Page 61 Complete Your CE Test Online - Click Here cancer. A big issue is that patients are often referred to hospice just a few days prior to death [28]. The patient and family may also believe that accepting hospice care means giving up hope. They may not understand that for many people, hospice care can afford them more symptom relief which can give them the chance to do what is most important to them, such as spending some quality time at home with loved ones. It may be important for patients and families to know that they can change their minds about hospice even if they have already been admitted to hospice care [28]. Hospices’ own enrollment policies may contribute to their underuse in the United States [28]. Results from a national survey of 591 U.S. hospices showed that 78% had at least one enrollment policy restricting access to care for patients with higher-cost medical care needs, such as chemotherapy, radiation, transfusions, and total parenteral nutrition. Such policies are more likely to be found at smaller hospices, for-profit hospices, and hospices in rural areas of the country [2]. For patients who choose hospice or other in-home care, it is important for caregivers to know what to expect as death approaches. For example, caregivers may find it alarming or jarring when the patient starts to show little interest in food and drinks less liquid. Mental status changes, pain, constipation, and other issues can be managed with help from hospice or home care nurses. It is important that all the caregivers know that, if the patient does not want life-sustaining measures, they should call hospice or home care providers for any problems, rather than calling Emergency Medical Services (EMS). In most cases, calling 911 means that EMS must take resuscitation measures and route the patient to emergency care, unless the patient is conscious and can verbally refuse such care [35]. CANCER SCREENING Cancer screening can help find and treat several types of cancer early. Early detection is important because when abnormal tissue or cancer is found early, it is typically less complicated to treat, and treatment tends to be more successful. By the time symptoms appear, cancer might have begun to spread which makes it harder to treat, averaging less successful outcomes. However, there are hundreds of possible screening methods with varying levels of supporting evidence, and each with its own possible benefits and harms. Because of this, there are organizations that review the evidence, evaluate the pros and cons of various cancer screening methods, and make recommendations for clinical practice. Given the potential fallibility of public health measures, this is a serious task that requires wide-ranging vision and careful consideration. Even with these caveats, a surprising number of groups participate. Some physician groups make recommendations within their practice areas (for example, the American Congress of Obstetricians and Gynecologists and the American College of Gastroenterology). Even cancer treatment centers will have their own interpretations of cancer screening guidelines. So when health professionals speak of cancer screening guidelines, it is important to know which guidelines are under discussion. This section will focus on the best-known national groups that have been making broad cancer screening recommendations for many years. These include the U.S. Preventive Services Task Force (an independent panel of volunteer health experts since 1984) and the American Cancer Society (a donor-supported nonprofit since 1913) [283,8]. Both are reputable and well-respected. Their cancer screening recommendations are different in a few places, but agree on many points. Sometimes the differences are based on how certain research findings are valued or weighted, and often indicate issues that need more research or consideration. Health care providers can choose options from one or the other set of cancer screening guidelines based on the patient’s values and preferences, health insurance situation, and even what is available in the geographic area. Screening recommendations change from time to time as new tests are studied and new evidence comes in to support or counterbalance the older studies. It is a good idea to visit these websites (http://www. and and review their cancer screening guidelines at least once a year to find out what changed. Limitations of cancer screening Even the best cancer screening tests are imperfect, and fail to detect every case of cancer. Sometimes abnormalities are found that are not cancer. Several screening tests have been shown to be fairly reliable at detecting cancer early and reducing the chances of dying from that cancer. Other screening tests have been shown to detect cancer early, but less reliably. Some cancer screening tests work well in the hands of experienced health care providers, but not so well in those who are new to it or who do not do it often. And others may be reliable enough but have not yet been shown to reduce the risk of death overall. In some cases, the screening is too new for research to have been conducted, but in other cases, the research has been done but has not shown improvement in the death rate from cancer. Reducing the death rate is the gold standard for cancer screening tests [149]. Higher levels of cancer risk may modified screening methods The screening guidelines discussed most often are aimed at people of average cancer risk, and health professionals may have to look to source documents to find the most recent recommendations for higher risk patients. Professionals also have to verify what constitutes high risk because not every factor that may seem relevant has been shown to truly increase cancer risk. People at high risk of certain types of cancers may need to start screening at younger ages, have more frequent screening tests, or even have extra screening tests than those at average risk of cancer [149]. It is also important to know that even the most innocuous cancer screening tests have potential harms as well as benefits [149]. False-positive tests An obvious concern is a false-positive result, in which the test suggests cancer is present even when it is not. False-positive tests can cause stress and anxiety, and often require follow-up testing and procedures that are more invasive and have more potential harm. The ability of a test to exclude people who do not have the condition (or only give true positives) is called specificity. The concern in this case is that the follow-up procedures following the positive test are more invasive and more likely to have complications than the screening test itself. For example, a positive mammogram may require a breast biopsy. A positive stool fecal occult blood test (FOBT) or fecal immunochemical test (FIT) typically requires a colonoscopy for follow up, which might include polyp removal and biopsy. Positive Pap tests often require colposcopy and sometimes biopsy procedures. Less obviously, biopsies may result in finding a low-grade cancer which might be treated even though it would be unlikely to cause problems in the person’s lifetime. Technically, this is a true positive (i.e., it is a true case of cancer), but its treatment might be unnecessary (see “Overdiagnosis and Overtreatment” for discussion).