Cancer Screening Made Personal

Low-dose CT scanning is now offered as a screening test for lung cancer in people at increased risk for this disease. There’s no question that cancer screening tests, such as mammography and PSA testing, are capable of finding cancers in their earlier, more curable stages. But years of evaluation and hundreds of thousands of patients later have taught healthcare professionals something else: Cancer screening is not “one size fits all.”

That’s precisely why, as the NYU Cancer Institute expands its cancer screening facilities, the screening exams recommended for each patient are being customized — taking into account the patient’s personal medical history, family history, and other risk factors, such as lifestyle, known to affect cancer risk (such as smoking and alcohol). “There are clear benefits to cancer screening, but it has to be tailored to each patient’s personal situation,” explains William L. Carroll, MD, NYU Cancer Institute Director.

Which cancer screening tests do you need? Here are some guidelines for and updates on the most common exams:

Breast Cancer Screening

Mammography has been shown to save lives. Studies show that breast cancer death rates are 25 percent lower among women who have regular mammography screening. Moreover, treatment for early-stage breast cancer is typically less intense and easier to tolerate than therapy for more advanced disease.

For women at average risk of breast cancer, the American Cancer Society recommends an annual screening mammogram starting at age 40. But according to the U.S. Preventive Services Task Force (USPSTF) guidelines, having a mammogram every two years between the ages of 50 and 74 is sufficient. The USPSTF also states that mammography in women younger than 50 should be based on medical and family history and personal values, and notes that evidence supporting screening mammography in women age 75 and over is “insufficient.”

The newly opened Center for Women’s Imaging provides screening mammography services (including same-day results on weekends) and convenient hours in a warm and inviting environment. Other professional groups are closer to the ACS guidelines, with some noting that women ages 40 to 49 should have mammography every one to two years. The differences center on the benefits (detecting breast cancer early) versus harms (performing biopsies for lesions that turn out to be benign) of the test and its cost-effectiveness (such as how many lives it saves).

“Many women feel like they are receiving mixed messages,” says Freya Schnabel, MD, Professor of Surgery and Director of Breast Surgery. “Some physicians have also changed the recommendations they give to their patients. As a result, fewer women are being screened.”

Dr. Schnabel notes that while overdiagnosis may not harm a patient, overtreatment might. When a woman is diagnosed with breast cancer, her healthcare team should assess the biology of her tumor and other aspects of her health to tailor a treatment plan that is as effective as possible while reducing the impact on a woman’s life.

To learn when and how often you should get a mammogram, speak with your doctor.

PSA Testing for Prostate Cancer

PSA testing has helped increase the number of early-stage prostate cancers that have been detected, and men treated for cancers that are detected with screening before they have spread beyond the prostate have an excellent chance of long-term survival. That’s the good news.

But for all its benefits, the PSA test — which detects a protein in the blood called prostate-specific antigen (PSA) that rises with prostate cancer growth — has several limitations as well. For one thing, it is not highly specific to prostate cancer, rising in response to noncancerous conditions such as benign prostate enlargement or infection. And most importantly, while it is very sensitive for detecting cancer, many small cancers that are detected are not likely to cause death (particularly when a biopsy is performed in a man with a low PSA level, or the patient is older and more likely to die of other causes).

Because prostate cancer is so common with aging, physicians must exert caution in not being overly aggressive in searching for small cancers in the elderly. In fact, prostate cancer is so common in elderly men that many die with the disease, rather than from it.

The most important current controversy is whether or not routine PSA testing should be used to screen for prostate cancer. Current studies suggest that while there may be an overall reduction in the number of prostate cancer deaths, the reduction in death achieved through screening may not be enough to offset the significant side effects and costs incurred by biopsies and treatment. This is an important question, because while most prostate biopsies are harmless, some men develop complications such as infections. And treatment for prostate cancer can raise the risk of impotence, incontinence, and rectal problems, depending on the therapy, so it is important to know who really needs to be treated and who can be monitored.

The American Cancer Society has eased its guidelines for PSA testing over the years, stating that asymptomatic men age 50 and over with at least a 10-year life expectancy should have an opportunity to make an informed decision with their healthcare providers about screening for prostate cancer “after receiving information about the uncertainties, risks, and potential benefits associated with screening. Prostate cancer screening should not occur without an informed decision-making process.” The USPSTF has backed away from recommending PSA screening at all, supporting its use only in men who have symptoms — noting that the benefits of PSA testing are not sufficient to offset the cost of prostate cancer therapy and its side effects.

“While many cancers of the prostate are not lethal, unfortunately many are and can be effectively treated through early detection. So rather than avoiding PSA testing altogether, we need to do better at deciding who should be tested and how to interpret the test results in individual patients,” says Samir Taneja, MD, the James M. Neissa and Janet Riha Neissa Professor of Urologic Oncology and Director of Urologic Oncology. “The fundamental question should be, ‘When do we treat, and when do we observe?’”

NYU Langone Medical Center is designated as a “Breast Imaging Center of Excellence” by the American College of Radiology. The NYU Cancer Institute supports a “risk-stratified” approach to prostate cancer screening, considering a man’s PSA level in context with other risk factors for prostate cancer, like obesity, diabetes, ethnicity (African Americans have an elevated risk), and family history. In some men with an elevated PSA and those with other risk factors for prostate cancer, doctors are coupling the test results with the findings of imaging tests, such as magnetic resonance imaging, to better assess the cancer and determine what additional care is necessary. They may also conduct imaging in combination with a urine test for a protein called PCA3, which is more specific than PSA (more likely to signal prostate cancer over noncancerous conditions).

 “We’d like to use imaging tests and biomarkers, such as urine PCA3, to decide who should have a prostate biopsy and how it should be performed,” says Dr. Taneja. “Our aim is to make screening and assessment an individualized and beneficial process, rather than to simply abandon it.”

CT Screening for Lung Cancer in Smokers

NYU Langone Medical Center has long been a leader in research to evaluate the effectiveness of low-dose CT scanning to screen smokers and others at increased risk for lung cancer through its participation in the National Cancer Institute Early Detection Research Network. In the summer of 2011, the results of the National Lung Cancer Screening Trial reported what doctors have been hoping for a long time: that low-dose CT screening can actually save lives, reducing the death rate from lung cancer by 20 percent among the more than 53,000 individuals who participated, and was far superior to chest x-ray.

“We now have proof that patients whose lung cancer is detected early by CT scanning have a better chance of survival than if the cancer remained undetected,” says Harvey Pass, MD, the Stephen E.

Banner Professor of Thoracic Oncology, Chief of Thoracic Oncology, and Chief of the Division of Thoracic Surgery.

People at increased risk for lung cancer can now get the test at NYU. The exam is typically not covered by insurance, and costs $350. Patients require a prescription from a doctor and fill out a health questionnaire before having the exam. The radiation dose from the scan is very low — about one-fifth the dose of a standard CT scan. Patients whose scans are negative will be told to come back a year later. Those with suspicious findings on the CT scan may have another scan in six months or be referred for other follow-up, depending on the results.

People at high risk for lung cancer in whom CT screening may be recommended include those age 50 and over with a 20-pack-year smoking history and patients with other lung cancer risk factors, such as occupational exposure to asbestos or other cancer-causing substances.

Other Screening Tests

The American Cancer Society also recommends screening for colorectal cancer starting at age 50 for men and women, and periodic cervical cancer screening with a Pap test for women. These services are also available through the NYU Cancer Institute. For more details on the guidelines, visit www.cancer.org.

 

NYUCI Expands Screening Centers

The NYU Cancer Institute is expanding its screening facilities. These include:

A New Center for Women’s Imaging

Screening mammography services, previously offered at the NYU Clinical Cancer Center, recently moved around the corner to the new NYU Langone Center for Women’s Imaging at 221 Lexington Avenue at 33rd Street. The center features:

  • New dedicated facility designed for comfort and personal attention
  • Same-day appointments and convenient weekday, evening, and Saturday hours
  • New real-time reading option, with results provided at time of visit (on weekdays)
  • Ability to book next appointment before you leave the center
  • Participation in most insurance plans
  • Genetic counseling and evaluation for individuals at increased risk for cancer

For an appointment at the Center for Women’s Imaging, call 212-731-5002.

Screening mammography will also be available at the Joan H. Tisch Center for Women’s Health at 207 East 84th Street in New York City. To make an appointment, call 646-754-3300.

CT Screening for Lung Cancer

Low-dose CT screening is now available at NYU Langone’s facility at the Rivergate building on 401 East 34th Street. To make an appointment, call 855-NYU-LUNG. For more information, visit http://lung-cancer-screening.med.nyu.edu.