Back when I went to medical school in 1992, things seemed a lot easier.

Women needed pap smears and mammograms. Men needed prostate testing. Colon cancer screening was recommended for everyone over 50 for as long as they lived. There was a sense of reassurance that people were doing their best to prevent cancer by following the guidelines set by the medical profession.

Then things got messy. But for good reasons.

First, there were the questions about prostate testing. The blood test known as PSA or prostate specific antigen came under fire. Too often it was high for reasons other than cancer, leading to biopsies, surgeries, and a whole slew of potential side effects of the testing that routinely took place. Potential side effects include urinary and fecal incontinence, not pleasant side effects for unnecessary surgeries. Then came the question of the utility of testing for a cancer that might not be the cause of death, or even shorten a man’s lifespan.

But after the pendulum swung from everyone screening, to the other end of the spectrum, with no one screening, the guidelines settled in the middle. Targeted testing for those men at risk, and a cautious approach to further evaluation for those found to have positive PSA results. Active surveillance was adopted, the process of monitoring early stage prostate cancer, and treatment with various modalities for men who had more aggressive forms of cancer that were likely to impact long term health and longevity. After all, studies have shown that a one-size-fits-all approach doesn’t work when it comes to cancer.

Men were not the only ones dealing with changing recommendations over the past few years.  Women were also left to decipher the changes in their health care as well.

Mammograms have been in question for decades. First, women were told to have a baseline at 40 and then yearly exams after age 50, with no upper age limit.  Then questions arose when the recommendation was temporarily changed to every other year. Switzerland looked at the data and decided to stop doing screening mammograms entirely.

The pendulum continued to swing with the use of 3-D mammography and the potential for earlier stage diagnoses for women who did this instead of traditional mammograms. Insurance carriers don’t often cover this routinely, leading to an additional copay for women who want this extra screening. Studies have shown it’s effective, but still not proven to be superior to standard mammography for all women.

Another question arose with the upper age limits for mammograms, which are not as clearly defined as for other tests, but are based on the overall health of the woman as she ages, and the likelihood that any treatment would be either tolerated, or help to extend life.

There will always be research that is hoping to discover even better ways to improve the health of the entire population.

The current guidelines suggest that after the age of 75, women can make a personal choice to continue to do the test. Some very healthy women may choose to continue to screen, others with serious medical conditions like heart failure, kidney failure and more may decide to stop doing mammograms at any age, or when they reach 75, with the idea that whatever might be missed would not lead to any difference in their lifespan even if it went untreated.

The age limits for younger women have recently been scrutinized by our local insurance company, HMSA.

They have eliminated routine coverage for low risk women in their 30s to do screening mammography. This doesn’t mean women who feel a mass on a breast exam can’t do any further evaluation. But it follows the nationally established guidelines that discourage unnecessary screening for all women in those age groups, as mammograms are not known to be helpful for younger women with denser breast tissue.

Pap smears are the latest test under fire. The former recommendations of starting at age 21 and yearly thereafter were changed to every three years after three normal tests, and now the standard is every three years for most women with normal findings.

This includes HPV (human papilloma virus) testing as well, given that cervical cancer is a direct result of HPV infection. Pap smears are not indicated to detect any other type of cancer, including endometrial or ovarian cancer.

With the use of HPV vaccines to prevent infection, the future of pap smears is uncertain. Someday, they might not even be necessary. But the latest studies show that testing every year is not needed and can lead to surgeries that could cause complications, and even effect future fertility for younger women.

So, why do the guidelines change so rapidly, and who makes such decisions?

The group known as the United States Preventative Task Force, or USPTF is responsible for most of the screening guidelines for the U.S. This group of physicians looks at the overall effect of screening for all different health conditions, including cancer.

Each test is given a grade based on the evidence that is carefully analyzed regarding the benefits or harms of screening, and further diagnostic work up of abnormalities or problems.

The group is a volunteer organization that includes Hawaii native, Dr. Chien-Wen Tseng, and other physicians that analyze the data available through research publications and provides a general guideline for what is needed to keep the overall population healthy.

As medical science advances, so does the analysis of what really saves lives.

There will always be changes to what doctors recommend based on the latest evidence in peer-reviewed published studies, just as there will always be research that is hoping to discover even better ways to improve the health of the entire population.

As confusing as it seemed, in the past 25 years, much has changed since I entered medical school, and I can only hope that even more advances are discovered in the next quarter century as well.

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