Book Review

Should I Be Tested for Cancer? Maybe Not and Here's Why

N Engl J Med 2005; 352:422January 27, 2005

Article

Should I Be Tested for Cancer? Maybe Not and Here's Why
By H. Gilbert Welch. 224 pp., illustrated. Berkeley, University of California Press, 2004. $19.95. ISBN: 0-520-23976-8

In the absence of well-reasoned skepticism, medical practice can become enraptured with the potential of new technological advances. In this insightful how-to book on health care, Welch provides a comprehensive overview of current challenges in cancer screening. He draws from published literature, case histories, and his own medical practice in discussing the risks and benefits of screening, thereby exposing the true limits of current technology and of our knowledge as to how and when to intervene against early neoplasia.

This comprehensive book has two parts, “Problems You Should Know About” and “Becoming a Better-Educated Consumer.” Part I lays out the premise for early detection and gauges the risks and benefits that most people might derive from screening, given their susceptibility to cancer and the competing causes of illness and death. Part II details the practice of early detection and instances in which nonmedical factors — such as human vulnerability, social forces, and fear of litigation — have sometimes led to overzealous adoption of unevenly effective techniques for cancer screening. A comprehensive index accompanies the text, along with useful commentary that expands on and qualifies selected excerpts.

Welch's lucid presentation of complex and timely issues is an achievement in itself, but even more, this is an eminently readable book that is bound to inform and complement the ongoing debate about screening. The author maintains that cancer screening may have been oversold to the public and health care practitioners alike. By challenging commonly held assumptions, Welch stimulates a critical dialogue between patients and providers regarding the effect of screening on cancer-associated morbidity and mortality, the sequelae of false positive results, and the slippery slope of diagnosing and managing incidentally detected cancers, many of which may pose no immediate health threat. To balance this cautious approach to cancer screening, the author acknowledges the successes of rigorously proven screening methods and weighs them against the high costs that invasive cancer imposes. Indeed, leading health economists recently estimated that as little as a 10 percent reduction in cancer would translate into a savings of $4.4 trillion to society.

This book, which offers a sobering view of the status of cancer screening today, deserves to be widely used by patients and providers as they navigate an expanding and often bewildering array of screening options. Nevertheless, improvements in our understanding of carcinogenesis, enhanced performance characteristics of early-detection technology, and noninvasive approaches to diagnosing early neoplasia are likely to narrow the gap between the detection of disease and its appropriate medical management. These advances are likely to recalibrate the risk–benefit ratio of cancer screening. Indeed, transient uncertainties and potential harm should serve as an impetus for scientific advancement, rather than as evidence of conceptual failure. In an evolutionary sense, the dilemmas so well detailed in this book may be viewed as natural preconditions for continued progress.

Ernest T. Hawk, M.D., M.P.H.
Jaye L. Viner, M.D., M.P.H.
National Cancer Institute, Bethesda, MD 20892
eh51p@nih.gov