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  • Review Article
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Population-based screening for cancer: hope and hype

Nature Reviews Clinical Oncology volume 13, pages 550–565 (2016)Cite this article

Subjects

Key Points

  • Tumours within any organ site can have a spectrum of biological phenotypes, ranging from indolent to highly aggressive

  • Screening for cancer is most likely to be beneficial when the target tumour type has a relatively uniform biology and a slower rate of progression

  • Not all precursor lesions are on an obligate pathway towards invasive-cancer development

  • Strategies for early detection of cancer must balance the benefits of mortality reduction (and reduction in invasive-disease incidence with screening for precancers) with the heterogeneity of the target disease and the consequent risk of overdiagnosis

  • Screening can be viewed as a 'cascade' involving multiple steps, such as selection of individuals to be screened, administration of the screening test, workup of positive findings, and, ultimately, treatment

  • Efforts are underway to individualize decision-making surrounding risk stratification, the modality and frequency of screening, and diagnostic and therapeutic interventions tailored to the biology of the detected tumour

Abstract

Several important lessons have been learnt from our experiences in screening for various cancers. Screening programmes for cervical and colorectal cancers have had the greatest success, probably because these cancers are relatively homogenous, slow-growing, and have identifiable precursors that can be detected and removed; however, identifying the true obligate precursors of invasive disease remains a challenge. With regard to screening for breast cancer and for prostate cancer, which focus on early detection of invasive cancer, preferential detection of slower-growing, localized cancers has occurred, which has led to concerns about overdiagnosis and overtreatment; programmes for early detection of invasive lung cancers are emerging, and have faced similar challenges. A crucial consideration in screening for breast, prostate, and lung cancers is their remarkable phenotypic heterogeneity, ranging from indolent to highly aggressive. Efforts have been made to address the limitations of cancer-screening programmes, providing an opportunity for cross-disciplinary learning and further advancement of the science. Current innovations are aimed at identifying the individuals who are most likely to benefit from screening, increasing the yield of consequential cancers on screening and biopsy, and using molecular tests to improve our understanding of disease biology and to tailor treatment. We discuss each of these concepts and outline a dynamic framework for continuous improvements in the field of cancer screening.

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Figure 1: Age-adjusted incidence rates of invasive cancers for which population-based screening is practiced in the USA.
Figure 2: A framework for ongoing improvement of cancer-screening programmes.

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Acknowledgements

We wish to thank Michael Pignone, MD, of the University of North Carolina at Chapel Hill, USA, for his thoughtful editing of this manuscript. We also wish to thank Alexandra Barratt, PhD, of the University of Sydney, Australia, for her helpful discussions and communications regarding cervical-cancer screening. Lastly, we wish to thank Mamta Shah of the University of California, San Francisco, USA, for her assistance in creating the draft figures for our manuscript.

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Authors and Affiliations

  1. Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, 1545 Divisadero Street, San Francisco, 94115, California, USA

    Yiwey Shieh

  2. Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels väg 12A, Stockholm, 17177, Sweden

    Martin Eklund

  3. Departments of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of California, San Francisco, 550 16th Street, San Francisco, 94158, California, USA

    George F. Sawaya

  4. Department of Radiology, Geisel School of Medicine at Dartmouth, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, 03756, New Hampshire, USA

    William C. Black

  5. Division of Cancer Prevention, National Cancer Institute, 9609 Medical Center Drive, Bethesda, 20892, Maryland, USA

    Barnett S. Kramer

  6. Departments of Surgery and Radiology, University of California, San Francisco, 1600 Divisadero Street, Box 1710, San Francisco, 94115, California, USA

    Laura J. Esserman

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  1. Yiwey Shieh
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  2. Martin Eklund
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  6. Laura J. Esserman
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Contributions

All authors researched the data for article, contributed substantially to discussions of content and reviewed/edited the manuscript before submission. Y.S. and L.J.E. wrote the manuscript.

Corresponding author

Correspondence to Laura J. Esserman.

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Competing interests

M.E. is named on four patents applications for prostate-cancer diagnostics. G.F.S. is Principal Investigator of an NCI-funded grant that aims to identify the range of reasonable options for cervical-cancer screening from a patient-centred and economic perspective (R011CA169093). Y.S., W.C.B., B.S.K., and L.J.E. declare no competing interests.

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Shieh, Y., Eklund, M., Sawaya, G. et al. Population-based screening for cancer: hope and hype. Nat Rev Clin Oncol 13, 550–565 (2016). https://doi.org/10.1038/nrclinonc.2016.50

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