Intellectual Dishonesty

As students we were taught to think rigorously about problems; to apply our minds to the evidence provided by the science of our profession; to bring ethical principles to our judgments about our management of patients to ensure that, on balance, we do more good than harm. Any intervention has to be weighed from the public health and the private points of view, from the theoretical to the pragmatic, from the cost-effective to the affordable, and take into account the patient’s emotional and social circumstances. So why do the principles desert us when it comes to screening?

Ovarian Cancer Screening in Low-Risk Women

Three quarters of patients with ovarian cancer present late because of the lack of symptoms; the overall 5-year survival rate is—-at best—-one-third, which makes it the fifth leading cause of malignant death in women. This positions it as a high priority for early diagnosis, but our present screening methods of ultrasound combined with cancer antigen 125 are neither sensitive nor specific enough to meet the criteria of a valid screening tool.

The accepted terms for screening include an understanding of the natural history of the disease, which we lack probably because of the heterogenicity of ovarian lesions. In addition, the latest data demonstrate that screening does more harm than good.¹ This research showed that more women who were screened had oophorectomies than the nonscreened control subjects, most of which were negative for cancer but nevertheless carried significant morbidity rates. It also showed that more screened women than control subjects died. The UK Collaboration Trial of Ovarian Cancer Screening pilot study² was not convincing. Less than 1% of the trialists had surgery but 70% of those operated on did not have cancer. A Japanese study again showed the large number of laparotomies needed to confirm the correct diagnosis (33 to 1) with no gain in early detection leading to lives saved.²

Now the influential United States Preventative Services Task Force (USPSTF) has confirmed its previous position saying that ovarian cancer screening increases harm, although there is fair evidence that it has no significant effect on mortality. If a low-risk woman inquires about routine ovarian cancer screening we have to tell her that on balance it is a bad idea and the evidence shows that it does more harm than good.

Prostate Cancer Screening With Prostate-Specific Antigen in Low-Risk Men

The same authority in America that pronounced on ovarian screening, the USPSTF, in May 2012 concluded that prostatic-specific antigen screening in low-risk men was associated with a very small reduction in mortality and resulted in considerable overdiagnosis and overtreatment. This gives rise to potential harms, including pain, fever, bleeding, and infection from prostate biopsy, as well as the possibility of erectile dysfunction, incontinence, and bowel dysfunction following surgery. Put simply, a test that its inventor never intended as a screening tool does more harm than good.⁴ Screening programs should be just as rigorously tested as any intervention. Norway is certainly considering doing just that.⁵