Screening for Cancer: Are Resources Being Used Wisely?

  • Robert M. Kaplan
Part of the Recent Results in Cancer Research book series (RECENTCANCER, volume 166)


Cancer screening is commonly offered in order to detect tumors at an early, treatable stage. These efforts are highly advocated and widely accepted by the general public. However, there is conflicting evidence about the benefits of screening for breast cancer in pre-menopausal women, prostate cancer in older men, and colorectal cancer for both sexes. This paper examines cancer screening in relation to a disease reservoir hypothesis. There is a reservoir of undetected disease that can be found with more aggressive screening. However, much of the disease that is detected may be classified as pseudodisease because it will have no effect of life expectancy or health-related quality of life. Pseudodisease is defined as detectable disease that will never be clinically significant. A second concern about screening is that randomized clinical trials often show benefits of cancer screening for disease-specific endpoints but no benefit for total mortality. Further, screening for some cancers may significantly increase healthcare costs without enhancing population health status. Improvements in biomarkers and in screening methodologies will significantly increase the number of cancers detected. Future research is necessary in order to determine which population-based screening programs are the best use of public health resources.


Breast Cancer Prostate Cancer Cancer Screening Prostate Specific Antigen Natl Cancer Inst 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Schwartz LM, Woloshin S, Fowler FJ Jr, Welch HG (2004) Enthusiasm for cancer screening in the United States. JAMA 291: 71–78PubMedCrossRefGoogle Scholar
  2. 2.
    Aronowitz RA (2001) Do not delay: breast cancer and time, 1900-1970. Milbank Q 79:355–386, IIIPubMedCrossRefGoogle Scholar
  3. 3.
    Eddy DM (1987) The frequency of cervical cancer screening. Comparison of a mathematical model with empirical data. Cancer 60:1117–1122PubMedGoogle Scholar
  4. 4.
    Harris P, Carnes M (2002) Is there an age at which we should stop performing screening pap smears and mammography? Cleve Clin J Med 69: 272–273PubMedCrossRefGoogle Scholar
  5. 5.
    Parnes BL, Smith PC, Conry CM, Domke H (2001) When should we stop mammography screening for breast cancer in elderly women? J Fam Pract 50:110–111PubMedGoogle Scholar
  6. 6.
    Shapiro S, Coleman EA, Broeders M, et al (1998) Breast cancer screening programmes in 22 countries: current policies, administration and guidelines. International Breast Cancer Screening Network (IBSN) and the European Network of Pilot Projects for Breast Cancer Screening. Int J Epidemiol 27:735–742PubMedCrossRefGoogle Scholar
  7. 7.
    Kaplan RM, Saltzstein SL (2004) Screening for breast cancer among older women: costs and outcomes. Eur J Cancer ECJ Suppl 2:35Google Scholar
  8. 8.
    Arnold K (2002) Mammography guidelines in the national spotlight...again. J Natl Cancer Inst 94:411–413PubMedGoogle Scholar
  9. 9.
    [No authors listed] (1994) Screening for prostate cancer: commentary on the recommendations of the Canadian Task Force on the Periodic Health Examination. The U.S. Preventive Services Task Force. Am J Prev Med 10:187–193Google Scholar
  10. 10.
    Levenson D (2003) Routine prostate screening may be unnecessary and harmful. Rep Med Guidel Outcomes Res 14:5–7Google Scholar
  11. 11.
    Weston R, Parr N (2003) New NHS guidelines for PSA testing in primary care. Lancet 361:89–90PubMedCrossRefGoogle Scholar
  12. 12.
    Farhat WA, Habbal AA, Khauli RB (2000) A guideline to clinical utility of prostate specific antigen. Saudi Med J 21:223–227PubMedGoogle Scholar
  13. 13.
    Birkmeyer JD, Sharp SM, Finlayson SR, Fisher ES, Wennberg JE (1998) Variation profiles of common surgical procedures. Surgery 124: 917–923PubMedGoogle Scholar
  14. 14.
    Kaplan RM, Ganiats TG, Frosch DL (2004) Diagnostic and treatment decisions in US healthcare. J Health Psychol 9:29–40PubMedCrossRefGoogle Scholar
  15. 15.
    Kaplan RM, Wingard DL (2000) Trends in breast cancer incidence, survival, and mortality. Lancet 356:592–593PubMedGoogle Scholar
  16. 16.
    Kaplan RM (1994) The Ziggy theorem: toward an outcomes-focused health psychology. Health Psychol 13:451–460PubMedGoogle Scholar
  17. 17.
    Welch HG, Black WC (1997) Using autopsy series to estimate the disease “reservoir” for ductal carcinoma in situ of the breast: how much more breast cancer can we find? Ann Intern Med 1 127: 1023–1028Google Scholar
  18. 18.
    Welch HG, Schwartz LM, Woloshin S (2000) Do increased 5-year survival rates in prostate cancer indicate better outcomes? JAMA 284: 2053–2055PubMedGoogle Scholar
  19. 19.
    Cancer Facts and Figures (2002) American Cancer Society, AtlantaGoogle Scholar
  20. 20.
    McGlynn EA, Asch SM, Adams J, et al (2003) The quality of health care delivered to adults in the United States. N Engl J Med 348: 2635–2645PubMedCrossRefGoogle Scholar
  21. 21.
    Epstein AM, Lee TH, Hamel MB (2004) Paying physicians for high-quality care. N Engl J Med 350:406–410PubMedCrossRefGoogle Scholar
  22. 22.
    Strong JP, Malcom GT, McMahan CA, et al (1999) Prevalence and extent of atherosclerosis in adolescents and young adults: implications for prevention from the Pathobiological Determinants of Atherosclerosis in Youth Study. JAMA 281:727–735PubMedCrossRefGoogle Scholar
  23. 23.
    Klingler K (2004) Early detection of lung cancer by CT-screening. Eur J Cancer ECJ Suppl 2:23Google Scholar
  24. 24.
    Marcus PM, Bergstralh EJ, Fagerstrom RM, et al (2000) Lung cancer mortality in the Mayo Lung Project: impact of extended follow-up. J Natl Cancer Inst 92:1308–1316PubMedCrossRefGoogle Scholar
  25. 25.
    Coley CM, Barry MJ, Fleming C, Mulley AG (1997) Early detection of prostate cancer. Part I: Prior probability and effectiveness of tests. The American College of Physicians. Ann Intern Med 126(5):394–406PubMedGoogle Scholar
  26. 26.
    Manolio TA, Burke GL, O’Leary DH, et al (1999) Relationships of cerebral MRI findings to ultrasonographic carotid atherosclerosis in older adults: the Cardiovascular Health Study. CHS Collaborative Research Group. Arterioscler Thromb Vasc Biol 19:356–365PubMedGoogle Scholar
  27. 27.
    Black WC, Welch HG (1997) Screening for disease. Ajr Am J Roentgenol 168:3–11PubMedGoogle Scholar
  28. 28.
    Kaplan RM (2000) Two pathways to prevention. Am Psychol 55: 382–396PubMedCrossRefGoogle Scholar
  29. 29.
    Kaplan RM (1997) Decisions about prostate cancer screening in managed care. Curr Opin Oncol 9:480–486PubMedCrossRefGoogle Scholar
  30. 30.
    American Cancer Society, California Division (2004) California cancer facts and figures. California Cancer Registry. American Cancer Society California Division, OaklandGoogle Scholar
  31. 31.
    Black WC, Welch HG (1997) Screening for disease. AJR Am J Roentgenol 168:3–11PubMedGoogle Scholar
  32. 32.
    Welch HG, Black WC (1997) Evaluating randomized trials of screening. J Gen Intern Med 12:118–124PubMedCrossRefGoogle Scholar
  33. 33.
    Black WC, Welch HG (1993) Advances in diagnostic imaging and overestimations of disease prevalence and the benefits of therapy. N Engl J Med 328:1237–1243PubMedCrossRefGoogle Scholar
  34. 34.
    Welch HG (2004) Should I be tested for cancer? University of California Press, BerkeleyGoogle Scholar
  35. 35.
    Black WC, Haggstrom DA, Welch HG (2002) All-cause mortality in randomized trials of cancer screening. J Natl Cancer Inst 94: 167–173PubMedGoogle Scholar
  36. 36.
    de Koning HJ (2003) Mammographic screening: evidence from randomised controlled trials. Ann Oncol 14:1185–1189PubMedGoogle Scholar
  37. 37.
    Mandel JS, Church TR, Ederer F, Bond JH (1999) Colorectal cancer mortality: effectiveness of biennial screening for fecal occult blood. J Natl Cancer Inst 91:434–437PubMedCrossRefGoogle Scholar
  38. 38.
    Barry MJ (2000) Early detection and aggressive treatment of prostate cancer: groping in the dark. [Comment On: J Gen Intern Med. 2000 Oct; 15(10):739-48]. J Gen Intern Med 15:749–751PubMedCrossRefGoogle Scholar
  39. 39.
    Barry MJ (1998) PSA screening for prostate cancer: the current controversy-a view point. Patient Outcomes Research Team for Prostatic Diseases [see comments]. Ann Oncol 9:1279–1282PubMedCrossRefGoogle Scholar
  40. 40.
    U.S. Preventive Services Task Force, United States (1996) Guide to clinical preventive services: report of the U.S. Preventive Services Task Force, 2nd edn. U.S. Dept. of Health and Human Services, Office of Public Health and Science Office of Disease Prevention and Health Promotion: Supt. of Docs. U.S. G.P.O. distributor, WashingtonGoogle Scholar
  41. 41.
    Mooney MM, Mettlin C, Michalek AM, Petrelli NJ, Kraybill WG (1997) Life-long screening of patients with intermediate-thickness cutaneous melanoma for asymptomatic pulmonary recurrences: a cost-effectiveness analysis. Cancer 80:1052–1064PubMedCrossRefGoogle Scholar
  42. 42.
    American Academy of Family Physicians (AAFP) (2000) Summary of policy recommendations for periodic health examinations. Cited 7 June 2004Google Scholar
  43. 43.
    American Urological Association (AUA) (2000) Prostate-specific antigen (PSA) best practice policy. Oncology 14:267–272, 277-268, 280Google Scholar
  44. 44.
    Society AC (2001) Prostate cancer: treatment guidelines for patients version II. American Cancer Society, AtlantaGoogle Scholar
  45. 45.
    McLellan F (2002) Independent US panel fans debate on mammography. Lancet 359:409PubMedGoogle Scholar
  46. 46.
    Miettinen OS, Henschke CI, Pasmantier MW, Smith JP, Libby DM, Yankelevitz DF (2002) Mammographic screening: no reliable supporting evidence? Lancet 2 359:404–405Google Scholar
  47. 47.
    Nystrom L, Andersson I, Bjurstam N, Frisell J, Nordenskjold B, Rutqvist LE (2002) Long-term effects of mammography screening: updated overview of the Swedish randomised trials. Lancet 359:909–919PubMedCrossRefGoogle Scholar
  48. 48.
    Gelmon KA, Olivotto I (2002) The mammography screening debate: time to move on. Lancet 359:904–905PubMedCrossRefGoogle Scholar
  49. 49.
    Navarro AM, Kaplan RM (1996) Mammography screening: prospects and opportunity costs. Womens Health 2:209–233PubMedGoogle Scholar
  50. 50.
    Barton MB, Moore S, Polk S, Shtatland E, Elmore JG, Fletcher SW (2001) Increased patient concern after false-positive mammograms: clinician documentation and subsequent ambulatory visits. J Gen Intern Med 16: 150–156PubMedGoogle Scholar
  51. 51.
    Fletcher SW (1997) Whither scientific deliberation in health policy recommendations? Alice in the Wonderland of breast-cancer screening. N Engl J Med 336:1180–1183PubMedGoogle Scholar
  52. 52.
    Olsen O, Gotzsche PC (2001) Cochrane review on screening for breast cancer with mammography. Lancet 358:1340–1342PubMedCrossRefGoogle Scholar
  53. 53.
    Wennberg JE (1998) The Dartmouth atlas of health care in the United States. Trustees of Dartmouth College, HanoverGoogle Scholar
  54. 54.
    Andersen LD, Remington PL, Trentham-Dietz A, Robert S (2004) Community trends in the early detection of breast cancer in Wisconsin, 1980-1998. Am J Prev Med 26:51–55PubMedCrossRefGoogle Scholar
  55. 55.
    Fahs M, Mandelblatt J (1990) Cost-effectiveness of cervical cancer screening among elderly low-income women. In: Goldbloom R, Lawrence R (eds) Preventing disease: beyond the rhetoric. Springer-Verlag, New York, pp 441–446Google Scholar
  56. 56.
    Krahn MD, Mahoney JE, Eckman MH, Trachtenberg J, Pauker SG, Detsky AS (1994) Screening for prostate cancer. A decision analytic view. JAMA 272:773–780PubMedCrossRefGoogle Scholar
  57. 57.
    Tabar L, Fagerberg G, Duffy SW, Day NE (1989) The Swedish two county trial of mammographic screening for breast cancer: recent results and calculation of benefit. J Epidemiol Community Health 43:107–114PubMedCrossRefGoogle Scholar
  58. 58.
    Andersson I, Aspegren K, Janzon L, et al (1988) Mammographic screening and mortality from breast cancer: the Malmo mammographic screening trial. Br Med J 297:943–948Google Scholar
  59. 59.
    Bjurstam N, Bjorneld L, Duffy SW, et al (1997) The Gothenburg breast screening trial: first results on mortality, incidence, and mode of detection for women ages 39-49 years at randomization. Cancer 80: 2091–2099PubMedCrossRefGoogle Scholar
  60. 60.
    Roberts MM, Alexander FE, Anderson TJ, et al (1990) Edinburgh trial of screening for breast cancer: mortality at seven years. Lancet 335: 241–246PubMedGoogle Scholar
  61. 61.
    Miller AB, Baines CJ, To T, Wall C (1992) Canadian National Breast Screening Study: 1. Breast cancer detection and death rates among women aged 40 to 49 years. CMAJ 147:1459–1476PubMedGoogle Scholar
  62. 62.
    Miller AB, To T, Baines CJ, Wall C (2000) Canadian National Breast Screening Study-2: 13-year results of a randomized trial in women aged 50-59 years. J Natl Cancer Inst 92:1490–1499PubMedGoogle Scholar
  63. 63.
    Hardcastle JD, Chamberlain JO, Robinson MH, et al (1996) Randomised controlled trial of faecal-occult-blood screening for colorectal cancer. Lancet 348:1472–1477PubMedCrossRefGoogle Scholar
  64. 64.
    Kronborg O, Fenger C, Olsen J, Jorgensen OD, Sondergaard O (1996) Randomised study of screening for colorectal cancer with faecal-occult-blood test. Lancet 348:1467–1471PubMedCrossRefGoogle Scholar
  65. 65.
    Kubik A, Parkin DM, Khlat M, Erban J, Polak J, Adamec M (1990) Lack of benefit from semi-annual screening for cancer of the lung: follow-up report of a randomized controlled trial on a population of high-risk males in Czechoslovakia. Int J Cancer 45:26–33PubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2005

Authors and Affiliations

  • Robert M. Kaplan
    • 1
  1. 1.Department of Family and Preventive MedicineUniversity of California, San DiegoLa JollaUSA

Personalised recommendations