Yes, We Have No Bananas!

I am troubled by the approach we seem increasingly to be taking, as a profession, in advising the public on cancer screening.

Derek Raghavan, MD, PhD

In recent months, we have seen a public release of new breast cancer screening guidelines, based on a retrospective review of extant data for 40 to 50 year olds, with no advanced discussion with the oncology medical community, and this has created confusion and consternation in the patient community, and wasted a considerable amount of time for busy physicians who have had to discuss these issues in detail with patients who are genuinely concerned. After the initial rush of excitement, it seems that the committee has backed down, a bunch of public figures have issued many public statements, some of the learned professional societies have gone underground, and things seemed to have returned to normal, correctly or incorrectly.

More recently, the American Cancer Society decided it needed to buy into the prostate screening debate, modifying its previous stance somewhat, and came up with the earth shattering conclusion “Patients should discuss this with their doctors.” This is the best that this wonderful and committed patient advocacy team could produce? There are two major randomized trials, published in the New England Journal of Medicine, and innumerable guidelines, written opinions and nonrandomized investigations that have produced enough information to draw some type of conclusion, rightly or wrongly. So why is there a need to issue a public statement that is tantamount to saying “We have no conclusion so figure it out for yourselves with your doctor”?

I happen to believe that prostate screening, the routine investigation of asymptomatic otherwise healthy males via DRE and PSA checks, is not proven to be of value to the community at large. I accept that this is my opinion, which is partly predicated on the two NEJM papers and partly on the number of screened early diagnostic pick-ups who still eventually present with metastases, but I also acknowledge that many wiser clinicians and scientists do not share my view, and that each of these studies has its flaws. On the other hand, there is precious little in either manuscript that gives a good reason to support community-wide screening with extant methodologies. It also seems that there are some conflicts of interest in play when many of the extant recommendations are reviewed carefully, and it is troubling that this important factor never seems to be considered when editors of newspapers and scientific journals promulgate the information.

I have to admit that I also didn’t (and don’t) believe that an annual chest x-ray is a useful screening tool for lung cancer, and previous trials and subsequent conventional wisdom appear to have rationalized that view. That said, I’m still struggling to figure out the impact of CT scans on early diagnosis of lung cancer, a domain also marred by purported conflicts of interest. Either way, it doesn’t always follow that early testing and action necessarily equate with improved outcomes.

We seem to have evolved into a society that is dominated by the need for medical information, high visibility of so-called experts, public pronouncements and, worst of all, GUIDELINES. 

Now don’t get me started…perhaps in a future blog we can consider whether published “guidelines”, and particularly those absent level 1 underpinning data, are necessarily worth the paper (or bytes) expended in their genesis. Whether they are or are not, many of these documents are attracting more attention and impact from the health payers than is perhaps justified by their factual basis.