Early diagnosis of ovarian cancer may reduce mortality

A study published by Jacobs et al in Lancet reports on a new approach for earlier diagnosis of ovarian cancer which is known for its poor prognosis. Their strategy was based on a series of CA125 tests, identifying women to be given ultrasound by a mathematical formula that took into account a woman’s age and the degree of change in CA125 over time, and calculated a risk score. In this randomized controlled trial, postmenopausal women aged 50–74 years from Great Britain were assigned to annual multimodal screening (MMS) with serum CA125, annual trans-vaginal ultrasound screening (USS), or no screening, in a 1:1:2 ratio. The primary outcome was death due to ovarian cancer, comparing MMS and USS separately with no screening. Between June 1, 2001, and Oct 21, 2005, 202 638 women were randomly allocated: 50 640 to MMS, 50 639 to USS, and 101 359 to no screening. Screening ended on Dec 31, 2011, and included 345 570 MMS and 327 775 USS annual screening episodes. At a median follow-up of 11·1 years, ovarian cancer was found in 1282 (0·6%) women: 338 (0·7%) in the MMS group, 314 (0·6%) in the USS group, and 630 (0·6%) in the no screening group. Of these women, 148 (0·29%) women in the MMS group, 154 (0·30%) in the USS group, and 347 (0·34%) in the no screening group had died of ovarian cancer. The primary analysis using a Cox proportional hazards model gave a mortality reduction over years 0–14 of 15% with MMS and 11% with USS. Although the mortality reduction was not significant in the primary analysis, the authors noted a significant mortality reduction with MMS when prevalent cases were excluded. They also noted encouraging evidence of a mortality reduction in years 7–14, but further follow-up is needed before firm conclusions can be reached on the efficacy and cost-effectiveness of ovarian cancer screening as 641 women had to be screened annually for 14 years for each life saved.

Elderly undergo cancer-screening tests that may not be necessary

Abdollah et al report in a JAMA Oncology article their findings that suggest some older individuals undergo screening tests for breast and prostate cancer despite the fact that those tests aren’t recommended for them.

The investigators looked at data from 149 514 individuals, 65 years or older selected among those who responded to the Behavioral Risk Factors Surveillance System Survey and resided in the United States. The primary outcome was non-recommended screening, defined as receipt of prostate-specific antigen (PSA) testing or mammography in individuals with a life expectancy of less than 10 years.

Of the 149 514 individuals, 76 419 (51.1%) had a PSA test or mammography in the past year; 23 532 (30.8%) of those individuals had a life expectancy of less than 10 years, corresponding to an overall rate of non-recommended screening of 15.7% (23 532 of 149 514 individuals).

Significant state-by-state variation in the rate of non-recommended screening was observed. Moreover, non-recommended screening at the state-by-state level had a correlation of 40% between the 2 forms of screening (P = .01). Therefore, a state with a high rate of non-recommended screening for prostate cancer is likely to have a high rate of non-recommended screening for breast cancer and vice versa.  The extent and variation of non-recommended screening across states, fluctuated from 11.6% in Colorado to 20.2% in Georgia.

The authors suggest that efforts should be made to reduce non-recommended screening as such scheme may reduce harms to individuals from false positives, and decrease the cost to the US health system from overdiagnosis that may be as high as $1.2 billion annually therefore improve the overall efficiency of screening initiatives.

Editor’s note:  The authors maybe are underestimating the cost to the US health system.  According to the US census individuals over 65 were 14.5% in 2014.   This percentage corresponds to 46 million in a total population of 318 million.  If we consider that the cost of mammography is $120 and of the PSA blood test $80 then the cost to the US health system could be as high as 4.6 billion dollars annually.