Several days ago I wrote about the USPSTF recommendation against prostate cancer screening. This recommendation is causing some controversy, especially with urologists – Panel’s Advice on Prostate Test Sets Up Battle.
What should physicians do? How should patients put this controversy into perspective?
Here is the problem: the USPSTF has humans; the American Urological Association has humans. While the data seem objective, interpretation always has a subjective component. My friend and colleague, Allan Detsky, wrote about this problem persuasively – Sources of bias for authors of clinical practice guidelines.
To improve the validity of their guidelines, they need to recognize all of the other sources of bias as well. In doing so, they will face the challenge of balancing the expertise of those with intimate knowledge, who are more likely to be subject to these forms of bias, with nonexperts who may have less knowledge but fewer of the influences that contribute to bias — no easy task.
As a generalist, I view most problems focused on the patient. I worry about side effects. I worry about errors of commission.
In this case, urologists naturally focus on the prostate, and the management of prostate cancer. They worry more about errors of omission. They have a bias towards more aggressive treatment. I have a bias towards less aggressive treatment.
In the NY Times article from Friday we read this explanation:
At the heart of its advice is the startling finding that thousands of doctors in the United States have been doing many of their patients more harm than good. While the panel did not explicitly level such a charge, Dr. LeFevre said that the dangers of common treatments were what drove the members to recommend against screening. “If you’re the guy doing the treatment, that’s pretty hard to swallow,” he said.
Sure enough, urologists — the doctors who most often treat prostate cancer — promised to fight. The American Urological Association issued a statement saying that the recommendation “will ultimately do more harm than good.” Many urologists reacted angrily.
“All of us take extraordinary issue with both the methodology and conclusion of that report,” said Dr. Deepak Kapoor, chairman and chief executive of Integrated Medical Professionals, a group that includes the nation’s largest urology practice. “We will not allow patients to die, which is what will happen if this recommendation is accepted.” He and other urologists said that the P.S.A. test is just one part of an overall strategy that, in the hands of well-trained doctors, can help prevent death and other consequences of cancer.
Treating patients with prostate cancer is a highly profitable business in the United States, and much of the practice of urology is dedicated to this fight. If men no longer get screened routinely, urologists will see a steep decline in patient visits and income. But Dr. Kapoor rejected the notion that profit plays any role in his defense of screening.
“That I’m going to treat patients that don’t need therapy is morally repugnant,” he said.
But Dr. Otis Brawley, chief medical officer of the American Cancer Society, suggested that is what doctors like Dr. Kapoor are doing. “We in medicine need to look into our soul and we need to learn the truth,” he said. “If your income is dependent on you not understanding something, it is very easy not to understand something.”
I favor the USPSTF viewpoint, but I do understand why the urologists have their viewpoint.
The challenge in most medical situations comes because even the best treatments have untoward consequences. We physicians have a responsibility to balance the risks and benefits, but that balance is not objective, rather it has a subjective component. Because we view the problem differently, we likely cannot develop a consensus. And that means that we are human beings, not computer decision aids.