BOSTON—The national discourse on cancer screening has come a long way since 1988, when Ronald Reagan became the first president to say “breast cancer” in public, noted Alec Stone, MA, MPA, Health Policy Director, Oncology Nursing Society (ONS). In 2009, after the US Preventive Services Task Force (USPSTF) recommended mammography screening every 2 years instead of annually, beginning at 50 years of age instead of 40, the public outcry was widespread and loud. Controversy has also been swirling about prostate cancer screening recommendations.
Several organizations offer guidelines for breast and prostate cancer screening, but “patients get confusing messages from all of these different organizations about how or when to be screened,” said Heather Greene, RN, MSN, FNP, AOCNP, an oncology nurse practitioner with Blue Ridge Medical Specialists, Bristol, Tennessee. Many oncology nurses care for patients who already have cancer, but ONS believes their role as a cancer educator obligates them to stay current on cancer screening and prevention guidelines.
For years, women were told to undergo annual mammography screening for breast cancer starting at 40 years of age because early detection saves lives. Women were also encouraged to perform a monthly breast self-examination (BSE). Greene said the American Cancer Society (ACS) and the National Comprehensive Cancer Network (NCCN) continue to recommend an annual mammogram once women reach 40 years of age and a clinical breast examination every 1 to 3 years from age 20 to 39 years and annually starting at age 40.
“ACS and NCCN don‘t recommend that we tell our patients to do monthly self-examinations any more. They‘re more in favor of teaching breast awareness,” said Greene. The BSE can be incorporated in awareness education, but the focus should be on breast changes that might signal a problem, such as heaviness, redness, or nipple concerns.
Whereas USPSTF guidelines advise against mammography screening for women older than 75 years, citing insufficient evidence of effectiveness, ACS and NCCN guidelines leave it to the physician’s discretion. “If the clinician deems them healthy enough to benefit from intervention, they should have a mammogram,” Greene said.
Early detection of breast cancer via mammography clearly reduces mortality and morbidity, said Greene, who opposes implementing the USPSTF guidelines. She suggested nurses talk to patients about mammography risks, such as false positives, which might require additional tests and increase expense and anxiety. Patients also should be told about false negatives and informed that certain tumors, even if detected early, are associated with worse prognosis.
After years of debate, guidelines are leaning against routine prostate cancer screening in men with low to average risk. Prostate tumors are often indolent and men with positive prostate-specific antigen (PSA) tests frequently die of causes other than the malignancy. PSA velocity may be more useful than absolute PSA levels.
ACS guidelines recommend talking to men about PSA screening at 50 years of age and encouraging them to take an active role in decision making. Men with a family history of prostate cancer or African-American men should get screened starting at 45 years of age.
NCCN continues to advise discussing risks and benefits of prostate cancer screening and offering a baseline PSA screen and digital rectal examination once men reach 40 years of age. USPSTF does not recommend any prostate cancer screening and opposes it in men aged 75 years and older. The American Urology Association (AUA) suggests screening “well-informed men” starting at 40 years of age if their life expectancy is at least 10 years. For asymptomatic men of low to average risk whose PSA screens suggest prostate cancer, NCCN and AUA guidelines include observation as a follow-up option.
No organization recommends lung cancer screening for asymptomatic individuals, but it might be appropriate for tobacco users with high risk. NCCN’s 2011 guidelines recommend high-risk individuals enter a chemoprevention or screening trial. At least one study has shown that lung cancer screening with low-dose spiral computed tomography scanning reduces mortality among heavy smokers.
Stone pointed out that “cost drives everything,” including screening. Some employers are electing not to include cancer screening in their insurance plans. Other plans cover initial mammography but not a repeat test to clarify results. Patients may need help finding financial assistance for screening when it is indicated.