Cancer screening and common sense

Short White Coat is a blog about learning to be a doctor. Posts appear here as part of White Coat Notes. Ishani Ganguli is a third-year Harvard medical student. E-mail her at shortwhitecoat@gmail.com.

Like with scabs and wasps nests, sometimes it’s better to leave well enough alone. That's increasingly true when it comes to screening for cancer.

My last internal medicine patient of the morning Tuesday was a man in his late 80s who was doing remarkably well. Mr. A had high blood pressure and cataracts, conditions I had grown to consider inevitable over my weeks at the West Roxbury veteran’s hospital, but his were well-controlled with medicine and surgery. I ran through my usual barrage of questions and learned that his memory was not as sharp as it was fifty years ago and that he’d cut back on his daily walks because he just didn’t have the energy he once possessed.

When I got to the topic of cancer screening, he told me that as far as he could remember, he had never undergone a colonoscopy. Alarm bells sounded, and images of my previous day’s stint in gastrointestinal oncology clinic flashed in my preventative care-primed head. I made a mental note to tell my preceptor about this glaring omission when I presented this patient to her.

Cancer screening teeters on delicate balances of cost and benefit, and of individual and population-centered goals. Guidelines recommending when to stop screening are not usually as clear cut as those for when to start, perhaps in part because this comes with an uncomfortable sense of giving up. But recent studies and revived debate on prostate cancer screening lend credence to the idea that less is more.

Mr. A sat patiently on the exam table as I made my presentation to my preceptor. She and I confirmed that guidelines recommended colonoscopies until 10 years before a patient reaches his or her life expectancy. And then she reminded me that guidelines take us only so far. There is also the power of common sense, and at his age, invasive testing may do more harm than good.

Mr. A, who was hard of hearing, paused before heading out the door. May I tell you something, he asked with an air of confession. I’ve had a good life. All of this testing for cancers, I don’t really see the point at my age.

My preceptor winked at me as we replied simultaneously: we agree completely.