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Monday Oct 16, 2017

Do 'Disease of the Month' Campaigns Lead to Overscreening?

It's hard to miss the fact that October is Breast Cancer Awareness Month. The White House was lit pink on Oct. 1. Athletes are donning pink gear, and pink ribbon promotional products range from magnets and soap to candy bars and soda pop.

But no one has brought more recent attention to breast cancer than actress Julia Louis-Dreyfus. The Veep star revealed Sept. 28 (less than two weeks after winning her eighth Emmy award) that she has been diagnosed with the disease. That highly publicized announcement may leave more women wondering whether they should be screened this month.

[Young woman getting a mammogram]

I have a love-hate relationship with Breast Cancer Awareness Month -- and really, any disease of the month campaign. September is Prostate Cancer Awareness Month. November is Pancreatic Cancer Awareness Month. March is Colon Cancer Awareness Month. And so on.

The emphasis tends to be on general testing for these diseases (which may or may not affect mortality) without any mention of tailoring screening to appropriate groups.  

The barrage of Breast Cancer Awareness messages I've seen are mammogram-centric, such as "Early detection is the best protection." But is it?

Study after study has shown that we've historically overstated the benefits of breast cancer screening, especially in the wrong population. Evidence indicates that mammograms decrease the chance that a 50-year-old woman will die from breast cancer in the next 10 years from 0.53 percent to 0.46 percent(www.bmj.com), a decrease of 0.07 percent.  

Meanwhile, disease of the month awareness campaigns avoid wading into the nuances of who should be screened and fail to explain the risks of too much testing. Unfortunately, this leads to false positives and overtreatment.

In fact, half of the women who have annual mammograms will have a false-positive(www.cancer.org) result, with the highest rate among those ages 40-49.

Additionally, although mortality rates have improved since the widespread use of mammograms began, the benefit may be due to advances in treatment rather than detection.

The stats on prostate cancer tell an even bleaker tale. Among men who underwent biopsy after receiving a positive prostate-specific antigen (PSA) result, more than three-fourths(www.nejm.org) were found to have false-positive results.  

And detection of thyroid cancer since 1975 has tripled(www.livescience.com), but deaths from thyroid cancer are not improving.

It's worth noting that the AAFP recommends against PSA-based screening for prostate cancer, and the Academy recommends against screening for thyroid cancer in asymptomatic adults.

Whenever the issue of overtesting and overdiagnosis comes up, there will invariably be a fervent counterargument: "Isn't every single life worth saving?" "Isn't it worth all the false positives to save one life?"

It's a moral quandary with no easy answer. Rather, that answer takes a discussion of the evidence with patients and shared decision-making.

I'm still torn regarding the disease awareness months. A percentage of revenue from promotional products supports research funding. And that sort of public awareness of a women's health issue, in particular, is refreshing given that attention to women's health issues historically has been notoriously underfunded.

But perhaps a more appropriate campaign would be a Prevention of (insert health concern here) Awareness Month. In the case of breast cancer, we should devote our efforts to maximizing the benefits of screening while minimizing the potential harms. We should focus on evidence-based medicine and prevention.

Rather than focus on testing, a better message would be to remind patients that the best ways to prevent many diseases still center around the basics: healthy eating, exercise, no smoking and avoiding excess alcohol use.

Natasha Bhuyan, M.D., is a board-certified family physician in Phoenix. You can follow her on Twitter @NatashaBhuyan(twitter.com).

Posted at 05:00PM Oct 16, 2017 by Natasha Bhuyan, M.D.

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