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1-16 SHOULD WE SCREEN FOR PROSTATE CANCER?
"To tell all men that screening causes net harm is
no more evidenced-based than claiming it is
beneficial." Should not patients (who face the
consequences of being or not being screened) be informed
of their options and allowed to choose for themselves?
Shared decision making should be reserved for situations
in which the superiority of one option over another is
uncertain. It depends on patient preferences.
Men over age 50 have a right to know about screening and
to decide for themselves. BMJ April 5, 1997; 314: 989-90 1-16 SHOULD WE SCREEN FOR PROSTATE
CANCER?
Men over 50 have a right to decide for themselves
Routine screening for any condition is unwarranted
without evidence that the test accurately detects early
disease, that early detection improves outcomes, and that
benefits outweigh harms. Unfortunately, such evidence is
lacking for prostate cancer (PC).
The prostate specific antigen produces many false
positive results. About 1/3 of tumors detected by the
test are localized and likely to progress, but there is
no good evidence that treatment improves outcomes.
Moreover, the complications from screening and treatment
may offset the potential benefits.
This year the National (UK) Health Technology Assessment
Program advised against routine screening. Is this
recommendation reasonable? The answer differs for
populations and individuals. Deciding whether to screen a
population requires an assessment of the benefits and
harms to society. The average preferences of the
population, rather than those of individuals must be
considered. The interests of the majority should prevail.
Other population concerns apply. It may be unethical to
recommend potentially harmful interventions in healthy
people when national resources are limited. The public
good may be better served by diverting resources to
services of proved value.
But, does discouraging screening provide good counsel for
individual patients? Should a man who requests a PSA be
told that it is inappropriate? If the patient does not
bring up screening should the doctor remain silent and
let the omission pass? [Should the doctor perform a PSA
as part of a routine screening blood panel without
informing the patient?]
The lack of evidence of effectiveness does not prove
ineffectiveness. Although the harms of screening and
treatment are known, without information on benefits we
cannot know which outcome prevails. "To tell all men
that screening causes net harm is no more evidenced-based
than claiming it is beneficial." Should not patients
(who face the consequences of being or not being
screened) be informed of their options and allowed to
choose for themselves? Shared decision making should be
reserved for situations in which the superiority of one
option over another is uncertain. It depends on patient
preferences. Men over age 50 have a right to know about
screening and to decide for themselves.
BMJ April 5, 1997; 314:
989-90 Editorial from Medical College of Virginia,
Fairfax
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