Physicians failing to educate patients on screening harms

A majority of patients would like to be made aware of the risks associated with cancer screening, such as overdiagnosis and overtreatment, prior to screening, according to a research letter published online Oct. 21 by JAMA Internal Medicine.

“Our patients have been taught to think differently about screening,” commented H. Gilbert Welch, MD, MPH, of the Dartmouth Institute for Health Policy and Clinical Practice on the new research. “There are no harms…In reality, the truth is more nuanced. There are benefits and harms to consider in screening—just as there are in treatment.”

Despite potential benefits of cancer screening—like detecting true and treatable cancer in its early stages—screening also can recognize abnormalities that meet the definition of cancer but will never evolve to cause symptoms. Overdiagnosis is addressed with overtreatment, leading to “solutions” like surgery, chemotherapy, or radiation that don’t benefit the patient but instead cause adverse effects.

Odette Wegwarth, PhD, of Germany’s Max Planck Institute for Human Development, and colleagues conducted a national cross-sectional online survey of 317 U.S. men and women ages 50-69 to ascertain if patients are informed about overdiagnosis by physicians when discussing cancer screening. Furthermore, Odette and colleagues wished to determine how much overdiagnosis patients would tolerate when deciding to start or continue screening.

The research sample, a population of people with the highest exposure to screening programs, was taken from the U.S. panel of Survey Sampling International in December 2010 based on official U.S. statistics regarding sex, ethnicity, and level of education. The survey began with two screener questions, which ensured that participants were only those with no cancer history and had been asked to undergo cancer screening by doctors in the past.

To ensure all participants had the same amount of knowledge about overdiagnosis and overtreatment, the researchers introduced a set of concepts to them before the survey. Results indicated that 19.9 percent had attended one routine cancer screening, 36 percent had gone to two, 27.1 percent reported three or more screenings, and 17 percent hadn’t gone to any. The most common form of screening for women was mammography and for men was colonoscopy and PSA testing.

Of the demographic surveyed, 9.5 percent were informed by their physicians about overtreatment and overdiagnosis when discussing cancer screening. Of that population, nine patients said that doctors quantified the risk of overdiagnosis.

Some 80 percent of participants expressed the desire to be told of screening harms before testing. Fifty-one percent said they were unprepared to start screening that results in more than one overdiagnosis per one life saved from cancer death. However, 58.9 percent would continue screening even if they learned that test results in 10 overtreated people per one life saved.

“The results of the present study indicate that physicians’ counseling on screening does not meet patients’ standards,” Wegwarth and colleagues wrote. “Our results should prompt medical educators to improve the quality of teaching about screening and encourage medical journal editors to enforce clear reporting about overtreatment when publishing results on the effectiveness of cancer screening.”