Chief Medical Officer, Predictive Health, Paradise Valley, AZ. Email:
Am J Manag Care. 2020 Nov;26(14 Suppl):S300-S306. doi: 10.37765/ajmc.2020.88534.
Despite significant improvements in mortality over the past 20 years, cancer remains the second leading cause of death in the United States. One reason for the improvement in mortality is screening for several common cancers in people at average risk for breast, cervical, colorectal, and prostate cancers, and screening for lung cancer in those with a 20-plus pack-year history. Such screening may result in earlier diagnosis when the cancer is most likely to respond to treatment. However, there are no population-based screening recommendations for the majority of cancers in average-risk patients, most of which are not diagnosed until the later stages. One question is whether earlier diagnosis could not only reduce mortality rates but also reduce medical costs. Screening comes with several potential risks, including false positives and overdiagnosis, both of which can affect patients' mental health, increase morbidity and mortality, and lead to excess spending. Additionally, certain cancers can evade traditional screening tests and lead to false-negative results, which delays cancer detection, treatment, and may affect treatment efficacy. The advent of liquid biopsy tests that could screen for dozens of cancers holds promise for identifying more cancers early. However, the cost, the potential for overdiagnosis and false positives, and a lack of evidence demonstrating clinical utility or an improvement in health outcomes call into question their potential use for widespread screening. Government and managed care organizations will need to consider the risks and benefits of these assays in determining coverage.
尽管在过去的 20 年中，癌症患者的死亡率有了显著的下降，但它仍然是美国的第二大致死原因。死亡率下降的一个原因是对有乳腺癌、宫颈癌、结直肠癌和前列腺癌患病风险的人群进行了几种常见癌症的筛查，以及对有 20 年以上吸烟史的人群进行了肺癌筛查。这种筛查可能会在癌症最有可能对治疗产生反应的时候进行早期诊断。然而，对于大多数处于平均风险的患者来说，大多数癌症都没有基于人群的筛查建议，这些癌症大多数直到晚期才被诊断出来。一个问题是，早期诊断是否不仅可以降低死亡率，还可以降低医疗费用。筛查有几个潜在的风险，包括假阳性和过度诊断，这两者都会影响患者的心理健康，增加发病率和死亡率，并导致过度支出。此外，某些癌症可能会逃避传统的筛查测试，并导致假阴性结果，这会延迟癌症的检测、治疗，并可能影响治疗效果。液体活检测试可以筛查几十种癌症，这为早期发现更多癌症提供了希望。然而，其成本、过度诊断和假阳性的可能性，以及缺乏证据表明其具有临床实用性或改善健康结果，这些都对其在广泛筛查中的潜在应用提出了质疑。政府和管理式医疗组织将需要在确定保险范围时考虑这些检测的风险和收益。
