Sep 20, 2012
Author: Otto Akkerman
Death is the most common end point used in clinical decision analysis1 and was the basis for the U.S. Preventative Task Force’s recommendation against routine PSA
screening in men to detect prostate cancer. The rationale was simple: trials showed no difference in death rates between a PSA-screened group and a control group. With no difference in death rates, the task force concluded that the harm from the treatment of early stage prostate cancer diagnosed with PSA testing was not warranted.
The recommendation was bold, broad ranging, and on the surface, appears based on sound, rational facts and evidence. Even the task force’s chairperson described
it as a ‘no-brainer’. A similar recommendation was made against woman’s mammograms for breast cancer screening for the same reason.
I would also use the term ‘no brainer’ for this recommendation, but in quite another spirit.
Yes, there is harm in early-stage prostate cancer treatments, including the potential for impotency and incontinence. There is also harm associated with advanced
prostate cancer in later life, including the risk of bone fractures and intense pain that can sometimes be avoided with early-stage treatment.
This is a very difficult tradeoff patients need to make in consultation with their families and physicians. The statistical fact (individual results will vary) that the rate of mortality is the same in both cases should only be part of the consideration. Our own social values research into patient motivations suggests that various men will look at these potential harms from different perspectives, and make different choices as a result.
Our analysis of physicians’ social values through MDConnect tells us that doctors will, predictively, vary in terms of their buy-in to the Task Force’s recommendation. Some will actively seek to educate patients, and encourage patients to consider their full range of options. Others will defer to the Task Force and expect their patients, in turn, to defer to them.
These findings have major implications for patients and the makers of prostate cancer therapies alike.
Patients who see physicians who buy into the task force’s recommendation may not know they even have a choice to make about their treatment.
For manufacturers of prostate cancer treatments, even late stage treatments, framing an effective discussion with physicians will depend largely or their school of thought toward this issue. The challenge is that this will differ widely among the doctors they target. Knowing who you are talking to and what messages will resonate is key.
New England Journal of Medicine, p.987 September 13, 2012