Q&A Cancer Screening

Q&A with Therese Bartholomew Bevers, MD, FAAFP
Professor, Department of Clinical Cancer Prevention
Medical Director, Cancer Prevention Center
Medical Director, Prevention Outreach Programs
University of Texas MD Anderson Cancer Center, Houston
Q: Why is cancer screening an important element of a woman’s overall healthy aging plan?

A: There are a number of cancers that, when caught early through screening, have better outcomes—and may require less intensive treatment. Screening is recommended to catch cancers at an early stage, before they present with symptoms. Cancers that present with symptoms are often later-stage disease.

Q: What is the best resource for screening recommendations?

A: I think the best general resource is the American Cancer Society (ACS, cancer.org). They outline recommendations for average-risk individuals and those at increased risk. There are other organizations, such as the US Preventive Services Task Force (USPSTF), that issue cancer-screening recommendations, however in a number of cases the recommendations may differ significantly from those of the ACS. Most clinicians lean toward the ACS.

Q: Women can be confused by conflicting recommendations— including the differences you note in the ACS and USPSTF guidelines. What should we know about how the various guidelines have been developed and which recommendations are best to follow?

A: In developing screening recommenda­tions, the ACS and the USPSTF both con­sidered the evidence, including the bene­fits and the harms associated with cancer screening. With screening mammograms, the USPSTF felt that because breast cancer is less common in women in their forties and because women who are screened in their forties are more likely to have a false-positive test result, there was no clear benefit; specifically, they felt that the harms (false positives, which might lead to callbacks and, for some women, a biopsy) may, for some women, outweigh the benefits (a decreased risk of dying from breast cancer).

Many clinicians on the front lines, however, while agreeing that false positives are a harm and are greater in women in their forties, do not equate a callback, or even multiple callbacks, with a reduced risk of dying from breast cancer; these are two vastly different things. Most clinicians and patients feel that the burden of false positives is acceptable for women in their forties to get the benefits that are realized. That is why the ACS and other organizations, as well as most clinicians, still recommend annual mammograms starting at age 40.

Q: What questions should women ask about cancer screening to be sure they are following an appropriate schedule?

A: A woman and her physician should discuss her risk of developing cancer. All recommendations should be based on her level of risk: if she is at average risk for breast cancer, we would recommend annual mammograms starting at age 40; if she is at increased risk, we may wish to start earlier and use additional screening modalities, such as a breast magnetic resonance imaging (MRI) scan. The only way to devise an appropriate screening schedule is to do a risk assessment, during which a clinician looks at family history, health history, exposure history, and lifestyle factors. Women should ask about their risk and engage in a dialogue with the clinician. If there is not enough time during a well-woman (annual) exam, be sure to ask your clinician if you can schedule another appointment to more thoroughly discuss risk and screening.

Q: What should women know about the role of genetic testing and family history as those topics relate to cancer screening?

A: Family history is an important piece of a cancer risk assessment, especially for breast, colon, and some other cancers. Women should understand their family history and discuss it with their clinician. To provide the clinician with an accurate picture of family history, it is important to know the following: who had breast cancer (which blood relative) on both the mother’s and the father’s side; what age that family member was at diagnosis; what type of cancer (original site) it was; and whether that relative has more than one type of cancer, or whether it was a metastasis of the original cancer to different sites. Answers to these questions help us understand genetic predisposition. This information should be gathered and recorded before the appointment so that valuable time during the visit is not spent trying to remember and record the family history.

If the family history is concerning enough, the clinician might recommend genetic counseling, which for some women may ultimately lead to genetic testing. Genetic counselors are invaluable in determining if genetic testing is necessary. I strongly discourage women from going straight to genetic testing. Primary care physicians are outstanding at what they do, but there is not enough time in that visit to go through all the issues related to genetic testing. Genetic counselors explain all aspects and potential results. If you make the leap to testing without thoroughly understanding the issues, you are missing a lot of valuable information.

Q: What should women know about cost or insurance issues related to cancer screening?

A: Almost all insurance plans cover stan­dard cancer-screening tests, often at 100 percent. This encourages indi­viduals to participate in screening, which means cancer is caught earlier and requires less intensive (and less ex­pensive) treatment. Often screening does not have a co-pay. If you are uninsured, there are a variety of low-cost or free screening programs available around the country.

Therese B. Bevers, MD, FAAFP, is a professor of clinical cancer preven­tion and the medical director of the Cancer Prevention Center and prevention outreach programs at MD Anderson Cancer Center. In her role as medical director, Dr. Bevers has overseen the growth and program development of the Cancer Prevention Center—the first comprehen­sive clinical cancer prevention service program in the country—since its opening in 1996. Dr. Bevers chairs the National Comprehensive Cancer Network’s guide­line panels on breast cancer screening and diagnosis and breast cancer risk reduction. She is the recipient of many awards, including the Julie and Ben Rog­ers Award for Excellence in Prevention in 2006, the Kathryn S. Stream Award for Excellence in Women’s Health in 2011, and the Faculty Achievement Award in Prevention in 2011.