Almost everyone has had some experience with cancer screening. Your parents was tested for cancer. You may have been tested yourself particularly if you are female because almost all women have had at least one Pap smear, the test for cancer of the cervix. And you'll know those who have had small cancers detected by screening tests particularly in the breast and prostate, where the chances are good that small cancers will be found.
At first glance, it all seems simple enough: screening tests find early cancers. People who have early cancers do better than people with advanced cancers. Screening tests can prevent advanced cancers. Screening saves lives.
Unfortunately, it's not that simple. In the following paragraphs, I summarize what we know of the benefits of screening for cancer and review a few of the major studies of screening. But what I most want to do is give you some perspective on the size of the benefit you might expect from cancer screening under the best conditions.
The fact is that every screening test will have only a limited effect. One reason is that most people who are tested will never get cancer, and people who will never get cancer do not benefit from cancer screening. But there is another reason for the limited effect of screening, which is that even with an ideal test, some people will die of cancer anyway. Let's begin with an unfortunate reality: screening tends to miss the worst cancers.
Many of my regular patients can be described as old-time Vermonters rugged, elderly men who have spent most of their lives outdoors (and because I work for the Department of Veterans Affairs, all of my patients have spent some portion of their life in the military). One of my favorite patients still works, at age 77.
It's hard work, too: drilling water wells. He has an old drilling rig that uses a winch to wind up a metal cable that, in turn, lifts a tremendous weight maybe 25 feet in the air. The entire rig shimmies a bit under the load. When the weight is released, it drops and smashes into the well casing below. The process is repeated over and over, slowly banging the casing into the ground. Heavy weights, taut metal cables, extreme forces . . . it's the type of thing I like to watch from a distance. Suffice it to say, this man's primary health concern is not cancer.
Nevertheless, we have discussed prostate cancer screening. I told him that while we have studies that show some screening tests work, such as mammography for breast cancer and fecal occult blood for colon cancer, we also know that some, like chest X-rays for lung cancer, do not
. I added that many tests have never been rigorously studied, including the blood test for prostate cancer, which measures prostate specific antigen (better known as PSA). He had participated in a study in which patients watched a video developed by some of my colleagues that laid out what physicians do and don't know of the PSA test.
For him the decision about whether to have the test was easy: he didn't want it. He even went on to appear in a television documentary on PSA testing, serving as one member of a pair of patients who made opposite decisions about having the test.
But a few years later he came to the clinic and was not his usual joyful self. Typically he would manage to find the bright side of things and would punctuate our conversations with wonderful hearty laughter. I had never seen him teary before and asked him what was wrong. He told me that his daughter in Connecticut had been diagnosed with breast cancer a few months previously. The cancer was now all over her lungs. She had had a mammogram just three months before the diagnosis. He thought I had said that mammography was among the tests that had been proven to work. Now he wanted to know why the screening test had missed the cancer.
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