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Smarter Screening for Cancer Possibilities and Challenges of Personalization

Sameer D. Saini, MD, MS1,2; Frank van Hees, MSc3; Sandeep Vijan, MD, MS1,2
[+] Author Affiliations
1Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan
2Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
3Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
JAMA. 2014;312(21):2211-2212. doi:10.1001/jama.2014.13933.
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An important emerging model for screening and many preventive strategies is personalization. This approach uses individual patient characteristics to project the benefit of screening for a given patient and has the potential to improve cancer outcomes while reducing the probability of harm and preserving scarce health care resources. Yet all too often, the existing health care system fails to personalize screening in even the most rudimentary way. A recent study found that 75-year-old patients with severe comorbidities were nearly 2 times more likely to be screened for colorectal cancer than 76-year-old patients with no comorbidities, even though healthy 76-year-old patients tend to live longer and gain greater benefit from screening.1 In another study, 48% of primary care physicians reported that they would recommend breast cancer screening for women diagnosed with terminal lung cancer, a group of patients for whom screening cannot provide any benefit, may cause harm, and is a waste of resources.2 Although most clinicians would agree that cancer screening should focus on patients most likely to benefit, the US health care system is failing to achieve this type of personalized care.

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Figure.
Example of Relationship of Risk Factors With Lifetime Benefit of Colorectal Cancer Screening With Colonoscopy

CRC indicates colorectal cancer; RR, relative risk.aIndividuals are classified as having moderate comorbidity if diagnosed with an ulcer, rheumatologic disease, peripheral vascular disease, diabetes, paralysis, or cerebrovascular disease and in case of a history of acute myocardial infarction; as having severe comorbidity if diagnosed with chronic obstructive pulmonary disease, congestive heart failure, moderate or severe liver disease, chronic renal failure, dementia, cirrhosis and chronic hepatitis, or AIDS; and as having no comorbidity if none of these conditions is present.bThe range of the background risk for CRC is based on the National Cancer Institute’s Colorectal Cancer Risk Assessment Tool.7 In white women, the minimum background risk for CRC is 0.5, the maximum background risk in the absence of a family history of CRC is 1.8, and the maximum risk in the presence of a family history of CRC is 3.5.

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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