Physicians suggest expert recommendations ignore vital issues for patients

September 12, 2012

In the medical world, where decisions invariably involve risk and uncertainty, two Beth Israel Deaconess Medical Center physicians note that experts generally base their recommendations on the outcome of death, which is "readily determined, easily quantified, concrete."

"There is more to life than death," Pamela Hartzband, MD, and Jerome Groopman, MD, write in the Sept. 12 edition of the . "Basing decisions on the outcome of death ignores vital dimensions of life that are not easily quantified."

For example, death has been the outcome at the bottom of two recent and controversial recommendations from the US Preventive Services Task Force involving the use of the to screen for among men and the value of mammography in women ages 40 to 49 to screen for .

In each instance, Hartzband and Groopman note, Task Force members presented their conclusions with absolute certainty, declaring it was a "no-brainer" that the harm from the treatment in men and the screening in women outweighed any benefit.

But, the doctors' note, epidemiological data show a 75 percent decrease in the number of men presenting with advanced prostate cancer since the introduction of . And mammography increases the likelihood of identifying breast cancers that are small enough to be treated with conservative therapies such as a lumpectomy, rather than a mastectomy and chemotherapy.

"How do we balance that possibility of a later life with prostate cancer marked by bone pain, pathological fractures and urinary obstruction against the more immediate symptoms of incontinence and impotence that often follow surgical or of early stage prostate cancer," Hartzband and Groopman ask.

"For a woman in her '40s, how do you balance the anxiety and discomfort of a biopsy for a false positive mammogram against the possible need for more extensive surgery, radiation or chemotherapy for a larger cancer detected later in life?

"How do we quantify the utility or impact" of these decisions on a man or woman's life?

Hartzband and Groopman note expert groups typically use methods such as time tradeoff or the "standard gamble," that require people to forecast how they would feel in the future should they become ill or suffer complications of treatment.

"But these calculations are profoundly flawed. They require people to imagine themselves in a health state that they haven't experienced. Even we, as physicians who have cared for many patients with a particular condition, find in difficult to accurately imagine what our lives would be like if we were living with that condition ourselves."

Despite the severe flaws in how many expert groups calculate risk and benefit, their recommendations have a powerful impact on patients' care. In the wake of health reform, major policies could be crafted on the narrow criterion of death and using flawed methods of analysis.

"People have a remarkable capacity to adapt to … changes. Indeed, when the quality of life is assessed by patients themselves, there is no difference in assessments between men with prostate cancer who underwent prostatectomy and those who choose active surveillance.

There is often as profound disconnect between the way healthy people view medical conditions and the way patients with these conditions view themselves."

Hartzband and Groopman suggest patients and physicians alike not ignore the real complexities and uncertainties of medical choices.

"Wrestling with these uncertainties requires nuanced and individualized judgment. It is neither ignorant nor irrational to question the wisdom of expert recommendations that are sweeping and generic."

Explore further: Prostate cancer screening and treatment decisions must act on evidence, not beliefs

More information: www.nejm.org/doi/full/10.1056/NEJMp1207052

Related Stories

Prostate cancer screening and treatment decisions must act on evidence, not beliefs

January 25, 2012
Physicians advising men whether to be screened for prostate cancer with a PSA test must rely more on available evidence when recommending screening, biopsies and treatments rather than long held beliefs that PSA-based testing ...

Relief of urinary symptoms is an underappreciated benefit of early stage prostate cancer treatment

May 20, 2012
Treatment of early stage prostate cancer can also result in improved quality of life for a subgroup of men who suffer from lower urinary tract symptoms (LUTS), according to an abstract of a Beth Israel Deaconess Medical Center-led ...

New buzzwords 'reduce medicine to economics'

October 12, 2011
Physicians who once only grappled with learning the language of medicine must now also cope with a health care world that has turned hospitals into factories and reduced clinical encounters to economic transactions, two Beth ...

PSA screening to detect prostate cancer can be beneficial to younger and at-risk men: study

May 7, 2012
Screening younger men and men at risk of prostate cancer can be beneficial in reducing metastatic cancer and deaths and should not be abandoned, states an article published in CMAJ (Canadian Medical Association Journal).

Screening debate typifies prostate cancer uncertainties

August 10, 2012
(HealthDay) -- Though prostate cancer makes the news a lot, much of the information seems conflicting or inconclusive, leaving men with few absolute answers.

Recommendation against PSA test too drastic: WU expert

May 22, 2012
(Medical Xpress) -- A new recommendation issued today by the U.S. Preventive Services Task Force against routine PSA testing for healthy men age 50 and older goes too far, says a prostate cancer expert at the Siteman Cancer ...

Recommended for you

Vitamin E-deficient embryos are cognitively impaired even after diet improves

July 27, 2017
Zebrafish deficient in vitamin E produce offspring beset by behavioral impairment and metabolic problems, new research at Oregon State University shows.

Sugar not so sweet for mental health

July 27, 2017
Sugar may be bad not only for your teeth and your waistline, but also your mental health, claimed a study Thursday that was met with scepticism by other experts.

Could insufficient sleep be adding centimeters to your waistline?

July 27, 2017
Adults in the UK who have poor sleep patterns are more likely to be overweight and obese and have poorer metabolic health, according to a new study.

The role of dosage in assessing risk of hormone therapy for menopause

July 27, 2017
When it comes to assessing the risk of estrogen therapy for menopause, how the therapy is delivered—taking a pill versus wearing a patch on one's skin—doesn't affect risk or benefit, researchers at UCLA and elsewhere ...

Blowing smoke? E-cigarettes might help smokers quit

July 26, 2017
People who used e-cigarettes were more likely to kick the habit than those who didn't, a new study found.

Brain disease seen in most football players in large report

July 25, 2017
Research on 202 former football players found evidence of a brain disease linked to repeated head blows in nearly all of them, from athletes in the National Football League, college and even high school.

0 comments

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.