"The invitation to a colorectal cancer screening encourages people to look into this subject – it is not an enlistment," says Dr Johannes Bruns, Secretary-General of the German Cancer Society (German: Deutsche Krebsgesellschaft e.V.). Within the scope of several pilot projects, insured persons in Germany over the age of 55 receive this invitation letter from their health insurance provider. The reasons for this newly introduced invitation system are low participation rates for this particular preventive screening and an adjustment to European cancer prevention standards.
There are at least two obvious reasons for patients to skipping the screening. First, people might actually not know that there are specific screenings available and that insurance providers pay for them. "There is still discussion about the best organizational form for some preventive screenings. In the case of breast cancer prevention for instance, women are directly invited to a screening. One alternative is a so-called 'opportunistic screening', meaning to approach the person directly when they are already at the doctor’s office." The active invitation should at least reach more potential participants.
The second potential reason could be that many people are afraid of the screening – whether that’s because of the procedure itself or the fear of possible findings. Education and communication also help in this case. Colonoscopies for colon cancer prevention have been available for over ten years in Germany and they have shown that there is hardly any risk resulting from the procedure itself. This procedure is also performed under sedation, so that patients have no conscious recollection of the procedure. According to Bruns, a colonoscopy is also among the "most important cancer prevention screenings. This also applies to a mammogram (screening for breast cancer) and a Pap smear (cervical cancer), even if those procedures are not infallible."
Another advantage of a colonoscopy: polyps, potentially pre-cancerous tumors, can be directly removed during this procedure. The patient thus foregoes subsequent biopsies, such as those for suspected breast cancer for example.
Is a screening test always 100% accurate?
People can individually decide for or against preventive screenings based on basic information and sufficient counseling by their physician – again, if they are truly informed. In contrast, a review of costs, complexity and benefits as well as potential downsides of a procedure is important to the health care system. Screening tests should preferably not put any strain on participants, for instance due to radiation, and should not be too technically and financially elaborate so that many people can benefit from them.
What’s more, a procedure should be sound and meaningful. This includes how reliable a method is in detecting precancerous tumors (true positive result), how often persons are diagnosed as healthy (true negative) or how often the method wrongly diagnoses a precancerous condition (false positive) or how often a precancerous condition is overlooked (false negative). "Early detection, even with technically advanced procedures never delivers one hundred percent accurate results," Bruns clarifies. "Screening participants are sometimes confronted with positive results, even though they are in fact not affected by the tested disease. On the one hand, this causes mental stress, while it generates additional costs for further examinations to confirm the result on the other." False negative test results, which overlook cancer, can also occur, so that a treatment could not be performed in time. These potential 'inaccuracies' represent the tightrope, physicians and the health care system walk when it comes to screening tests.
Together with a cost report, based on this kind of data a decision about which exams the health insurance companies in Germany will pay for and which exams patients need to pay for themselves is being reached. The benefits, along with the reliability of the diagnosis are being considered in this case. It is defined by how many diseases are detected in time, so that patients can be cured.
"This is a question of scale," explains Bruns. "If you assume that out of 1,000 women undergoing breast cancer screening, one is diagnosed with cancer in time and this patient is being cured, it doesn’t sound like much at first. Yet when you extrapolate this to the entire female population that is eligible for screenings, it becomes obvious how many women we are actually talking about here."
For or against screening tests? Get informed!
This question can be simply answered in terms of the health care system simply by looking at the number of diagnostic errors and the reduction in mortality rates. To the individual patient however, those statistics do not mean much, because the patient has either cancer or a precancerous condition or he does not. Ultimately, the patient needs to decide for or against cancer screening tests. For some, fear of the procedure and the potential results might be reasons to decide against testing, whereas for others the certainty that "there is nothing there" or the knowledge that a precancerous condition can be treated successfully might outweigh the cons. "Screening tests are services provided by the health insurance provider," says Bruns. "Whether you want to use them is your own decision."
Comprehensive research results and great counseling help in making a decision; the same applies to personal experiences and public debates, even when input sometimes comes from unexpected sources. A famous person, who has sent an extreme signal in favor of screening tests, is American actress Angelina Jolie. She underwent genetic analysis, revealing a BRCA1 gene mutation, which significantly increases the risk for breast and ovarian cancer. Jolie subsequently chose to undergo preventive surgery to remove both organs. This decision and the fact that she made it public received positive feedback on the one hand. She was praised in the media for her "brave move" by both editorial departments and the public. Others accused her of "anticipatory obedience to medicine", "self-promotion" and "being afraid of taking risks" and that "she would be better off staying at home at all times".
As a physician, Bruns supports a more differentiated view: "For starters, this is just a personal decision you may take note of. It should not dictate how those with a genetic risk should act. However, Jolie's announcement has caused persons who are potentially at risk to look into this subject and ultimately give more thought to early detection."