Uninformed compliance or informed choice? A needed shift in our approach to cancer screening

It has been more than 30 years since the first consensus development meeting was held to deal with guidelines of mammography screening. Although the National Cancer Institute has wisely focused on the science of screening and of screening benefits vs harm, many professional organizations, advocacy groups, and the media have maintained a focus on establishing who should be screened and promoting recommendations for which age groups should be screened. Guidelines have been developed not only for mammography but also for screening at virtually all major cancer sites, especially for prostate cancer, and most recently, with the preliminary results of the National Lung Screening Trial, for lung cancer. It seems clear that we have done an inadequate job of educating screening candidates about the harms and benefits of cancer screening, including the extent to which screening can reduce cancer mortality. We must also question whether our practice of summoning women to have mammograms, while providing men informed choice for prostate cancer screening, is consistent with a scientific analysis of the relative harms and benefits. We have spent a staggering amount of time and energy over the past several decades developing, discussing, and debating guidelines. Professional and advocacy groups have spent much time aggressively advocating the adoption of guidelines supported by their respective groups. It seems that it would be much more productive to devote such energy to educating screening candidates about the harms and benefits of screening and to engaging in shared decision making.