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The "Fastest-Increasing" Cancers
In 2010, about 45,000 americans were diagnosed with thyroid cancer. That's about three times the diagnosis rate in 1975. But the mortality rate for the disease was the same. There was no more thyroid cancer than before; doctors were just looking and finding more of it. This means that when it comes to lives saved, thyroid-cancer screening may be doing little or no good. In fact, it's probably mostly causing harm.
A recently launched public-awareness campaign called Check Your Neck identifies the disease as "the fastest-increasing cancer in the U.S." Doctors screen for thyroid cancer by palpating the neck, but most necks are lumpy, and it can be hard to tell by touch whether a thyroid is enlarged. Once there's uncertainty, the cascade can take over. Remarkably, many of us, possibly even most of us, will develop thyroid cancer at some point in our lives, but very few of us will die of it. In a 1985 study, researchers examined the bodies of 101 people who had died of causes other than thyroid cancer and found that a third of them contained cancerous thyroid cells. Because of the sampling method, the researchers knew that they were certainly missing some cases, meaning the percentage was even higher, and yet none of those people were killed by the disease.
Still, the vast majority of people in whom thyroid cancer is diagnosed undergo radiation treatment or have their thyroid removed. The surgery leaves some patients hoarse and all forever dependent on medication. Something similar is happening with melanoma, a skin malignancy that kills about 9,000 Americans every year. Awareness campaigns like Melanoma Monday, sponsored by the American Academy of Dermatology, helped raise the melanoma-diagnosis rate 30% from 1975 to 2007. The mortality rate? Unchanged.
The Business of Screening
Among all the reasons overscreening is taking place, the least discussed and most disturbing is money. Back in the 1990s, when Brawley, now of the ACS, was an assistant director of the National Cancer Institute, he visited a large research hospital in Atlanta. There, a marketing expert explained that providing free PSA tests to 1,000 men at a local mall could lead to millions of dollars in subsequent revenue for the hospital. The income would come from biopsies, surgeries, radiation and even urinary-sphincter implants in men who experienced complications. This kind of strategy is common, according to Brawley.
Some health centers and urology practices use giveaways to entice men to get PSA tests. In recent years, men have scooped up tickets to Atlanta Hawks, Buffalo Sabres and Tampa Bay Rays games in exchange for getting tested. A nonprofit national organization called Zero, for "zero prostate cancer," tries to get the word out about the benefits of PSA testing, parking a mobile testing unit outside sporting events and churches. The organization doesn't charge patients for tests but accepts donations from urologists, Big Pharma and Beckman Coulter, a PSA-test manufacturer.
The downstream costs of cancer-screening campaigns like this are enormous. Says Welch: "It may lower costs for an individual patient" if minor surgery to remove a suspicious early growth makes major, long-term cancer treatment unnecessary, "but because there are so many more patients created, that effect is overwhelmed." Doctors sometimes encourage screening in part because they believe it could protect them from liability. In addition, the new Affordable Care Act requires insurers to cover "preventive services" at full cost, meaning most patients will pay nothing out of pocket for procedures like mammograms, PSA tests and colonoscopies. This could drive up screening rates even further.
Welch and Handley are urging change upstream. According to a meta-analysis published in 2009, patients are 20% less likely to undergo PSA testing once they understand the potential harms, benefits and uncertainties of it. The VA offers male patients over 50 a DVD and a booklet titled Is a PSA Test Right for You? The material contains the statement "If you find out you have prostate cancer later in life, you will most likely die with the cancer, but probably not because of it."
Advanced screening methods are putting more of us in a similar situation. Many more of us are finding out we have cancer. But even if we can survive cancer, can we live with it? Says Kramer, formerly of the NIH: "The term cancer is so fearsome, many people can't accept the concept that you don't do anything about it." Combine that fear with the American medical system's seemingly limitless capacity for testing and intervention, and excess is inevitable.
"In the U.S. in particular, we just feel like more is always better," says Diana Miglioretti, a biostatistician and investigator for Group Health who studies cancer screening. "There is an uncomfortableness with ambiguity, so we're always looking for that perfect test to save a life."