I have written and talked about the problem of multiple guidelines on the same subject. Since I have published many papers on pharyngitis, I have often used pharyngitis as my example. Now I have another great example – A Step Backward: The ACPM Recommendations on Prostate Cancer Screening

Why do these recommendations differ so greatly?  First, we should understand the depth of the disagreement.

After reviewing the literature prior to July 2007, The American College of Preventive Medicine (ACPM) concluded that there is insufficient evidence to recommend routine prostate cancer screening with prostate-specific antigen (PSA) testing and digital rectal examination (DRE).^[1] Rather, they recommended that clinicians have an annual discussion with their patients about the potential risks and benefits of prostate cancer screening and the limitations of the evidence currently available. Furthermore, routine testing is not even recommended for high-risk groups, such as men with a positive family history and African-American men, and if the patient defers to the physician concerning the decision to screen, testing should not be offered.

Several other organizations have adopted a similar position, including the American Academy of Family Physicians, US Preventive Services Task Force, and American College of Physicians.^[2] These groups remain unconvinced that prostate cancer screening is worthwhile, despite the overwhelming emerging evidence that screening saves lives.

The rationale for the ACPM position involved a discussion of 2 randomized trials as well as case-control association studies that did not show a benefit.

They also expressed concern about false-negative and false-positive results, as well as the possible adverse psychological effects of screening on patients. Furthermore, they dismissed the use of various PSA-based adjunctive parameters to improve the accuracy of screening, because they found no evidence of a mortality benefit from using these variables.

The ACPM emphasized the high financial cost associated with the implementation of a national screening program and alluded to the additional costs of treatment in subsequent years. However, they did not consider the favorable cost trade-offs of treating early prostate cancer vs advanced-stage disease.

So we have multiple organizations agreeing against prostate cancer screening.

In contrast to the ACPM, the American Urological Association recommends offering PSA screening beginning at age 50 in men with at least a 10-year life expectancy.^[7] African-American men and those with a first-degree relative with prostate cancer are urged to consider screening at an earlier age. The American Cancer Society makes similar recommendations.^[8]

In our view, the National Comprehensive Cancer Center (NCCN) Guidelines on the Early Detection of Prostate Cancer are the most progressive, and provide the most helpful guidance to physicians and patients.^[9] Unlike many other guidelines, they incorporate much of the emerging information, including some that has not yet been validated in a randomized controlled clinical trial.

To really understand why, you should reacquaint yourself with Allan Detsky’s classic article – Sources of bias for authors of clinical practice guidelines.

Clearly the members of these panels have biases.  The preventive medicine group and the generalist groups worry more about costs and complications which follow the screening strategy.  The urologists and cancer experts worry more about curing cancer.  By implication, they worry less about the collateral damage  which comes from screening.

Now comes the difficult part.  What should a family physician do in their practice?  What do I want my physician to do for me?  And most important, should we evaluate performance on this issue?

The fact that guidelines differ highlights the problem of trying to measure practice.  Few of our decisions are crystal clear.  Trying to use algorithms to assess quality is a measurement flaw.  We can measure something, but can we interpret our measurement?

Related posts:

1. Prostate cancer screening
2. Not all screening helps patients
3. Mammograms and cost containment
4. Prostate cancer – to screen or not
5. Testing for prostate cancer

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