Screening — checking a seemingly healthy person for signs of hidden disease — is an important part of routine medical care. It is done for various types of cancer, heart disease, diabetes, and other chronic conditions. Screening makes sense when finding and treating a hidden condition will prevent premature death or burdensome symptoms. But it doesn’t make sense when it can’t do either. That’s why experts recommend stopping screening in older individuals, especially those who aren’t likely to live another five or 10 years. Yet an article published online in JAMA Internal Medicine shows that many doctors still recommend cancer screening tests for their older patients. Many don’t benefit, and some are even harmed by the practice. Asking people who can’t benefit from a cancer screening test to have one is a waste of their time and money, not to mention a waste of taxpayer money (since these tests are usually covered by Medicare). Screening tests can also cause physical and mental harm. Decisions about cancer screening should be mutually made by an individual and his or her doctor. Equally important, the person should be well informed about the risks of the test and about what will happen if a test suggests there may be cancer that won’t shorten the his or her life.
A study published in JAMA Internal Medicine this week found that men who used the erection-enhancing drug sildenafil (Viagra) were 84% more likely to develop melanoma, the most dangerous form of skin cancer, over a period of 10 years. That finding makes for an attention-grabbing headline. But it doesn’t tell the real story—that the study found an association (not cause and effect), that this hasn’t been seen in other studies of men, and that, even if it holds true, the absolute increase is small, from 4.3 cases of melanoma for every 1,000 men who didn’t take Viagra to 8.6 of every 1,000 men who took it. The take-home message is that it’s important to worry about melanoma—which is largely caused by getting too much sun—but not yet about Viagra and melanoma.
Some good news on the cancer front: between 2000 and 2010, rates of colorectal cancer in American adults fell by about one-third. That decline mirrored a sharp rise in colorectal cancer testing during the same period. American Cancer Society researchers found that the drop in colorectal cancer rates was highest among Americans aged 65 years and older. Cases fell 3.6% a year from 2001 to 2008, then dropped even more by 7.2% a year from 2008 to 2010. But the researchers saw a troubling trend in younger adults: an increase in colorectal cancer of 1.1% a year among people under age 50. Rising obesity rates may be to blame. The researchers attribute the decline in colorectal cancer to early testing for the disease. Despite the optimistic findings, colorectal cancer is still a scourge. In the U.S. this year, an estimated 72,000 men and 65,000 women will be diagnosed with colorectal cancer; 26,000 men and 24,000 women will die of it.
Mass marketing of testosterone therapy may have men eager to try this seemingly simple fix. But the latest science should have them scratching their heads and putting away the credit card—at least for now. A new study published in the online journal PLOS One shows an increase in the risk of having a heart attack in the months after starting testosterone therapy. The potential for danger was highest in older men. A report in the November 6, 2013, issue of JAMA showed that men who used testosterone therapy didn’t fare as well after artery-opening angioplasty as men who didn’t take testosterone. Neither was the type of study that can prove cause and effect. They can only show associations, or links. That means there’s no smoking gun here that testosterone therapy is harmful. But the studies do suggest caution. Given the uncertainly over the benefits and risks of testosterone therapy, what’s a man to do? Take a cautious approach, advises the Harvard Men’s Health Watch.
Radiation, on its own or coupled with other treatments, has helped many women survive breast cancer. Yet radiation therapy can cause the appearance of heart disease years later. New research published in JAMA Internal Medicine estimates that the increased lifetime risk for a heart attack or other major heart event in women who’ve had breast cancer radiation is between 0.5% and 3.5%. The risk is highest among women who get radiation to the left breast—understandable, since that’s where the heart is located. The heart effects of radiation begin emerging as soon as five years after treatment. However, future heart risk should not be the reason to abandon this important component of treatment. Cancer experts are doing more and more to minimize the amount of radiation the heart receives.
There’s no question that tests to detect cancer before it causes any problems can save lives. But such tests can also cause harm through overdiagnosis and overtreatment. A study published yesterday in JAMA Internal Medicine indicates that the majority of people aren’t informed by their doctors that early warning cancer tests may detect slow-growing, or no-growing, cancers that will never cause symptoms or affect health. Undergoing surgery, chemotherapy, or radiation for such cancers provides no benefits and definite harms. The researchers found that only 9.5% of people were informed by their doctors of the risk of overdiagnosis and possible overtreatment. Compare that to 80% who said they wanted to be informed of the possible harms of screening before having a screening test. Informing patients about the risks of screening isn’t easy to do in a brief office visit. It’s complicated information. And the researchers suggest that many doctors don’t have a good grip on relative benefits and harms of screening.
Checking seemingly healthy people for cancer—what doctors call screening—seems like a simple process: Perform a test and either find cancer early and cure it or don’t find it and breathe easy. It works for colon, breast, and cervical cancers, but not for others. For colon cancer, there are several effective screening tests: colonoscopy, sigmoidoscopy, and stool testing. Two new studies in yesterday’s New England Journal of Medicine help further quantify their benefits. In the studies, all three types of test reduced the risk of developing or dying from colon cancer. Colonoscopy worked best, followed by sigmoidoscopy and then stool testing. The biggest challenge for colon cancer screening is getting people to have the available tests. About 50,000 Americans die of colon cancer each year—many of these can be prevented with early screening.
In many men diagnosed with prostate cancer, the cancer cells grow so slowly that they never break free of the gland, spread to distant sites, and pose a serious risk to health and longevity. Instead of embarking on immediate treatment, a growing number of men choose active surveillance, in which doctors monitor low-risk cancers closely and consider treatment only when the disease appears to make threatening moves toward growing and spreading. A new Harvard study shows that the aggressiveness of prostate cancer at diagnosis remains stable over time for most men. If confirmed, then prompt treatment can be reserved for the cancers most likely to pose a threat, while men with slow-growing, benign prostate cancer—which is unlikely to cause problems in a man’s lifetime—can reasonably choose active surveillance.
A new report suggests that skin cancer can sometimes hide in a tattoo. Writing in JAMA Dermatology, three German clinicians describe the case of a young man who wanted to remove large, multicolored tattoos on his arms and chest. During the removal process, his doctors discovered a suspicious mole inside the tattoo. It turned out to be cancerous—stage II melanoma. Tattoos may make it difficult to evaluate moles. Laser removal therapy is also problematic when moles are present. If you are considering getting a tattoo, either make sure it will be applied to skin that is free or moles or birthmarks, or have your doctor check any moles in the to-be-tattooed area beforehand. If you are planning to have a tattoo removed, check for moles within the tattoo. If you see any, ask your doctor or dermatologist to check them out before starting laser therapy.
Proposed recommendations from the influential U.S. Preventive Services Task Force call for annual CT scans for some current and former smokers. Implementing these recommendations could prevent an estimated 20,000 deaths per year from lung cancer. The task force suggests annual testing for men and women between the ages of 55 and 79 years who smoked a pack of cigarettes a day for 30 years or the equivalent, such as two packs a day for 15 years or three packs a day for 10 years. This includes current smokers and those who quit within the previous 15 years. According to the draft recommendations, which were published today in the Annals of Internal Medicine, the benefits of annual checks in this group outweighs the risks. According to the Task Force recommendations, not all smokers or former smokers should undergo yearly CT scans. This group includes smokers or former smokers who are younger than 55 or older than 79, who smoked less or less often than a pack of cigarettes a day for 30 years or the equivalent, who quit smoking 15 or more years ago, or who are too sick or frail to undergo treatment for lung cancer. These draft recommendations have been posted for public comment until August 26, 2013.