Controversies in Medicine (Blog)

Medicine is an ever-changing field.  As new discoveries occur, the “old way” of doing things gives way to the newest, latest, and best tests.   Many recent changes in guidelines have occurred that will affect your next annual physical.  The best way to get good care is to be informed, and be involved, in your healthcare decision making.  I want to help you become educated before your next checkup, so you can make informed decisions.

**These recommendations are from the United States Preventive Services Task Force (USPSTF).  It should be noted that these are only one set of guidelines, and that other medical groups may disagree with the recommendations.

MEN:

The prostate.  It’s a gland that sits in the pelvis, and surrounds the urethra (urine tube).  It can enlarge with age, causing obstructive symptoms – frequent urination, nighttime urination, trouble starting or stopping the flow of urine.  It can also develop cancer.  Prostate cancer is the 2^nd most common cancer in men.  In the US, the lifetime risk of prostate cancer is 16%, however the risk of death is <3%.  Most prostate cancers are fueled by testosterone, which naturally declines with age.  Most cancers are slow growing, and may never become “clinically relevant” (medical speak for it will never cause problems or be the cause of death).  There are a small percentage of cancers that are fast growing and aggressive.

There is a blood test called PSA (prostate specific antigen).  It picks up early changes in the prostate, but doesn’t differentiate between enlargement and cancer.  It is very sensitive to small changes, therefore can have a lot of false positives (an abnormal test, with no actual prostate problem).  The old guidelines were to check this yearly in men starting at age 50, sooner if there is a strong family history or if African American.

There are new guidelines (from USPSTF) that state this test should not be done.  Why not?  The adverse effects from a positive test (worry, pain of biopsies, expense of further testing and treatment, side effects of treatment), may not be worth it if it was a non-clinically relevant cancer.  However, it could potentially be life-saving if it was one of the few aggressive cancers.

So what should you do?  Talk to your doctor about the test, weigh your risks, and think about what you would want done if a positive result returned.  Would you go for the biopsies and further testing, or just leave it alone?  If you would do nothing, then it makes sense to skip the testing.  Most insurance companies do cover yearly testing.

WOMEN:

The Breasts.   Breast cancer is the 2^nd most common cancer in women, and the second leading cause of women’s cancer deaths in the US (first in the world).  The lifetime risk of developing breast cancer is 1 in 8.  Men can get breast cancer as well, though it’s much less common.

A mammogram is an x-ray of the breast tissue.  It can detect early suspicious changes, and full-fledged cancers.  Because of the sensitivity of the test, it can detect changes that may not be related to cancer (false positives).  The old guidelines recommended starting at age 40 (possibly a baseline at age 35 for high-risk women), and performing yearly tests.

The USPSTF is recommending to start at age 50, and perform the test every other year.  Why the huge difference?  Again, the potential risks of a false positive (the worry, the pain and cost of a biopsy or further testing) may outweigh the benefit.  The number of cancers in women age 40-50 is much less than women over 50.  However, the cancers in younger women tend to be more aggressive, and early mammogram can potentially be life-saving. 

This may be one of the most strongly argued recommendations.  I will note that the American Cancer Society and the American College of OB/Gynecology STRONGLY disagree with this recommendation.  It is still covered by insurance companies yearly starting at age 40.

The Cervix.  It’s the lower portion of the uterus, and it is very susceptible to infections.  In the US, cervical cancer has decreased to the 10^th most common cancer.  However in countries without routine pap smear screening, cervical cancer is still the 2^nd most common cancer, and the 2^nd leading cause of cancer deaths.  Most cases of cervical cancer in the US are in women who have never been screened, or very sporadically screened.  A virus called HPV (human papilloma virus) is responsible for a majority of cases (the top 8 strains of this virus make up 95% of cervical cancers).  But the body is an amazing thing, and can actually spontaneously clear this infection in about 8-24 months, especially in young women (meaning an abnormality on pap smear, if retested later, can become normal again with no treatment).

The pap smear can detect pre-cancerous changes, cancer and HPV infection.  A significantly abnormal pap smear is followed by biopsies, and potentially removal of the lower portion of the cervix, which then grows back.  However, this can have complications (scarring or weakening of the cervix) which can affect future pregnancies.

The old guidelines were to start pap smears when a woman became sexually active, or desired to be on birth control pills, and then to repeat yearly.  The new guidelines recommend not starting until age 21 (regardless of when she becomes sexually active), and performing every 3 years.  Why the change?  To prevent the unnecessary biopsies and procedures on young women who may be able to spontaneously clear this infection on their own.  Also, cervical cancer tends to be a slowly progressive cancer, and is unlikely to change in severity in less than 3 years.  It is still being covered by insurance companies yearly.

My goal with this blog was to get new information out there, for people to become educated about their health care choices, and to realize there is no one right way of practicing medicine.  So think about these tests before you schedule your next physical.  What do you want to have done?