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You've read the article. Now tell us what you think. Related Sites Guide to Clinical Preventive Services |
By
Anne Federwisch You’re looking at a crowd of apparently healthy people; statistics tell you that a certain number of them probably have a particular disease. So you decide to do a screening test to find out which ones do. In the process, you tell some people they’re probably sick when it turns out later they’re not, and you reassure some people they’re well when it turns out later they’re sick. You saved some lives in the process, but can you say for sure that the crowd as a whole is better off? Each year in the United States we spend millions on tests to screen for a wide range of diseases, and that’s just the beginning. We also spend lots of sleepless nights—and plenty of healthcare dollars—waiting to find out whether initial screening tests are right, sometimes undergoing unnecessary surgery in the process. So some experts say we need to rethink our reliance on screening as a healthcare panacea. In any case, nurses need to understand the risks and benefits so they can help their patients make informed decisions. Balancing risks, benefits “We just assume screening is beneficial because we only look at the benefits to those who are in fact sick,” said Heidi Malm, PhD, an associate professor of philosophy at Loyola University Chicago who has written about the ethics of medical screening. Malm argues that we shouldn’t do screening tests that haven’t been proved to be beneficial, on balance, for all those who take them. She thinks we often underestimate the importance of the downside of screening. Several factors need to be weighed in controlled clinical studies to determine that balance, including the effects of false positives and false negatives, she said. Other considerations include whether the benefit for those whose disease is detected early balances the risks to those who are disease free and whether early detection and treatment actually improve outcomes. Because at first blush it’s hard to see a downside to screening, many people don’t understand how risks could possibly outweigh benefits. To illustrate that point, Malm uses an extreme example. People die every year of acute appendicitis. If all people were encouraged to get their appendix out before they were sick, we could save all those lives. “But the benefits wouldn’t be worth the risks,” she said. The same comparison of benefits to risks needs to be done for screening. “Until we know that the probability and size of benefit is enough to make that worthwhile, we shouldn’t be encouraging it.” Malm is not alone in suggesting caution in making screening recommendations. “Just finding more disease isn’t the same as making people better off,” said David Atkins, MD, MPH, coordinator for preventive services at the Agency for Health Care Policy and Research and project officer for the U.S. Preventive Services Task Force. If people won’t live longer or healthier as a result of detecting a disease early, he said, the test isn’t warranted. For example, lung cancer screenings find more cases of lung cancer, but don’t significantly alter death rates. So they are not routinely recommended, he said. Acting on results Health professionals and the public also need to understand the consequences of finding out test results. “The tests themselves aren’t very harmful; it’s what we do with them,” Malm said. Adopting a conservative approach to wait and see whether something develops rather than immediately treating the disease aggressively could significantly curb the negative results of screening, she said. But once cancer is suggested, patients aren’t likely to be content to wait, she said. Malm said that studies show that even when women are told that their breast lump is very likely benign (as are 95 percent of breast lumps revealed through mammography), they still worry until they get conclusive results. “They’ve gone through a mini-medical crisis, when in fact they never were sick,” Malm said. “There was no reason for the worry, and they never would have been worried had they not been encouraged to be screened.” Health professionals may not want to delay treatment either, said Judith Saunders, DNSc, FAAN, RN, a primary integration specialist for PacifiCare Behavioral Health in Van Nuys, Calif. A lawsuit-happy public and consequent defensiveness of clinicians leads to overdiagnosis and treatment, she said. No harm in knowing? Even if a growth is not benign, screening asymptomatic patients may lead to difficult decisions they might not have had to face otherwise. For example, because prostate cancer is a very slow-growing cancer, most men die with the disease, not of the disease. Yet many men with elevated prostate-specific antigen (PSA) opt for surgical removal of the cancer, which can lead to impotence and incontinence. Many people argue that they’d rather be safe than sorry, particularly when it comes to cancer, Malm said. “But you’re not safe by getting treated for something that never would have hurt you,” she said. If 80 percent of the men with prostate cancer will die before the cancer ever has time to affect their lives, Malm said, then is screening and subsequent surgery—with its inherent risks—really the best alternative? Confusing advice The public isn’t likely to wade through years of scientific evidence to determine the suitability of screening tests. Instead, they rely on recommendations of healthcare providers and organizations. But those can be confusing, particularly if they’re conflicting. Atkins said the U.S. Preventive Services Task Force did not recommend routine PSA screening in its most recent recommendations (published in 1995), because the evidence was not compelling enough that the benefits outweighed the risks. The American Cancer Society, however, recommends that a PSA blood test and a digital rectal examination be offered annually, beginning at age 50, to men who have a life expectancy of at least 10 years and to younger men who are at high risk. “You have to begin with the understanding that prostate cancer is not a toothless tiger,” said Robert Smith, PhD, director of cancer screening for the American Cancer Society. “It’s the second-leading cause of cancer death in men.” He stressed that the American Cancer Society does not recommend that men get their PSA checked annually. “It’s a recommendation to at least be aware of the option and to think through the decision,” he said. That’s not the message the public is hearing, Atkins said. No hard data exists on how many men over age 50 get PSA screening, but he estimates that it could be as high as 70 percent. “The explosion in surgery has not been in the men in whom it might be most beneficial: 50-year-old men who have 20 years or more for their prostate cancer to develop,” Atkins said. “It’s been in men in their 70s or 80s.” Smith said that there’s no question that men’s lives have been saved because their prostate cancer was detected early through PSA screening. On the other hand, some men have had unnecessary surgery as a result, he said. “That’s the clinical dilemma we face.” The American Cancer Society is developing educational material to help men and their health professionals understand the pros and cons of PSA testing and prostate cancer treatment options and make more informed decisions, Smith said. Educating patients The role nurses play in educating patients about different screening tests depends on their education, expertise, and job description, said Paula Rieger, MSN, RN, FAAN, nurse practitioner and advanced oncology certified nurse with the M.D. Anderson Breast and Ovarian Risk Assessment Clinic in Houston. Ideally, when you discuss screening with patients, you need to be aware of the standard guidelines, what organizations support those recommendations, and your patient’s personal and family risk factors that might require an alteration of those recommendations, Rieger said. Patients also need to know what to expect from the results of screening, Smith said. “There’s no such thing as a screening test that doesn’t have false positives and false negatives,” he said. Patients should be told upfront about the presumed benefits and limitations of a procedure. Future of screening The demand for screening isn’t likely to abate. Preventive health services (including screening programs) account for 10 percent of the overall accreditation score that health plans receive from the National Committee for Quality Assurance. Patients often ask for screening even if their health plan doesn’t suggest it first, Atkins said. But health professionals need to help patients understand that a glimpse into the future isn’t always beneficial or accurate. Screening has risks, and getting a positive result could lead to difficult decisions, he said. Testing should not be done without informing patients of the possible benefits and limitations, Atkins said. Patients should have the right to say, ‘If you can’t find better proof that this is going to save my life, I’m going to pass.’ ” |
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