Today in the San Francisco Chronicle

This is taken from the "New" Prostate Cancer InfoLink and their view on an article.

InfoLink view:

"Most prostate cancer activists (and certainly those on the West Coast) will want to be aware of an “OpEd” into today’s issue of the San Francisco Chronicle. The OpEd says it is by Laura Esserman, MD, but the credits suggest that actually it is by Dr. Esserman in conjunction with Ian Thompson, MD, the co-authors of a recent review on controversies related to prostate and breast cancer screening and related actions.

The “New” Prostate Cancer InfoLink is in complete agreement with the authors when they state categorically that, “We are not proposing that we stop all screening; we are saying that we can and must do better.”"

Today in the San Francisco Chronicle

The Article:

OPEN FORUM: On prostate cancer screening
By Laura Esserman

As cancer surgeons, we witness the fear and anxiety we create when we tell patients that they may have cancer. This fear is understandable, as cancer can be a deadly disease. Choices for therapy can be overwhelming and treatments emotionally and physically taxing. We want to use all of the tools at our disposal to minimize the impact of cancer and maximize the chance of a good outcome. Screening for cancer is one such tool, but it needs to be used wisely, and the results interpreted carefully.

We recently published an analysis (JAMA Oct 21, 2009) of the impact of current screening for breast and prostate cancer and found significant room for improvement. Screening has led to an increase in cancers detected, many of which are not life threatening, and we haven't been as successful as we had hoped in preventing more advanced stage cancers. We are not proposing that we stop all screening; we are saying that we can and must do better.

Screening is complex because cancer is complex. Not all breast cancers or prostate cancers behave the same, and as a result, some people benefit more than others from screening. Screening is most effective for moderate to slow-growing tumors or where removing a precancerous condition prevents the disease, as in cervical cancer and colon cancer. For fast-growing or very aggressive tumors, traditional screening may not be able to help, as these types of tumors pose significant risk even when they are small and seem curable. For very slow growing tumors, finding them early will not make much if any difference.

For both breast and prostate cancer, we have substantially increased the chance of being diagnosed with a slow-growing tumor that might never have come to attention in the absence of screening, leading people to think they have a killer cancer when they do not. In this situation, we may be doing harm and creating anxiety, which often leads to more aggressive treatment choices. The more we (public and physicians) are aware of the limitations of mammography and PSA testing, the better we can tailor screening recommendations, use the results of screening wisely and provide more appropriate options for our patients.

Importantly, we propose a strategy for moving forward. First, we must focus on understanding who is at risk for developing the most aggressive cancers and test targeted new drugs to improve treatment and prevention. We also must be aware that the most aggressive cancers can turn up as masses or high PSA's between normal screens, and not ignore symptoms just because there has been a recent normal screening test.

Second, we need to use the tools available (and develop new ones) for determining the aggressiveness of cancers at the time of diagnosis. This will help patients and physicians have conversations weighing the risks and benefits of interventions, and lead to new trials designed to help some patients safely forgo treatment.

Third, we need to think more about prevention. Our concept of screening should include the use of tools that identify how much risk a person has for developing cancer. For prostate cancer, tools like the online Prostate Cancer Risk Calculator, predicts not only the risk of cancer, but the risk for high grade disease. When high, prevention interventions, such as finasteride, should be discussed, not just PSA screening. For breast cancer there are a number of risk models that we can use today to help patients and physicians think about the available medical and surgical prevention options as well as intensive and more frequent surveillance for those at highest risk.

We can also use risk assessment tools to identify people unlikely to benefit from screening; we should avoid screening them. In women over 70, for example, there is no evidence that mammographic screening saves lives, as such women most often develop less aggressive or IDLE tumors. Our advice to women in this age group is to continue to do breast exams, and to seek care if they find a lump. Men, and their physicians, can turn to the prostate cancer risk calculator to inform their decision about whether to get a PSA test as well.

Finally, we need a concerted national effort to invest in large scale long-term studies and demonstration projects that accelerate the pace of learning about screening and prevention. We will all welcome the day when screening and treatment options are more tailored and effective and fewer women and men have to face the phrase, "you may have cancer".

Dealing with the complexities of screening honestly will lead to more options for our patients and make care better tomorrow than it is today.

Laura Esserman M.D., is a professor of surgery and radiology at UCSF. Ian Thompson, M.D., is a professor of urology at the University of Texas Health Science Center, San Antonio.

OPEN FORUM: On prostate cancer screening