Striking the right tone on prostate and breast screening

Dr. Otis W. Brawley took a courageous stand late last week, one he has taken many times before, but which had until then gone all but unnoticed. Responding to a Journal of the American Medical Association article detailing the scientific and medical limitations of breast and prostate screening, the chief medical officer of the American Cancer Society acknowledged that "in the case of some screening for some cancers, modern medicine has overpromised."

Screening campaigns aimed at getting women 40 and older to have screening mammograms have left little room for doubt about the value of these exams. But Dr. Brawley last week mapped out a far more scientific-and credible-position, saying that "cancer is a complicated disease." Too often, he said, we have tried to simplify it and simplify messages about it, "to the point that we do harm to those we want to help."

An article in The New York Times interpreted Dr. Brawley's comments to mean that the ACS had changed its guidance on cancer screening to emphasize the risk of overtreatment from screening for breast, prostate, and other cancers, which sparked a firestorm of debate. ACS promptly released a detailed statement under Dr. Brawley's name to the contrary.

"The bottom line is that mammography has helped avert deaths from breast cancer, and we can make more progress against the disease if more women age 40 and older get an annual mammogram," he said in the prepared statement.

What Dr. Brawley told The NYT wasn't anything new. He and ACS had been candid about the shortcomings of PSA and mammography for years. Still, they continued to advocate the use of these technologies. And for good reason.

"Although breast cancer screening may have an overdiagnosis and overtreatment problem," he told me, "we have studies to show that it saves lives, that it decreases the death rate by 20% to 35%.

"In the past, I've been critical of people who say you're a fool not to get screened," he continued. "In the same vein, I feel that I should be critical of anyone who says you're a fool if you do get screened."

Dr. Brawley should be applauded for his balanced statements. They pave the way for the public to come to grips with the imperfections of screening technologies. For too long an unbridled fear of cancer has reinforced a common belief that newer and more sophisticated technologies would not only find cancers earlier but save lives. This belief has been buoyed by our inability to imagine a cancer that we don't have to worry about. The JAMA article questioned this belief in technology and the intuitive reasoning behind it. The article, Dr. Brawley told me, was based on "a wonderful study that did not get the attention I think it deserves."

In the Oct. 21 issue of JAMA, Dr. Laura Esserman, a professor of surgery and radiology and the director of the University of California, San Francisco Carol Franc Buck Breast Care Center, and colleagues argue that the increased detection rate of breast and prostate cancer has not come with a similarly sized drop in mortality. Most disconcerting to them is the strong possibility that the apparent discovery of cancers that pose little danger has been accompanied by overtreatment.

The research needed to tell which kinds of breast and prostate cancer present the greatest danger needs doing. This work may lead to in vitro tests to distinguish less dangerous cancers from those that pose the greatest risk. But if the past is an accurate guide, what develops from this research probably will not live up to our brightest hopes. With few exceptions, notably penicillin and the polio vaccine, medical progress is a struggle.

This realization is at the core of Dr. Brawley's statements. The public needs to hear and understand that cancer presents monumental challenges. Some, but not enough, progress has been made against breast and prostate cancers. This is the message the American public needs to hear. Inflating accomplishments and overpromising results from screening are sure ways to lose credibility. It can, as Dr. Brawley said, hurt the very patients oncologists are trying to help.