Cancer Facts and Figures. Atlanta, Georgia
43
Woloshin, S., & Schwartz, L. M. (2010). The benefits and harms of mammography screening:
understanding the trade-offs. JAMA. 303:164-5.
44
Ibid, 165

27
characteristics of breasts of an individual woman are presented via certain imaging structures,
there is no doubt that some are more revealing than others. Standard film mammography has
been delineated as the basis of the breast cancer screening programs and a foundation for a large
part of knowledge on the effectiveness of screening.
Mammography, in women, is the single screening test revealed to decrease mortality
rates attributed to breast cancer, roughly wholly through the reduction in the detected cancers.
There has been a 25% reduction of mortality when using mammographic techniques. Women
with average risk are screened using digital mammography which is authoritatively better than
visible through the use of simple eye film.
B. Technology in Colorectal Cancer Screening
There are three principle technologies used in screening for colorectal cancer. They
include 1) fecal occult blood test (FOBT), 2) sigmoidoscopy, and 3) digital rectal examination.45
The digital examination presents as the simplest technology. However, through the examination,
certain lesions may be overlooked since they may be too tiny. In addition, they may mix with the
stool or mucus. The test is safe, inexpensive, and quick and is firmly entrenched in routine
physical assessments. Sigmoidoscopy is applied where 1/5 – 2/3 of adenomatous polyps and
cancers (which might be premalignant) grow. The technology allows biopsy and direct
visualization, or even withdraws of chary lesions. The last colorectal screening test is FOBT used
to screen for occult blood that may be present in a person’s stool.
45
http://www.uspreventiveservicestaskforce.org/uspstf/uspscolo.htm

28
The digital examination has been termed as old while studies have revealed that it has
demonstrated its effectiveness over the years.46
Over the years, studies have found it particularly
difficult to describe the effectiveness of colorectal cancer screening technologies through
variables such as the benefits, risks and costs. This is because there are complications in
ascertaining cost-effectiveness especially in cancer screening procedures.
C. Technology in Prostate Cancer Screening
Generally, due to prostate screening technologies, a considerable segment of men is
screened with the disease. However, the effectiveness of the PSA method is not questionable.
This is because this significant portion of screening occurs through this method and it is clear
that through clinical testing methods, the disease would be hard to identify especially in cases
where there are no symptoms involved.47
Following screening, there can be application of
aggressive treatment for the identified malignancy, often requiring supplementary treatment for
the adversaries emerging from the intervention. The technologies have enabled evaluation of
patients through continued PSA testing.
However, with the additional application of these technologies are the economic, physical
and emotional costs of processes such as surveillance and screening which are considerable. This
is especially so for men screened with potential cancers through this testing process. However,
the current nature of these technologies calls for prospective research especially into survivors of
prostate cancer and the comprehension of the existing evaluating tools as well as the subjective
46
Ibid, 206
47
Harris R. P., Helfand, M., Woolf, S. H., Lohr, K. N., Mulrow, C. D., Teutsch, S. M.,et al..
(2001). Current methods of the US Preventive Services Task Force: a review of the process. Am
J Prev Med , 20, 21-35.

29
effects on the life of patients following treatment.48
With relevance to the continuing disputes
regarding the screening using PSA and its advantage in reducing morbidity and mortality from
the illness, it is vital that the survivors of prostate cancer are incorporated into evaluation of
advantages and restrictions of the technology.
Current Status of Cancer Screening according to the Experts
Satisfying the process of cancer screening requires the serious assessment of high-risk
and average-risk adults.49
These processes need an amalgamation of networks, systems and
incentives that are currently not implemented in a majority of primary care practices. This has
been recommended by the ACS and the USPSTF. Research studies recently concluded the
literature based on the relationship between cancer screening rates and organizational factors.
The studies revealed that the rates of cancer screening were most elevated when approaches were
implemented that: 1) enhance appointment scheduling, referral, and recruitment; 2) decreased the
figure of institutional interfaces needed to finish screening; and 3) enhanced constant patient care
(this means that there should be therapy, management and patient information continuity).50
Currently, particular health care reform aspects that fit in to the Patient Protection
Affordable Care Act (2010) have been planned to reinforce the execution of transformations of
the practice system. These aspects enable the application of approaches and novel concepts of
delivery of primary care, especially the medical home. The aspects also comprise the
organizational attributes that allow for these approaches and are related to increased preventive
care rates. This form of enhancement of practice is greatly required since the National Survey of
Primary Care Physicians by NCI (National Cancer Institute) provided recommendations intended
48
Ibid, 22
49
Ibid, 25
50

30
for cervical, prostate, breast, lung and colorectal cancer screening practices.51
These experts have
demonstrated that <50% of practices carried out through primary care possess a reminder
structure set to inform patients about their pending schedules of cervical or breast cancer
screening.
The elements that have been unambiguous for a while are that these features regarding
the system promote and further facilitate the more elemental factors that are related to regular
and recent cancer screening.52
These include access to care just as evaluated through a basis of
customized interventions, health insurance, screening recommendation from a clinician and
resource of usual care. While practices of screening cancer among health-care providers and
organizations have been given substantial attention, much less interest has been directed on their
attitudes and knowledge associated with cancer screening. The ACS has over the past few years,
carried out national surveys directed towards physicians practicing primary care (general and
gynecologists, obstetricians, internists, and family practitioners) associated with early cancer
screening among adults without symptoms.53
Between the years 1984 – 1989, physicians offering primary care appraised an
augmenting emphasis on detection of cancer early, with the largest rise in emphasis being
attributed to mammography, which had 44%. Furthermore, in 1989, roughly 90% and above
physicians signified that they carried out cancer screening procedures for prostate, cervical,
colorectal, cervical and breast cancer. The questions employed in these surveys revealed
51
Ibid, 346
52
Ibid, 347
53
Kerlikowske, K., Grady, D., & Ernster, V. (1995). Benefit of mammography screening in
women ages 40-49 years: current evidence from randomized controlled trials [Letter]. Cancer.
76.1679-81

31
physician behaviors conducted during the 1980s. It is important to note that prostate and
colorectal cancer screenings were commonly defined by FOBT and DRE.54
Harris also reported
that almost all physicians appraised conducted breast examinations and pap tests and were
consulting women for mammography practices. Only approximately 1 of 10 physicians
appraised used tests for lung cancer. There is no answer to this finding since questions related to
it were not pursued.
Between the years 2006 – 2007, there was a survey led by NCI which gathered analogous
data, but much more specific, on the practices, attitudes, knowledge and practice attributes of
physicians giving primary care associated with lung, colorectal (CRC), cervical, and breast
cancer screening. These appraisals, collectively and individually revealed that physicians
offering primary care are not well founded in the underlying proof sustaining the justification for
recommendations that are age-specific for cancer screening.55
Even though they consider general
guidelines and those from specific institutions as very significant, their self-reported procedures
frequently differ from the guidelines existing across and within practice specialties. Consistent
with these appraisal authors, these differences may be because of lack of knowledge regarding
the guideline details, patient expectations and issues regarding medicolegal liability. Of these
appraisals, self-reported observance with guidelines of national breast cancer screening is most
consistent and strongest for screening of mammography.
Greater than 90% of physicians providing primary care proposed screening of breast
cancer in women of 40 years and above.56
Nevertheless, almost all physicians also propose self-
54
http://www.uspreventiveservicestaskforce.org/uspstf/uspscolo.htm
55
Tabar, L., Fagerberg, G., Chen, H. H., Duffy, S. W., & Gad, A. (1995). Screening for breast
cancer in women aged under 50: mode of detection, incidence, fatality, and histology. J Med
Screen. 2. 94-8
56
Ibid, 96

32
examination of breast on a monthly basis, a performance that is not recommended by both
USPSTF and ACS. The physicians of primary care from these two organizations appraise that
they depend on the majority for recommendations. Additionally, even though these two tests
were generally proposed, most respondents in the survey appraised dissimilar confidence levels
in their efficiency. Physicians performing primary care practices are very positive regarding the
mammography screening effectiveness for 50-year-old women and those older. The percentage
level of confidence has been reported to be 80%. However, a reduced percentage is positive
regarding the mammography effectiveness for women aged 40 years. The percentage has been
reported as 54% showing that controversy still exists about mammography for different
organizations.57
The rates of screening colorectal cancer have increased over the past ten years, with an
increased prominence on FOBT and colonoscopy (CSPY). A reduced number of physicians who
have been apprised of or are aware of the ACS and USPSTF statements are making
recommendations that are consistent with guidelines across all screening modalities of CRC, and
the differences represent both over-screening and under-screening. For instance, some physicians
can propose of screening of CRC among patients aged 50 years using FOBT, a procedure not
advocated for adults at average risk, even though proposed for annual testing.58
This falls in
uniformity with the majority of guidelines derived from national institutes. On the contrary,
some physicians who belong to different medical organizations may instigate CSPY for the same
age group, even though they may suggest the test more often than the proposed 10-year duration.
In this case, the cases of under-screening and over-screening may differ for the different types of
cancers.
57
Ibid, 97
58
http://www.uspreventiveservicestaskforce.org/prostatecancerscreening.htm

33
It is therefore evident that, there is still work in progress regarding the involvement of
different organizations and laws such as the ACA in providing up to date information regarding
the processes of cancer screening. They also demonstrate efforts for coverage, an element that
offers increased screening access devoid of any issues of sharing costs.59
This is intended to add
into increased rates of screening, while contributing novel difficulties on the multistep
procedures required guaranteeing follow-up and screening uptake. To the extent that there is a
possibility in this element, efforts to organize cancer screening could justify this procedure to
enhance the effectiveness of service delivery.
The USPSTF as Primary Decision Driver
Before summarizing, it is important to note the role of the USPSTF. As a primary
provider of thought, the power of these bodies cannot be underestimated. How exactly does each
segment define their recommendations?
Each unit consigns one out of five given letter grades to each one of its proposals to
delineate the commendation’s strength.60
These letters include A, B, C, D, or I. In the year 2007,
the organization altered its grade delineations on the bases of method change, and during 2012, it
also revised the suggestions and definitions for performance of the recommendations assigned
grade C;
Clinicians may provide this service to selected Offer or provide this service only if
59
http://www.hhs.gov/healthcare/rights/law/index.html
60
Steven, H., & Woolf, MD, MPH. (2009). Breast Cancer Screening- United States Preventive
Services Task Force update.

34
patients depending on individual circumstances.
However, for most individuals without signs or
symptoms there is likely to be only a small benefit
from this service.
other considerations support the
offering or providing the service in
an individual patient.
Describing the power of a recommendation is a significant element of putting its
importance across to physicians and other users. Even though the majority of definitions of
grades have grown since the beginning of the Task Force, none has transformed more obviously
than different commendation definitions, such as C. Each letter, in having its own description,
highlights whether the organization endorses a certain practice or not. The level of certainty
relevant to benefits in cancer screening is also provided in the recommendations. The
organization highlights whether the degree is high, moderate, and low. This provides a basis
through which clinicians provide counsel to the patients regarding different forms of cancers.
The experts grade the quality of cancer screening regarding the general evidence offered
for a service of the clinician on whether it is poor, fair or good.61
The task force of the
organization is comprised of 16 members who have volunteered and who perform this job for a
period of 4 years. The experts are derived from fields of primary care and preventative medicine,
including nursing, gynecology, obstetrics, behavioral health, pediatrics, family medicine and
internal medicine. The recommendations are made by the task force to aid primary care patients
and clinicians perform a shared decision-making on the effectiveness of a service relating to the
needs of the patients.62
Its commendations apply to both people with and without symptoms on a
certain cancer and other disease conditions, to which there can be application of a
recommendation. In addition, they are for services delivered, ordered or prescribed in the setting
of primary care.
61
Ibid, 2
62
Ibid, 4

35
The recommendations of the USPSTF are themselves controversial because the
accumulation of evidence is often questioned by critics as being too specific to the action of
retrospective reporting and therefore are not statistically solvent for widespread use. It is often
said by those same critics that reporting data to a physician and then speaking to a patient are two
very separate things. Controversy therein lies.
Summary
The Ultimate Question then is whether cancer screening is the “Right Answer” for all
individuals? The simple answer is that indeed cancer screening is the most efficacious and
common tool required to diagnosis early stage cancers. And yet again, cancer screening can also
“Not” be the right answer for all people—that is the conundrum.
Each society creates a system of screening that it can afford, or to put it another way, “To
Each Its’ Own.” In the United States, a system of cancer screening has been established, that on a
basic level, works quite effectively. While the overall rates of cancer development are
approximately the same for both genders over the past twenty years, the mortality rates and
Quality of Life indicators QOL) have been substantially improved, in part due to screening
techniques.
The greater challenges derive from the effects of “too much” screening in certain groups
and not enough screenings in other groups. The authoritarian groups are striving to make

36
recommendations that are both facilitative of positive performance evidence and yet create
workable and economically based decisions that help the individual and the society in general.
So what is or will be the answer? It is this author’s hypothesis that each technology will
evolve so that, as in drug therapy, an individual will be offered a genetic rationale that focuses on
his or her probability to develop an illness such as those discussed before. They then will make a
decision to test based on that probability of illness.
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39

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