COLUMNS

To test or not to test?

The news media has spent considerable time and space recently raising questions about one of health care's most dearly held beliefs: that routine screening of healthy people for cancer can catch the disease early, and help save lives. On the surface, it seems intuitively true, and for many patients, that does seem to be the case. But clearly, some screens are better than others, and as a health care educator, I thought I'd spend a moment talking about what we know -- and don't know -- about some of the most common screening tests.

Let's start with the least controversial and probably most effective: the Pap test. There is no doubt that regular cervical cancer screening using the Pap test detects not only cancer, but precancerous lesions as well. The introduction and use of the Pap test is credited with reducing deaths from cervical cancer by 70 percent over the past four decades -- yet surprisingly, only 82 percent of women in Ohio over the age of 18 have had a Pap test in the last three years.

It's pretty much the same with colon cancer. Regular fecal occult blood tests show clear benefits. Studies show that fecal occult blood testing either annually or biennially in people aged 50 to 80 decreases deaths from colorectal cancer. The incidence of colon cancer goes down as the use of routine screening goes up. It's that simple. If you are over the age of 50, you need to be screened for colon cancer every year.

Some of the recent controversy over screening tests arose from a recently published article in Denmark that questioned the use of mammography as a means of reducing deaths from breast cancer. The study, which examined several other large studies, felt the data was inadequate and could not support that conclusion. The American Cancer Society, however, recommends women over the age of 40 get a mammogram every year, and breast cancer specialists continue to support mammography as the best tool for finding abnormalities at an early stage. Some studies show if breast cancer is caught early, when the tumor is very small, a patient stands over a 90 percent chance of full recovery.

A PSA test and a digital rectal exam are typically used to screen for prostate cancer. The PSA measures the level of prostate-specific antigen in the blood. When it is elevated, it may be related to cancer. But not always. Older men tend to have higher PSA than younger men. And sometimes a higher PSA is related to a variety of other diseases, not cancer. Still, the ACS thinks it's important enough to recommend a yearly exam and a PSA for men over 50, and for younger men if prostate cancer runs in the family.

Finally, we simply do not have a good way to screen for lung cancer, the cancer that kills more men and women in the United States than the next four most common cancers combined. Routine chest X-rays can pick up a lung cancer only once it's around one to two centimeters, already a pretty good size. Recently, some hospitals have begun to offer spiral CT scans, if patients or referring doctors request them. Spiral CT scans can pick up smaller tumors, but they are time consuming and very expensive. They also frequently reveal lots of benign nodes that physicians feel compelled to check out further.

Here at Ohio State, for example, physicians say 30 percent to 60 percent of people coming in for spiral CT scans have multiple benign nodes, often as a result of histoplasmosis, a common fungal infection in Ohio. Following up all the suspicious-looking spots costs time and money and adds dramatically to the escalating costs of health care. And so far, no study has shown that finding the lung cancer early has any bearing on extending life.

The National Cancer Institute is interested in studying that very question, however, and is proposing to spend millions of dollars over the next 15 years to find out. Opponents think that money might be better spent on prevention.

So the bottom line is, even with all the controversy, no one is saying you should not be routinely screened for cancer. It's just very important to understand what the test can -- and cannot -- tell you about your risk. It's also important to remember that cancer is, in part, a disease of aging. It takes a long time for cancer to develop. Screening for cancer should be a part of everyone's routine health care.

LETTERS

Toledo parent supports efforts to advance Ohio State's academic excellence

Editor:

My son and daughter both attend The Ohio State University. I fully support Dr. Kirwan's vision to make Ohio State an academic rival to Big Ten schools like Michigan and the best state schools from around the country like the University of Virginia.

The cost savings to Ohio families is enormous when compared to these out-of-state choices. And, the benefits to Ohio are enormous. Top-flight state universities like Georgia Tech and the University of North Carolina have driven growth over an entire region.

The proof of Dr. Kirwan's programs is in the pudding. Ohio State is closing in on these prestigious universities. It is rising rapidly in national rankings. It is attracting more of the best students from Ohio, who can now look to our flagship university as a real choice. It is doing a much better job of keeping these kids through to graduation. More importantly, it is doing it in the right way. Ohio State is raising standards and offering first-rate programs like its Honors Program.

Our legislature and governor were just plain wrong-headed to cut back funding to Ohio State. Historically, Ohio State tuition has been a bargain among state schools. Ohio State must now either raise its tuition to be nearer to the tuition at other state universities like Miami or Cincinnati, or it must cut back the programs that brought this progress. It would be a real mistake to back off from Dr. Kirwan's vision and backslide into something less.

Thomas R. Hays, Toledo, Ohio