Longevity is not the point of cancer care

By Julia Elder and Rachael Peroutky

The recent meta-analysis on the effectiveness of cancer screening has people wondering if all the mammograms, pap smears, and colonoscopies are worth it. From a patient perspective, it's a fair question — these tests are often invasive and uncomfortable. 

Purchasers and providers have a stake here too. Some may wonder if investing in these services is worthwhile when margins are small, and the workforce is in crisis. What should healthcare leaders do with this new data? Before rethinking your prevention strategy, here's what to consider: 

Proving long-term impact of cancer screening is an uphill battle

Unlike medications or services like surgery, linking a preventive service like a screening test to a long-term outcome is extremely difficult. Screening comes early in the patient journey, meaning several other factors and downstream points of care take place before the selected outcome — in this case longevity — is captured. 

Even if the test is positive for cancer, the parts of the care journey that come after (follow-up, therapy selection, management) arguably have a larger influence on long-term outcomes. Clinical utility — or the ability of the screening test to impact decision making — is a better standard of measurement for screening tests. 

But say we do want to look at long-term outcomes

"First do no harm" remains the north star of medical ethics. If we can't substantiate the benefit of invasive screening tests, why should clinicians carry on?  

Many health leaders we talk to agree with this point and want more outcomes-oriented data from manufacturers of screening tests and devices. The specific outcomes they look for are where the rubber meets the road — and this study falls short on two accounts.  

1.       All-cause mortality is too broad

The study included all deaths — not just cancer-related deaths. While all-cause mortality is a common outcome for assessing quality of care in other situations, it is too broad for assessing the value of screening tests. Recent research shows cancer screening trials require large sample sizes (at least 40,000 participants) to demonstrate a significant reduction in all-cause mortality. Out of those 22 studies included in this analysis, nine did not meet this criterion for significance.   

2.       Longevity is not the goal of cancer care

Those working closest with cancer patients agree that a longer life is not always the goal. For some, the right option may be to forgo treatment entirely, selecting a more comfortable life over a longer one. Health-related quality of life, is a prime example of a long-term outcome measure that elevates the quality of one's life alongside the length. 

So, do we keep screening?

Yes. Guideline developers maintain that screening for at least the most common forms of cancer is worthwhile. Continue to push diagnostic manufacturers for outcomes data, but make sure you are thinking strategically about which outcomes matter most.