Reconciling primary care and specialist perspectives on prostate screening

I recommend that you read a thoughtful “Reflection” piece in the Annals of Family Medicine, “Reconciling Primary Care and Specialist Perspectives on Prostate Cancer Screening.” The authors quote Kipling:

“Oh, East is East, and West is West, and never the twain shall meet.”

And unfortunately that appears to be the case with many discussions about screening tests. But it doesn’t have to be that way, and the authors point to a blueprint.

The paper’s abstract reads:

When specialists propose screening guidelines for primary care clinicians to implement, differences in perspectives between the 2 groups can create conflicts. Two recent specialty organization guidelines illustrate this issue. The American Urological Association guideline panel and National Comprehensive Cancer Network recommend that average-risk men first be counseled about the risks and benefits of prostate-specific antigen screening for prostate cancer at age 40 rather than at the previously recommended age of 50 years. There is no direct evidence, however, that this recommendation has any impact on prostate cancer-specific mortality. To avoid distracting primary care clinicians from providing services with proven benefit and value for patients, professional organizations should follow appropriate standards for developing guidelines. Primary care societies and health care systems should also be encouraged to evaluate the evidence and decide whether implementing the recommendations are feasible and appropriate.

The paper calls for improved standards and methodology and transparency from those who issue guidelines:

A direct consequence of following the AUA and NCCN recommendations would be to enlarge the population being counseled about screening. This outcome would reduce the time available for implementing proven screening and preventive services in primary care. Furthermore, when the legal system argues that such guidelines represent the community standard of care, primary care clinicians who fail to follow them may be exposed to unjustified medical-legal action.Notably, the AUA has been aggressively targeting the media, lawmakers, and patients with proscreening messages after the release of the USPSTF recommendation.

Ideally, groups that develop guidelines will eventually achieve consensus on methodological issues, such as the optimal composition of expert panels, deciding what scientific evidence is strong enough to be admissible, and how to avoid going beyond the evidence when making practice recommendations. To strengthen the guideline development process, generalist clinicians and experts in evidence synthesis should be included on guideline panels and on external review panels. Guidelines should be based on systematic review of the evidence, and not based solely on expert opinion. Widespread use of the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system for categorizing the quality of evidence and the strength of recommendations would be an important step in the right direction. The Institute of Medicine recently issued performance standards for practice guideline developers, and the American Cancer Society has committed to following these principles.

In recent years, guideline-setting had become over-run by special interests.  Most patients probably have no idea; they see or hear about a professional organization of physicians issuing guidelines and they view it as sacrosanct.  Screening test issues may exacerbate the chasm between different professional perspectives more than any other topic.

Recent steps taken to improve the integrity of the guideline-setting process are important advances.  But before “the twain shall meet,” such steps must be more broadly accepted by all parties.

And, journalists, you could play a role by writing about these issues more often and in more depth.

Disclosure:  I have a connection with two of the authors.  Dr. Michael Barry is President of the Informed Medical Decisions Foundation, which has been the sole funder of this project for its entire 7-year run.  And Dr. Richard Hoffman is one of our story reviewers.  Neither had anything to do with what I wrote herein. 

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