Breast Cancer versus HIV screening: Always a good idea?

The Pediatric Insider

© 2012 Roy Benaroch, MD

Screening tests to looking for disease early may not always be a good thing.

On one side: The Unites States Preventative Services Task Force– or USPSTF– now recommends universal screening for HIV infection among all adults aged 15-65. Their draft statement, released this week, now agrees with the CDC’s 2008 recommendation, which essentially said the same thing in 2006.

Contrast this with a study of screening mammography published in the New England Journal of Medicine a few days ago. Looking at over 30 years of data, researchers found  that up to a third of tumors identified by screening mammography were likely diagnosed incorrectly. They were in fact harmless. That’s a lot of women undergoing biopsies, surgery, radiation, and chemotherapy. The authors say that their study supports the 2009 USPSTF recommendation that most women in their 40’s not undergo routine mammograms.

So why the difference?

Whether to screen or not depends on the answers to some tricky questions:

How accurate is the screen? In the case of HIV testing, it’s very accurate. Mammography? Many false positives, and some false negatives too.

What happens after a positive screen? HIV screening tests lead to a few more blood tests to confirm the diagnosis. A positive mammo leads to biopsies and surgery and maybe more.

What happens if we miss a diagnosis? HIV positive individuals spread infection. Earlier diagnosis of HIV can not only lead to effective treatment, but also to an overall reduced risk to the population. Breast cancer isn’t contagious, and it’s unclear that earlier treatment is always better—some small tumors may regress without any treatment at all.

We have a lot more to learn about the answers to these questions, and recommendations for screening should always be based on the best available science. What strategy keeps the most people healthy, does the least harm, and is the most effective way to spend health care dollars? These answers aren’t always obvious, and new studies sometimes lead to new perspectives.  But it is clear that not every screening test is a good idea for everyone.

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