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A CORE value of clinical medicine is to do the very best for every single patient. But the principles of evidence-based practice involve developing a management plan that is informed by studies showing the net result of an intervention is balanced towards benefit.
Accordingly, some patients will be helped by it, some will experience a null effect, and others will be harmed.
How can we reconcile this with the practitioner’s focus on each individual patient’s interests? This question, though not novel, is implicit in many clinical decisions but is rarely articulated.
A current prominent example is the contention over whether to screen men for prostate cancer. Several articles in the latest issue of the MJA revisit this question.
An analysis concludes that prostate-specific antigen screening is likely to only be cost-effective in the < 1% of men classified as very high risk. While this is valuable information, it begs the question of how to identify these high-risk men.
From a purely clinical perspective, the balance between the benefits and harms of prostate cancer screening remains unresolved, despite recent large studies, because of disagreement about how to interpret the evidence, say the authors of a Perspectives article. Nevertheless, they offer welcome advice for walking individuals through the maze of uncertainty — but suggest that the conversation only be had at the patient’s request.
In response, the authors cite their own study, which showed a survival benefit from screening that was largely offset by an almost equivalent loss of quality-adjusted life-years, mainly from the effects of treatment.
These can be difficult concepts for doctors, let alone patients.
But how do we make a decision about screening for any cancer? According to the authors of a “For debate” article, our thinking should go beyond benefits, harms and costs, to include social and ethical aspects. They say that “we need to ensure accountability to the citizens whose lives are changed, for better and for worse, by cancer screening programs”.
With regard to vaccination programs — an area of disease prevention with far less ambiguous outcomes — high participation rates are necessary for success. Here, doctors can be confident that the benefits outweigh the harms in spades.
Yet when adverse events (rarely) occur, rapid and accurate ascertainment is vital.
A useful study will inform postlicensure surveillance after this year’s roll-out of human papillomavirus vaccination for adolescent boys.
Using knowledge from the existing program for girls, they estimated the background rates of neurological and allergic events that might be potentially associated with vaccination in boys, to establish a benchmark for early detection if more than the expected number of events should occur.
Clinical guidelines assist in bringing population-level evidence to bear on individual patient management. However, they are open to interpretation and, even when fully applied to a management plan, not every patient will have the best possible outcome.
A father recounts his 29-year-old daughter’s delayed diagnosis of advanced and ultimately fatal colorectal cancer, and asks the Gastroenterological Society of Australia (GESA) to review its recommendations for investigating iron deficiency anaemia in young women, to advise earlier colonoscopy in severe cases.
A response on behalf of GESA, says that GESA recommendations would advise investigation of this patient’s persistent anaemia, but that the minimal yield from colonoscopy in a very low-risk population for colorectal cancer should be balanced against the procedure’s risks.
“Nightmare” clinical cases like this do not make for comfortable reading. They also give the lie to medicine being solely guided by rigid decision points, protocols and flowcharts.
Doctors’ seamless use of the one-on-one relationship with each of their patients — to give context to population-level evidence for the most appropriate management plan — will always be a cornerstone of clinical care.
After all, the benefits to patients of having someone versed in the evidence, but relentlessly supporting their interests, far outweigh any harms.
Dr Ruth Armstrong is the senior deputy of the MJA.
POINT 1: Screening for bowel cancer is (unlike prostate cancer screening) is backed by rock solid evidence. The risks of colonoscopy are minimal, particularly when no intervention is required. Polyp pick up rates are often above 50% of screened patients.
POINT 2: The tragic young woman who died of bowel cancer was never a candidate for screening which is, by definition, diagnosis before symptoms. She had gross iron deficiency which was refractory to treatment and was a candidate for full diagnostic assessment until the cause was found.
A Consumer Conundrum Caused by a Cornucopia of Screening Tests
Mary Osborn,
My concern about most of the invitations I receive is that there are often no explanations about the ethics of screening and no explanation about the limitations and potential harms of screening as an intervention. I strongly believe in the ethical principle of consumer autonomy as part of health care. This means that consumers must be informed and given the understanding that screening may not increase life expectancy and may be associated with adverse effects. If provided with this information most consumers will decline and those who choose to be screened are making decisions on the basis of their preferences. This is a strategy that can be agreed on by the individual doctor, their professional organisations, consumers and advocacy groups. Most of what is in the invitations was about fear mongering or as Ray Moynihan describes as disease mongering. Disease mongering expands the “disease” to “health” thereby increasing the market for products positioned as “healing and preventing the worst”.
Screening tests can become a hook to hang all our health fears on. What we need is good information to help us make good choices. What would happen if consumers gave up screening? What a conundrum.