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How beneficial are cancer screening tests? A recent study published in JAMA Internal Medicine suggests that the answer is not clear-cut. Does this mean healthcare leaders need to rethink their prevention strategies? Advisory Board's Rachael Peroutky and Julia Elder aren't so sure.
Does cancer screening increase longevity?
Last month, a systemic review and meta-analysis of 18 long-term randomized clinical trials evaluated whether six popular cancer screening tests increase life expectancy. In total, the analysis included more than 2.1 million individuals.
To determine each screening test's impact on life expectancy, researchers calculated the difference between observed lifetime among patients who received screening tests and those who did not.
According to the study, only one test — colorectal cancer screening with sigmoidoscopy — led to a significant gain in life expectancy (110 days). The analysis suggested that mammography (0 days), prostate-specific antigen testing (37 days), colonoscopy (37 days), fecal occult blood testing (0 days), and lung cancer screening (107 days) did not significantly improve longevity.
Since the study suggests that "current evidence does not substantiate the claim that common cancer screening tests save lives by extending lifetime," the study authors encouraged doctors to emphasize absolute benefits, harms, and burdens associated with cancer screening.
"Organizations, institutions, and policymakers who promote cancer screening tests by their effect to save lives may find other ways of encouraging screening," Michael Bretthauer of the University of Oslo, and colleagues wrote. "It might be wise to reconsider priorities and dispassionately inform interested people about the absolute benefits, harms, and burden of screening tests that they consider undertaking. Our estimates may serve that purpose."
"We do not advocate that all screening should be abandoned," the researchers wrote. "Screening tests with a positive-benefit-harm balance measured in incidence and mortality of the target cancer compared with harms and burden may well be worthwhile."
In a separate publication in JAMA Internal Medicine, Gilbert Welch and Tanujit Dey from the Center for Surgery and Public Health at Brigham and Women's Hospital's Department of Surgery noted that the "growing enthusiasm" for costly multi-cancer detection blood tests underscores the importance of large, randomized clinical trials to help patients and providers understand whether cancer screening tests extend longevity and warrant high costs.
"The critical question is whether the benefits for the few are sufficiently large to warrant the associated harms for many. It is entirely possible that multicancer detection blood tests do save lives and warrant the attendant costs and harms. But we will never know unless we ask," the study authors wrote. (Bretthauer et al., JAMA Internal Medicine, 8/28; Christensen, CNN, 8.28; Bassett, Medpage Today, 8/28)
Longevity is not the point of cancer care
By Julia Elder and Rachael Peroutky
The recent meta-analysis on the effectiveness of cancer screening has people wondering if all the mammograms, pap smears, and colonoscopies are worth it. From a patient perspective, it's a fair question — these tests are often invasive and uncomfortable.
Purchasers and providers have a stake here too. Some may wonder if investing in these services is worthwhile when margins are small, and the workforce is in crisis. What should healthcare leaders do with this new data? Before rethinking your prevention strategy, here's what to consider:
Proving long-term impact of cancer screening is an uphill battle
Unlike medications or services like surgery, linking a preventive service like a screening test to a long-term outcome is extremely difficult. Screening comes early in the patient journey, meaning several other factors and downstream points of care take place before the selected outcome — in this case longevity — is captured.
Even if the test is positive for cancer, the parts of the care journey that come after (follow-up, therapy selection, management) arguably have a larger influence on long-term outcomes. Clinical utility — or the ability of the screening test to impact decision making — is a better standard of measurement for screening tests.
But say we do want to look at long-term outcomes
"First do no harm" remains the north star of medical ethics. If we can't substantiate the benefit of invasive screening tests, why should clinicians carry on?
Many health leaders we talk to agree with this point and want more outcomes-oriented data from manufacturers of screening tests and devices. The specific outcomes they look for are where the rubber meets the road — and this study falls short on two accounts.
1. All-cause mortality is too broad
The study included all deaths — not just cancer-related deaths. While all-cause mortality is a common outcome for assessing quality of care in other situations, it is too broad for assessing the value of screening tests. Recent research shows cancer screening trials require large sample sizes (at least 40,000 participants) to demonstrate a significant reduction in all-cause mortality. Out of those 22 studies included in this analysis, nine did not meet this criterion for significance.
2. Longevity is not the goal of cancer care
Those working closest with cancer patients agree that a longer life is not always the goal. For some, the right option may be to forgo treatment entirely, selecting a more comfortable life over a longer one. Health-related quality of life, is a prime example of a long-term outcome measure that elevates the quality of one's life alongside the length.
So, do we keep screening?
Yes. Guideline developers maintain that screening for at least the most common forms of cancer is worthwhile. Continue to push diagnostic manufacturers for outcomes data, but make sure you are thinking strategically about which outcomes matter most.
Posted on September 07, 2023
Updated on September 07, 2023
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