WASHINGTON -- We've always heard the same message about cancer: early detection and early treatment is our best life-saver. But is it true? And is it possible that some of us are being overtreated for breast cancer or prostate cancer? Going through radiation and chemotherapy unnecessarily? Some experts say so.
D.J. Soviero wanted the least treatment that would beat back her small, early-stage breast cancer, but her first doctor insisted she had only one option: tumor removal followed by radiation and chemotherapy.
Then she found a novel program at the University of California, San Francisco, that gave her an unbiased evaluation of the pros and cons of all treatment options.
"I realized that I didn't need to use a sledgehammer. It was my choice," said Soviero of San Francisco, who went with the lumpectomy and radiation but refused the chemo.
It's an unthinkable notion for a generation raised on the message that early cancer detection saves lives, but specialists say more tumors actually are being found too early. That is raising uncomfortable questions about how aggressively to treat or to test for early growths.
"The message has been, 'Early detection, early detection, early detection.' That's true for some things but not all things," said Dr. Laura Esserman, a breast cancer specialist at UCSF. She helped lead a study, reported last week, that found mammography is increasing diagnoses of tumors deemed genetically very low risk.
"It's not just all about finding any cancer. It's about being more discriminating when you do find it," she added.
Today's cancer screenings can unearth tumors that scientists say never would have threatened the person's life. The problem is there aren't surefire ways to tell in advance which tumors won't be dangerous -- just some clues that doctors use in prescribing treatment.
Work is under way to better predict that, and even the staunchest supporters of screening call overdiagnosis a problem that needs tackling.
"WeOre really at a tipping point right now, where we have a trade- off between the benefits of finding cancer early and the harms that are caused," said Dr. Len Lichtenfeld of the American Cancer Society. "We treat more patients than we know will benefit. E We just don't know who they are."
Nowhere is the disconnect more obvious than with prostate cancer screening. Most men older than 50 have had a PSA blood test to check for it even though major medical groups don't recommend routine PSAs, worried they may do more harm than good for the average man. Thus, the American Cancer Society urges that men weigh the limitations of PSAs against their individual risk and fear of cancer before deciding for themselves. Government guidelines say men over 75 shouldn't get a PSA at all -- although about one-third do.
Mammograms aren't nearly as controversial, except for the when- to-start-them question. Most medical groups advise age 40; a government task force ignited complaints last year by advising not until 50.
The trade-off: More than three-quarters of the 1 million-plus biopsies done each year turn out to have been unneeded.
The bigger unknown is overdiagnosis, as closer mammogram readings spot ever-earlier growths.
A study in last month's Journal of the National Cancer Institute said nearly one-quarter of breast tumors found by mammograms may be overdiagnosed. That includes invasive cancer, but also a common milk- duct growth called DCIS, or ductal carcinoma in situ.
DCIS isn't an invasive cancer and isn't life-threatening; it's described as "stage zero" cancer or even precancer. But it is a risk factor for developing invasive disease.
"The problem with our tests is they can see too much," added study author Dr. H. Gilbert Welch of Dartmouth and the Veterans Affairs Outcomes Group, who led the overdiagnosis study published last month. She says raising the threshold at which tests signal suspicion could help.
Patients today face tough treatment choices -- and that's where "shared decision-making" programs come in.
"What's underuse to one person might be overuse to another," said Jeff Belkora, who directs the decision-services program at UCSF's Breast Care Center.
UCSF's program sends newly diagnosed breast cancer patients a DVD to watch before a visit with a cancer specialist, to outline treatment options. Patients also are offered the aid of an intern to create a list of questions to ask at that visit -- and then to attend with them, recording the doctor's answers.
Soviero, now 63, first used the program in 2000 and her right breast remains cancer-free. Last year, a mammogram spotted a tumor in her other breast, and she went through the program again and selected the same treatment.
"The hard part of making a decision is you never know. If you don't die, you'll never know that you maybe did too much," she said.
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