cancer screening


Colonoscopy Culture Clash: Why Am I Getting One When Canada Says Not So Fast?

Various colonoscopy prep options, none of them yummy (Courtesy of Dr. Ram Chuttani)

Various colonoscopy prep options, none of them yummy (Courtesy of Dr. Ram Chuttani)

My last thought before drifting off was: What am I doing here?

As the nurse hooked up the IV for my “conscious sedation” — a pain-killing, amnesia-inducing, anxiety-easing cocktail of fentanyl and Versed — I had checked my phone one last time and up popped this headline: “New Canadian recommendation against colonoscopy for routine screening of colorectal cancer.”

So why was I in the endoscopy suite on a recent Monday morning, my backside exposed in a hospital johnny?

Some background: I was supposed to get this routine colonoscopy when I turned 50 in 2014 but, like many people, I delayed — no family history and an emotionally tough year offered good excuses. When the year passed, I tried to procrastinate further, and asked my doctor about alternatives. “There are no real alternatives,” she told me. “If there were another good option, I would choose that for myself but I will be having my colonoscopy this year as well.”

As Dr. Ram Chuttani, chief of endoscopy at Beth Israel Deaconess Medical Center in Boston, put it: “Colonoscopy is still the gold standard.”

So, of course, I made the appointment, ate the low-fiber diet, complied with the clear liquid fast the day before and suffered through the prep. (Except I was unable, at 4:30 in the morning, gagging, to finish the full 16 ounces of prep mixture.) Like countless other middle-aged Americans, sitting on the toilet en route to a pristine colon, I thought: There’s got to be a better way.

Better In Canada?

Late last month, for the first time, Canadian medical professionals came out against colonoscopies for routine screening, saying that the evidence is lacking that this method is effective enough at preventing deaths from colon cancer.

“We recommend not using colonoscopy as a screening test for colorectal cancer,” the new guidelines, published in the Canadian Medical Association Journal, say, in a summary.

So, if colonoscopy is the gold standard here but not recommended there, what’s a patient to do? Maybe just acknowledge that different health systems, with different priorities and cost structures, end up promoting different flavors of medical care. What you should not do is nothing. If there’s one thing pretty much everyone agrees on: colon cancer kills, but it’s also largely preventable, so the best screening method is one that actually gets done.

The Canadian Task Force on Preventive Health Care, the group that wrote the new guidelines, cited two preferred colon cancer screening methods for low-risk, asymptomatic adults ages 50 to 74:

  • Fecal occult blood testing (FOBT), in which stool samples are analyzed for hidden traces of blood, every two years
  • Flexible sigmoidoscopy, which uses a scope to examine the lower part of the colon and rectum only, every 10 years (This procedure involves less prep than colonoscopy, no sedation, and in Canada it’s done by either a nurse practitioner or primary care doc, with no specialist needed)

In America, the U.S. Preventive Services Task Force, an independent panel of medical experts that issues guidelines, recommends a range of colon cancer screening methods for low-risk adults 50 to 74.

Dr. Albert Siu, chair of the U.S. Preventive Services Task Force, told me in an email that the main point of the guidelines is simply to encourage screening. Continue reading

What You Really Need To Know About Dense Breasts

From left: 1) a breast of normal density showing fat (white), fibrous tissue (pink) and glands within the rectangle, while a cancer is present (circle). This illustrates the fact that cancer can occur in breasts of any density; 2) an extremely dense benign breast without any fat, composed of pink fibrous tissue and minimal amounts of glands; 3) an extremely dense breast involved by cancer (infiltrating haphazard small glands), in contrast to Fig 2, but very similar in appearance, demonstrating the subtle similarities. (Courtesy Michael Misialek)

From left: 1) a breast of normal density showing fat (white), fibrous tissue (pink) and glands within the rectangle, while a cancer is present (circle). This illustrates the fact that cancer can occur in breasts of any density; 2) an extremely dense benign breast without any fat, composed of pink fibrous tissue and minimal amounts of glands; 3) an extremely dense breast involved by cancer (infiltrating haphazard small glands), in contrast to Fig 2, but very similar in appearance, demonstrating the subtle similarities. (Courtesy Michael Misialek)

By Michael Misialek, M.D.
Guest Contributor

Reading the pathology request on my next patient, I saw she was a 55-year-old with an abnormality on her mammogram. Upon further investigation I discovered she had dense breasts and a concerning “radiographic opacity.” The suspicion of cancer was high based on these findings and so, a breast biopsy had been recommended. As I placed the slide on my microscope and brought the tissues into focus, I immediately recognized the patterns of an invasive cancer. Unfortunately the suspicion had proven correct.

Just a few patients earlier, an almost identical history had prompted another breast biopsy. This time the results were far different, a benign finding and obviously a sense of relief for the woman. Every day these stories unfold; the never ending workup of abnormal mammogram findings. Both radiographically and microscopically, it can be challenging at times sorting out these diagnoses, particularly in the face of dense breasts.

But what, exactly, are dense breasts and why are they suddenly in the news?

Breast Tissue 101

Breast tissue is actually made up of three tissue types when viewed under the microscope. The percentage of each varies between patients. There is fat, fibrous tissue (the supporting framework) and glandular tissue (the functional component). This is what I actually see under the microscope. Cancer can occur in fatty or dense breasts. It can be toughest to assess when the background is dense.

Biopsy, considered the gold standard in diagnosis, may even prove difficult to interpret when in the background of dense breasts. Dense breasts can hide a cancer, making it more difficult to detect both by mammogram and under the microscope.

Breast density has taken a lot of heat recently. A new study published in the Annals of Internal Medicine found that not all women with dense breasts and a normal mammogram warranted additional screening, as was previously thought. Understandably this report has received much attention. The authors found nearly half of all women had dense breasts. This alone should not be the sole criterion by which additional imaging tests are ordered since these women do not all go on to have a cancer. Clearly other risk factors are at play.

Confusion All Around

This is confusing for patients and doctors alike, especially when it seems as if screening guidelines are a moving target. Recently, the American College of Physicians issued new cancer screening guidelines: among these was mammograms, being recommended every two years. This too is getting a lot of press.

The American College of Radiology, American Cancer Society, Society of Breast Imaging and American College of Obstetricians and Gynecologists recommend yearly mammograms beginning at age 40. Continue reading

Pathologist’s View On Prostate Cancer Grey Zone: ‘What Do My Numbers Mean?’

Prostate cancer, circled. (Photo courtesy Dr. Michael Misialek)

Prostate cancer, circled. (Photo courtesy Dr. Michael Misialek)

By Dr. Michael Misialek
Guest Contributor

We don’t like to admit it but cancer is rarely black and white. Increasingly a cancer diagnosis means living in a murky morass of constantly reassessing risk.

Here’s one man’s story of living on that precarious line. His saga, seen through a pathologist’s filter, illustrates the uncertainties surrounding prostate cancer. And, as the number one cancer in men, it is increasingly becoming a familiar story for many. Questions like, ‘What do my numbers mean?’ ‘Should we treat or not?’ and if so, ‘Which treatment is best for me?’ inevitably arise.

Mr. B. is a 64-year-old man who was found to have an elevated PSA four years ago on his routine physical exam. Obviously, prostate cancer was the first thought that came to mind, particularly since his father had the disease. What he soon learned is that prostate cancer is a complex diagnosis — one that requires the careful integration of the physical exam, biopsy results, radiographic studies and lab results.

And, of course, it’s a diagnosis that comes with many decisions and choices; choices that depend upon understanding the grey zone of medicine. Prostate cancer is rarely clear cut. As much as numbers like the PSA and Gleason score (the sum of the two most predominant grades in a patient’s tumor) guide diagnosis and treatment, they also contribute to the uncertainties on the best course of action.

When Mr. B’s elevated PSA was first detected, his primary care physician referred him to a urologist at Newton-Wellesley Hospital. His prostate was normal on physical exam and they elected no biopsy at the time. Over the next couple of years the PSA slowly continued to rise, still with no change in his physical exam. Last year a biopsy was done and was negative. No cancer, a relief. What was found was some inflammation. Could this have contributed to the rise in PSA? It certainly could have, but a negative biopsy did not rule out cancer. The journey of watching numbers continued.

This year Mr. B.’s PSA rose yet again, and his urologist ordered an MRI which was negative. Mr. B. underwent another biopsy. (Not an easy process since he takes the blood thinner Coumadin and any invasive procedure needs to be carefully coordinated with stopping and restarting this medication.) The biopsy is also uncomfortable: his first biopsy involved six needles, but this time it was twelve.

The slides came to me. I put them on my microscope and carefully studied each of them. As I scanned at low magnification I found two tiny foci of abnormal glands which qualified for a diagnosis of cancer. Continue reading

Yes, Medicare Will Cover Lung Cancer Scans For Longtime Smokers, But…

(Source: Wikimedia Commons)

(Source: Wikimedia Commons)

…to finish the sentence in the headline: But it was not the simple no-brainer that you might think.

Lung cancer is the biggest cancer killer of all, causing 160,000 American deaths a year. But should we use lung scans to screen longtime smokers en masse for it? That question has been vigorously debated of late in medical circles, as Medicare has weighed whether to pay for the scans.

This week, Medicare announced that it did indeed propose to cover annual low-dose CT scans for smokers and former smokers, ages 55 to 74, with a smoking history equivalent to a 30-year pack-a-day habit. (More details here.)

People say ‘You deserve this because you brought it on yourself, and thus, suffer the consequences.’

– Laurie Fenton Ambrose

The draft decision now gathers public comment for a month and will still need to be finalized, but cancer activists and some doctors are already hailing it as a victory. Laurie Fenton Ambrose, president of the Lung Cancer Alliance, which had helped lead the push for the coverage, predicted that the scans would save tens of thousands of lives.

So why has screening for lung cancer sparked such hot debate? Why did it even recently trigger a rare pointcounterpoint duel in the pages of a major medical journal, JAMA Internal Medicine?

Well, first, the pendulum has been swinging lately towards greater skepticism about routine cancer screening, from mammograms to prostate tests.

(Source: FDA)

(Source: FDA)

At issue is the pivotal question of whether some forms of cancer screening do more harm than good, given that some of the tumors they pick up would never have caused any trouble. Routine blood tests for prostate cancer have fallen out of favor, for example, and the New England Journal of Medicine just published a cautionary tale from Korea about how mass ultrasound scans for thyroid cancer saved no lives.

So that’s the broader medical context. Then there’s the money. I recently heard a Medicare official say with pained realism at a public forum, “We can’t cover everything good.” Close to 5 million people on Medicare would be eligible for the screening, NPR reports, and the scans cost an estimated $241 each.

So at a time of greater emphasis on health costs and greater doubts about cancer screening, “We just found ourselves caught in that crossfire,” said Fenton Ambrose of the Lung Cancer Alliance.

With lung cancer, there’s also the question of special stigma. People say “You deserve this because you brought it on yourself, and thus, suffer the consequences,” Fenton Ambrose said. “It has always had that type of stigma, that even carried through in some of the public comments that came forth during the Medicare consideration.”

Dr. Chrisopher Lathan, a medical oncologist at the Dana-Farber Cancer Institute, similarly cited stigma as a source of “hesitation” on the coverage. “This is a cancer that’s heavily linked to a behavior,” he said. “The amount of data needed to convince everyone that this was a good screening tool — that hurdle was much higher. And also, we are in a more skeptical time, academically, when we look at screening. We know that screening is good, but it’s good in certain circumstances.”

Which circumstances, when it comes to lung scans? This is the moment for the Public Service Announcement that says, “Talk with your doctor.”

“At the end of the day, this is about the relationship between doctors and patients,” Fenton Ambrose said. And in particular, there are some gray areas that require discussion, she noted. What if, for example, you’re a bit younger, or smoked a bit less than the cut-off? Research is now under way on that “second tier” of potential scan subjects, she said. Continue reading

Catching Cancer Early: Be Careful What You Screen For

By Richard Knox

True or false: It’s always better to catch cancer early.

Answer: False

But that absolutely doesn’t mean we should give up screening for early detection of cancer.

Yes, it’s confusing. But bear with me. Because two reports issued this week are a perfect illustration of why cancer screening is such a tricky topic.

Consider them both and you’ll have a better appreciation of the complexities of the issue. And why individuals and health policymakers need to think carefully about when to screen and what to do with the results.

One new report is about screening for thyroid cancer. It makes a strong case for why it’s not a good idea.

The other is about screening for cervical cancer. It’s an equally strong argument for why there’s not enough.

First, thyroid cancer screening. South Korea has gone in for it in a big way, as part of a national push for detecting all cancers for which there’s a screening test – cancer of the breast, uterine cervix, colon, stomach and liver.

Adenocarcinoma in Situ of the Cervix/Ed Uthman, flickr

Adenocarcinoma in Situ of the Cervix/Ed Uthman, flickr

South Korea is years ahead of the U.S in paying for cancer screening. Back in 1999, the government started providing free or very low-cost cancer screening, something that’s only now happening, and more cautiously, under the U.S. Affordable Care Act.

The Korean program doesn’t include thyroid cancer in its screening program. But so many hospitals and doctors have ultrasound machines – which can detect tiny thyroid tumors with a quick neck scan – that thyroid cancer screening has become routine in recent years, for a fee of $50 or less. It’s an easy sell, and an easy way to make money. Continue reading

My Right Breast: One Man’s Tale Of Lump And Mammogram

Journalist B.D. Colen chronicles  his own mammogram experience both in prose and in photos he took during the procedure. ((c) B. D. Colen, 2014)

Journalist B.D. Colen photographed his own mammogram during the procedure. ((c) B. D. Colen, 2014)

By B. D. Colen

It began with an itch I just had to scratch. Doesn’t every adventure begin that way?

I was lying in bed reading on a Saturday evening, and without even looking I idly scratched a spot on the right side of my chest –- at that point I had a chest, not breasts. As I did, my fingers rode over a small something, a little like a speed bump about an inch below and two inches to the left of my right nipple.

I stopped reading and started poking. And prodding. And pushing. And feeling. And manipulating. And panicking.

“That’s a lump!” I thought, and suddenly I had a right breast. With a lump in it.

I spent Sunday attending to the usual chores and pleasures, with a good deal of poking and prodding added in. There was absolutely no question that something was dwelling there, beneath my AAAA right breast. But what was it? And what was I worried about? After all, I’m a man, and men don’t…Well, yes, men do get breast cancer. In fact about one in every thousand men will develop breast cancer during their lifetimes. Granted, that’s barely worth mentioning compared to a woman’s one-in-nine chances, but it still means that the possibility was indeed real that something ugly and malignant was barely hiding beneath my skin.

The following day, I already had an appointment with my primary care physician about something else, and when we were finished I said, “So, Sam, I seem to have this lump in my right breast.”

(Photo c. B.D. Colen, 2014)

(Photo (c.) B.D. Colen, 2014)

Suddenly, my normally garrulous physician grew serious. “Let’s take a look,” he said, asking me to lie down on the examining table. He had me show him where I thought the lump was and I instantly isolated it – I’d already felt the damned thing enough times to be able to go right to it.

He felt it, felt around it, poked and prodded, and in less than a minute said, “You’re right, there’s something there.” Then, without further kidding – which I’d expect from him – and without any “Well, it’s probably nothing, but let’s be sure,” he sat down at the computer and started typing. “I’m putting in an order for a ultrasound and a mammogram,” he said. “For tomorrow.”

Mammowhat?! Mammogram? Me? But I’m a man! And at 67? Is this some really, really weird dream I’m about to wake up from? How in God’s name were they going to do a mammogram when there’s practically no mam on my chest?

But into the rabbit hole, through the door marked “Women (almost) Only” I went. Though not before Googling “male breast cancer” and convincing myself that I was going to die: Family history? Check. Average age of 68? Check. Sometimes Google is not your friend.

The nice woman down in radiology scheduled me for 10 the next morning, and told me that I shouldn’t worry. “It’s probably nothing,” she assured me. I thought, “That’s probably what you tell all the guys.”

I don’t need to tell any of you who are women what a painful, essentially degrading experience having a mammogram is. I’ve since read the jokes advising women to prepare for the procedure by placing a breast on the edge of their freezer and slamming the door on it – and that is pretty close to the reality. Continue reading

Mammogram? 50 Years Of Data And Decision Aids To Help You Think Through

A mammogram image, with arrow in upper left pointing to cancer

A mammogram image, with arrow in upper left pointing to cancer

Any procedure that involves sandwiching your naked breast between hard glass plates is personal. Very. But it’s becoming ever more clear that getting a mammogram also holds an element of personal decision. Medical authorities put out broad guidelines, but then you and your doctor can customize them, based in part on your own breast cancer risk and preferences.

How? Before we get into that, a paper just out in the Journal of the American Medical Association takes a sweeping look at a half century of mammogram data, and offers this big picture: mammograms do save lives, “but those benefits are not enormous,” said Dr. Nancy Keating of Brigham and Women’s Hospital and Harvard Medical School, the paper’s co-author. While the potential harms — that a woman will undergo cancer treatment for a tumor that never would have actually harmed her — have tended to be underestimated.

Here, Dr. Keating lays out the mammogram numbers that I found most helpful:

“If we take 10,000 women who are at average risk at age 40, over the course of ten years about 190 will be diagnosed with breast cancer. Most of these women will do well and would have done well regardless of screening. About five of those 10,000 women will have their life saved by the mammogram. Another 30 of those women will die regardless of the mammogram because unforutunately some breast cancers are so aggressive that they’re destined to be deadly despite the mammogram.

So there is benefit, five out of 10,000 women have their lives saved, but there are also these harms. One harm is false positives and unnecessary biopsies,: Of 10,000 women, about 6,000 will have at least one false positive. At this point, I say to patients, ‘You should expect that you’ll have some false positives, and don’t worry when they call you back.’ The over-diagnosis harm, we estimate: about 36 of those 190 cancers that were diagnosed could be over-diagnosed, and so those women will be treated — because we can’t currently tell the difference between the cancers we need to worry about and those that might not be so concerning, so we treat them all the same. So those women are then subjected to the harms of treatment without gaining any benefits.

So how to customize? How do you help create your own risk-benefit analysis? I asked the Informed Medical Decisions Foundation for helpful tools, and they suggested three:

The National Cancer Institute’s Breast Cancer Risk Assessment Tool

Public Health Agency of Canada Mammography Decision Aid


And for a bit more background, Dr. Keating discussed mammogram issues with co-host Anthony Brooks on Radio Boston, including these highlights:

On the questions Dr. Keating sought to answer in her review: Continue reading

The Latest Piece In The Mammogram Puzzle

It’s just hard to wrap your head around. Cancer screening tests — mammograms, PSA levels, colonoscopies — check for early tumors. Catching cancer earlier is better than later. And yet some research suggests that screening — at least for breast and prostate cancer — may be of dubious worth, because it catches many cancers that would never have posed a danger.

The latest salvo on this controversial topic came last week from Dartmouth’s Dr. H. Gilbert Welch, a leading voice on the problem of overdiagnosis, in a New England Journal of Medicine study and an op-ed in The New York Times. He sums up his findings on three decades of mammogram screening in the Times:

…More than a million women who were told they had early stage cancer — most of whom underwent surgery, chemotherapy or radiation — for a “cancer” that was never going to make them sick. Although it’s impossible to know which women these are, that’s some pretty serious harm.

But even more damaging is what these data suggest about the benefit of screening. If it does not advance the time of diagnosis of late-stage cancer, it won’t reduce mortality. In fact, we found no change in the number of women with life-threatening metastatic breast cancer.

Have lingering questions? Tune in to Radio Boston today a little after 3 p.m. for a discussion of the issue that will include a chance to call in. And it may help to view the video above, in which Dr. Welch explains his findings.

Analyzing Those Widespread Feelings Of ‘Hands Off My PSA Test’

(ABC News on Youtube)

I remember my own natural instincts about cancer screening before a friend in public health set me straight about false positives and other possible harms. I figured the more mammograms I got, the better, right? Same with tests for prostate specific antigen, or PSA, in men, no? The test can save your life. What could be bad?

A lot, of course, including potentially terrible complications from prostate surgery. And earlier this week, a federal panel issued final recommendations against routine prostate screening for healthy men. But the panel’s calculations that the tests do more harm than good have failed to convince many who reason as I used to, that catching cancer early must save lives.

In a paper that couldn’t be timelier, this month the journal Psychological Science publishes an analysis of the “uproar” over prostate screenings last October, when the panel issued its initial recommendations leaning in the same anti-PSA direction.

The Psychological Science paper identifies four psychological factors that “can help explain the furor that followed the release of the task force’s report.” They are:

• The persuasive power of anecdotal (as opposed to statistical) evidence

• The influence of personal experience

• The improper evaluation of data

• The influence of low base rates on the efficacy of screening tests.

The authors, from Ohio State University and The Max Planck Institute for Human Development in Berlin, suggest that the reaction might be different if the panel’s calculations were better explained: “Augmenting statistics with fact boxes or pictographs might help such committees communicate more effectively with the public and with the U.S. Congress.”

I’m all for better explanations. I also can’t help thinking that these psychological factors cannot apply to the experts whose opposition to the anti-PSA recommendations is quoted in this NPR story and in this previous CommonHealth post.

Putting potential arguments aside, the paper offers a wonderfully vivid explanation of public attitudes by presenting the thought experiment of a thousand older men in an auditorium:

Consider two auditoriums, each of which contains 1,000 men age 50 or older. Auditorium “Screened” contains 1,000 men who have had a PSA screening test. Auditorium “Not Screened” contains 1,000 men who have not had such a test. About 8 men from each auditorium will die from prostate cancer in the next 10 years. A very important conclusion to be drawn from these numbers is that screening does not decrease prostate-cancer mortality. How can this be, given that so many men claim to have been saved by a PSA test? Continue reading

Oh, Joy! The Prospect Of Laxative-Free Colonoscopies


Even now, weeks after my first colonoscopy, certain tastes and smells still trigger odd sensory flashbacks to the gallon of salty-swampy laxative liquid I had to glug to clean out my intestines before the procedure.

The taste didn’t seem so bad at first. I scoffed at all the whiners who have made the nastiness of colonoscopy prep so legendary. But near the end of the gallon, I found myself gagging and forced to suck on lollipops to help the swallowing along. Not that I’d ever skip the test. Colon cancer is too common and deadly, killing 50,000 Americans a year, and the effectiveness data on colonoscopies look good. Still, I couldn’t help wondering aloud: Does it really, truly have to be like this?

So even though the prospect of a laxative-free colonoscopy is years away, I can make no pretense of journalistic objectivity. I’m overjoyed to share this news: A new study out of Massachusetts General Hospital, following about 600 patients, suggests that a colonoscopy without the noxious preliminaries is feasible.

The point isn’t just to make life easier for people getting colonoscopies. It’s to help persuade them to get the test in the first place.

I did my due diligence: I asked the study’s leader, Dr. Michael Zalis, director of CT Colonography in the hospital’s imaging department, whether any potential financial conflicts needed to be disclosed — a start-up to develop laxative-free colonoscopies, that kind of thing? But no, no such disclosures, he said. The study was funded by the American Cancer Society, General Electric and the National Institutes of Health. Good enough — please sign me up for ten years from now.

A bit of background: Medical innovators had already invented the “virtual colonoscopy,” in which a patient’s innards are inspected using an abdominal CT scan rather than by inserting a long fiber-optic tube with a camera and a light on the end. But the patient still has to go through the colon-cleansing prep. The new study, just out in the May 15 Annals of Internal Medicine, takes the “virtual” one step farther: it uses software and a special contrast agent to make the colon cleanse virtual as well.

The point isn’t just to make life easier for people getting colonoscopies; It’s to help persuade them to get the test in the first place. Only about half of adults follow the recommendations for getting tested — which include universal testing for people over 50 — and surveys find that the nastiness of the prep is part of the problem.

Let me cut to the chase: If all goes well, I asked Dr. Zalis, how soon might the virtual cleansing be available? Conservatively speaking, he said, at least one more study is needed to confirm his team’s results, and that will probably take at least three years. Continue reading