Cancer screens for cancer patients reveal ‘auto-pilot’ culture
MKSAP Quiz: gradual memory loss
Patients with advanced cancers frequently undergo cancer screening tests that are unlikely to benefit them, researchers concluded.
Researchers tracked via SEER the use of mammography, Pap smear, prostate-specific antigen (PSA) testing, and lower gastrointestinal (GI) endoscopy in 87,736 fee-for-service Medicare enrollees diagnosed with advanced lung, colorectal, pancreatic, gastroesophageal, or breast cancer between 1998 and 2005. Results appear in the October 13 Journal of the American Medical Association.
In the cohort, 61% had stage IIIB-IV lung cancer, 14% had stage IV colorectal cancer, 14% had advanced stage pancreatic cancer, and 11% advanced gastroesophageal cancer or stage IV breast cancer. The cohort was matched by demographics to 87,307 cancer-free Medicare enrollees.
Among women with advanced cancer, 8.9% (95% confidence interval [CI], 8.6%-9.1%) received at least one screening mammography and 5.8% (95% CI, 5.6%-6.1%) received at least one Pap smear. Among the cancer-free cohort, 22.0% (95% CI, 21.7%-22.5%) and 12.5% (95% CI, 12.2%-12.8%) received screens, respectively. Screening rates were higher in women with a history of receiving the same screening test.
Among men with advanced cancer, 15.0% (95% CI, 14.7%-15.3%) received PSA testing compared with 27.2% (95% CI, 26.8%-27.6%) of controls. Again, screening rates were higher in men with a history of screening.
Lower GI endoscopy was performed in 1.7% (95% CI, 1.6%-1.8%) of all patients with cancer and in 6.1% (95% CI, 5.2%-7.0%) of patients with a history of screening. In comparison, 4.7% (95% CI, 4.6%-4.9%) of controls received lower GI endoscopy screening. Cholesterol was tested in 19.5% (95% CI, 19.3%-19.8%) of patients with advanced cancer and in 37.4% (95% CI, 37.0%-37.7%) of controls.
Half of the patients who received mammographies, Pap smears, or PSA tests did so within 10 months of cancer diagnosis, and half of the patients with a lower GI endoscopy screening received it within 18 months. Most patients screened had testing within 36 months of diagnosis.
Screening before diagnosis was the strongest predictor of screening afterward. Researchers, who described a culture of screening on “auto-pilot,” wrote that, “The most plausible interpretation of our data is that efforts to foster adherence to screening have led to deeply ingrained habits. … There is substantial evidence that even when physicians recognize that life expectancy is limited, they do not consistently communicate prognosis, and patients may use denial as a coping strategy to face impending loss.”
Overscreening leads to overdiagnosis, the screens are not without risks, and they contribute to health care overutilization in an already expensive system, the authors noted.