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Screening: seeking a balance
Leading Edge
Screening: seeking a balance Prospective screening is an important intervention in early cancer detection. The use of screening in certain settings, however, is controversial, and a ruling by the UK General Medical Council (GMC) on Nov 23, 2006, adds further confusion. The GMC Fitness to Practise Panel heard the case of the Penine Breast Screening Service clinical director, who was accused of misconduct. As part of routine screening, the doctor examined a woman (Mrs A) twice during the 1990’s, both clinically and by use of mammography, and declared her free of disease. However, Mrs A became aware of a mass in her right breast, which was diagnosed as advanced cancer by a different hospital, just months after the results of the second screening appointment. The woman died of progressive disease 2 years later, and her family consequently prepared a malpractice suit against the clinical director. The GMC found the doctor guilty of destroying the first mammogram after he became aware that Mrs A had breast cancer. Furthermore the council found that the doctor had not had formal training in assessing mammograms. Despite finding the doctor guilty, the GMC decided to neither issue a warning nor take any other action because “the panel [was] satisfied that Mrs A suffered no direct or indirect harm”. The GMC’s decision in this case sets a dangerous precedent. Whether the doctor’s actions would have caused harm to the patient, or not, could not have been foreseen at the time of screening. This conclusion could only be reached with the benefit of hindsight and should not have influenced the GMC’s decision. The doctor was found guilty of misconduct and a penalty should have been applied—without such penalty, the GMC has undermined it’s credibility as a gatekeeper of good, ethical clinical practice in the UK. There is seemingly now no deterrent to prevent doctors who make mistakes from destroying evidence. Plus, there is an inference that it does not matter whether a screening process is flawed because it does not affect prognosis; in other words, there is no benefit to be gained from use of prospective breastcancer screening—an inappropriate conclusion. Similar to this UK controversy surrounding the use of screening, a recent report on prostate-cancer screening
http://oncology.thelancet.com Vol 8 January 2007
done by the Veterans Affairs (VA) Hospitals in the USA also raises questions. A study published on Nov 15, 2006, in the Journal of the American Medical Association showed that one-third of male veterans over the age of 85 years have been tested for the expression of prostate-specific antigen (PSA). PSA testing is notoriously unreliable— two-thirds of men with high PSA concentrations do not have prostate cancer. The test also cannot detect all men with prostate cancer, because about a fifth will have concentrations within normal limits. Guidelines on who should be screened vary wildly, from the United States Preventative Task Force that do not recommend PSA testing at all to the American Cancer Society that recommends screening for men between the ages of 50–70 years. A false-positive result is more common in older men, and can be confounded by prescription drugs. Even if the patient does have cancer, it can sometimes be slow-growing in older men and unlikely to cause death. Given these considerations, the finding that PSA testing is being done in a group of men that do not meet the inclusion criteria of various clinical guidelines is suggestive of poor practice. It is possible, of course, that the men attending the VA Hospitals specifically asked for the PSA test, but the large numbers of men included in the study counters this argument. Indeed, this is not the first time over-screening has been reported in the USA, The Lancet Oncology commented on the overuse of colonoscopy in October 2004. Whatever the reason for over-screening older men for prostate cancer, a more considered approach would have prevented unnecessary worry and painful biopsies. The dichotomy emphasised by these two situations— ie, a decision that undermines the importance of screening in the UK versus an initiative that advocates over-screening in the USA—underscores a continuing problem of patient mismanagement in preventive oncology. Adequate training and education is still urgently needed to ensure screening procedures are implemented appropriately and results are interpreted and used in a clinically meaningful way. Without this, preventive oncology will never attain a central role in cancer management. ■ The Lancet Oncology
For more on PSA testing in VA Hospitals see JAMA 2006; 296: 2336–42
For more on influence of finesteride in PSA testing see Reflection and Reaction page 4 and Articles page 21
For more on the GMC decision see http://www.gmc-uk.org/ concerns/decisions/search_ database/20061123_ftp_panel_ philip.asp
See Lancet Oncol 2004; 5: 581
1
Screening: seeking a balance Prospective screening is an important intervention in early cancer detection. The use of screening in certain settings, however, is controversial, and a ruling by the UK General Medical Council (GMC) on Nov 23, 2006, adds further confusion. The GMC Fitness to Practise Panel heard the case of the Penine Breast Screening Service clinical director, who was accused of misconduct. As part of routine screening, the doctor examined a woman (Mrs A) twice during the 1990’s, both clinically and by use of mammography, and declared her free of disease. However, Mrs A became aware of a mass in her right breast, which was diagnosed as advanced cancer by a different hospital, just months after the results of the second screening appointment. The woman died of progressive disease 2 years later, and her family consequently prepared a malpractice suit against the clinical director. The GMC found the doctor guilty of destroying the first mammogram after he became aware that Mrs A had breast cancer. Furthermore the council found that the doctor had not had formal training in assessing mammograms. Despite finding the doctor guilty, the GMC decided to neither issue a warning nor take any other action because “the panel [was] satisfied that Mrs A suffered no direct or indirect harm”. The GMC’s decision in this case sets a dangerous precedent. Whether the doctor’s actions would have caused harm to the patient, or not, could not have been foreseen at the time of screening. This conclusion could only be reached with the benefit of hindsight and should not have influenced the GMC’s decision. The doctor was found guilty of misconduct and a penalty should have been applied—without such penalty, the GMC has undermined it’s credibility as a gatekeeper of good, ethical clinical practice in the UK. There is seemingly now no deterrent to prevent doctors who make mistakes from destroying evidence. Plus, there is an inference that it does not matter whether a screening process is flawed because it does not affect prognosis; in other words, there is no benefit to be gained from use of prospective breastcancer screening—an inappropriate conclusion. Similar to this UK controversy surrounding the use of screening, a recent report on prostate-cancer screening
http://oncology.thelancet.com Vol 8 January 2007
done by the Veterans Affairs (VA) Hospitals in the USA also raises questions. A study published on Nov 15, 2006, in the Journal of the American Medical Association showed that one-third of male veterans over the age of 85 years have been tested for the expression of prostate-specific antigen (PSA). PSA testing is notoriously unreliable— two-thirds of men with high PSA concentrations do not have prostate cancer. The test also cannot detect all men with prostate cancer, because about a fifth will have concentrations within normal limits. Guidelines on who should be screened vary wildly, from the United States Preventative Task Force that do not recommend PSA testing at all to the American Cancer Society that recommends screening for men between the ages of 50–70 years. A false-positive result is more common in older men, and can be confounded by prescription drugs. Even if the patient does have cancer, it can sometimes be slow-growing in older men and unlikely to cause death. Given these considerations, the finding that PSA testing is being done in a group of men that do not meet the inclusion criteria of various clinical guidelines is suggestive of poor practice. It is possible, of course, that the men attending the VA Hospitals specifically asked for the PSA test, but the large numbers of men included in the study counters this argument. Indeed, this is not the first time over-screening has been reported in the USA, The Lancet Oncology commented on the overuse of colonoscopy in October 2004. Whatever the reason for over-screening older men for prostate cancer, a more considered approach would have prevented unnecessary worry and painful biopsies. The dichotomy emphasised by these two situations— ie, a decision that undermines the importance of screening in the UK versus an initiative that advocates over-screening in the USA—underscores a continuing problem of patient mismanagement in preventive oncology. Adequate training and education is still urgently needed to ensure screening procedures are implemented appropriately and results are interpreted and used in a clinically meaningful way. Without this, preventive oncology will never attain a central role in cancer management. ■ The Lancet Oncology
For more on PSA testing in VA Hospitals see JAMA 2006; 296: 2336–42
For more on influence of finesteride in PSA testing see Reflection and Reaction page 4 and Articles page 21
For more on the GMC decision see http://www.gmc-uk.org/ concerns/decisions/search_ database/20061123_ftp_panel_ philip.asp
See Lancet Oncol 2004; 5: 581
1