Controversy in the office: dealing with close calls
By Harold C. Sox, FACP
Specialists in adult medicine don't agree about what to do when a 45-year-old woman asks about having a mammogram or when a 65-year-old man asks to have a screening test for prostate cancer. Some say that they engage these patients in a discussion of the harms and benefits of screening. Others just make a recommendation or accede to the patient's wishes. Which is the right approach?
Before answering this question, take a moment to go over the evidence for these two controversies. A recent National Institutes of Health consensus conference found that "the data currently available do not warrant a universal recommendation for mammography for all women in their 40s." This cautious conclusion reflected the results of randomized trials of screening in women aged 40 to 49, which do not show an effect on breast cancer mortality until after 10 years of screening.
The unanswered question is whether mammography alters the mortality rate in women who are premenopausal at the time that the mammogram detects their cancer. According to Kerlikowski et al in the Nov. 24, 1993, issue of the Journal of the American Medical Association, the false-positive rate of mammography means that 25 women in their 40s with a suspicious mammogram must undergo the anxiety and inconvenience of a breast biopsy to detect one cancer. Finally, there is the issue of how best to use societal resources. The yield of breast cancers per first mammogram in women younger than 50 years is one-fifth that of the yield in women aged 50 years and up, and its cost-effectiveness is correspondingly lower as well.
The evidence about screening for prostate cancer is much weaker than for breast cancer. An American Urology Association expert panel recently found that the experimental design of studies examining how to treat organ-confined prostate cancer has serious flaws. As a result, the panel concluded, it is not possible to decide if treatment does or does not work.
The harms of radical prostatectomy are well-understood. Medicare beneficiaries have reported a 30% incidence of post-surgical urinary incontinence that required them to use a pad, clamp or catheter, and only 10% had erections that were satisfactory for sexual intercourse. So, as noted in ACP's guideline on prostate cancer, the benefits of treatment are unknown and there are known harms that would concern many men.
ACP's position paper, which was published in the May 15, 1997, issue of Annals of Internal Medicine and is available on ACP Online (www.acponline.org/journals/annals/15may97/ppcolo1.htm), contains a cost-effectiveness analysis that projects what the gain in life expectancy would be if the cure rate after surgery was 100% or, more realistically, 75%. Assuming a 75% cure rate, screening men in their 50s would cost $19,820 per added year of life, a figure that compares well with treating moderate hypertension. For men in their 70s, this figure soars to $139,540, which is not considered cost-effective. This information is the best that we will have until 10 years from now, when we see the results of currently ongoing controlled clinical trials of treatment.
Clinically, these situations are toss-ups. The discipline of decision analysis, however, has something to teach us about this type of situation. When the expected outcomes of two treatments are very close, the value that patients place on the outcomes is most likely to determine which treatment they prefer. In other words, when the decision is a toss-up, physicians should eschew advocacy and try to find out how patients value the outcomes that they may face.
Advocacy has its role when the evidence is clear. Surveys suggest that the most powerful predictor of whether a woman will have a mammogram is the recommendation of a trusted physician. In women in their 50s, mammography reduces the breast cancer death rate by 30%. As a result, internists should advocate vigorously for mammography when counseling a 55-year-old woman, even if she has a strong aversion to the possible harms of screening.
As personal physicians, we have a uniquely powerful role in guiding patients to a decision about screening, but we must often contend with pre-formed attitudes. Anyone who has spent time in an airline terminal has seen advertisements trying to convince men to undergo screening for prostate cancer. Patients may feel pressure to undergo screening because respected peers talk about it. Evidence-based screening can benefit from such advocacy, but it often seems as if weak evidence begets stronger media messages or stronger peer opinions. We must be prepared to counter misinformation with facts.
Physicians who try to provide information rather than a firm recommendation in a toss-up situation face several hurdles. One problem is finding the time to counsel a patient properly. Ten or 15 minutes doesn't sound like much time to spend talking about an important health decision, but many internists only have 30 minutes or less for a well-person preventive medicine visit. Fortunately, the decision to screen can be put off to another visit, one scheduled expressly for counseling. We need to convince payers that physicians deserve to be paid for such counseling visits.
Another hurdle is having the requisite information at one's fingertips. The College could place very brief summaries of the pertinent facts about such clinical toss-ups on its Web site to allow physicians to print out the information. Better yet, physicians could send patients home with a videotape containing the pertinent facts, interviews with actual patients and guidance on how to use the information to make an informed decision. These shared decision-making tools are now available for many clinical dilemmas. (More information on these tools is available on the Internet at www.dartmouth.edu/dms/cecs/fimdm/.) With them, patients become active, informed participants in a discussion about whether to undergo screening.
The bottom line? When the decision is a toss-up, the patient's feelings about the outcomes should weigh heavily in the balance. That's the time to provide information about those outcomes, elicit the patient's feelings about them, and then help the patient work through to a decision. Even when the patient ends up asking you to decide, your advice will be much better for having listened to what the patient says. In addition, when it's your call, you have the opportunity, perhaps even the obligation, to take cost-effectiveness into account. In close calls, the patient's preferences get first priority, but society's needs come a close second.
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