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Medical screening consists of trying to detect an occult disease at a point in its course—earlier than if diagnosed by clinical manifestations—when treatment offers a meaningful benefit to the patient. If the cost is acceptable, one would think that most care providers and patients would embrace the concept. So why are there such heated controversies surrounding screening for breast, prostate, and lung cancer?
The answer to that question is interpretive and philosophical and depends in part on the frame of reference. Are we looking at screening from the perspective of the health care system or from the perspective of the individual patient who is contemplating being screened?
The US Preventive Services Task Force (USPSTF), whose guidelines on screening are reviewed by Dr. Craig Nielsen in this issue of the Journal, went to great lengths to generate evidence-based guidelines based on rigorously conducted trials. They did not consider observational information or the emotional contextual biases of individual patients. Since their guidelines carry great weight, they have a big impact, sometimes including effects on insurance reimbursement for certain screening tests.
As with all “evidence-based” decisions, when applying guidelines or trial data in the clinic, we weigh the effect of our recommendations on individual patients, not on populations. Is a test worthwhile if it offers a 1 in 250 (or fill in your own number) chance of prolonging a specific patient’s life but is expensive and uncomfortable and poses the possible stress of a false-positive result that will warrant more testing? Which is actually more stressful: undergoing additional testing (with expense and discomfort) or not knowing whether you have a potentially lethal tumor? What is a reasonable cost to the patient and to a financially failing health system in attempting to delay the end of life to some time in the future when the patient may well be frail and perhaps even incapacitated?
People may differ in how they answer these questions, some of which may not even be answerable. The USPSTF guidelines, I believe, offer solid scaffolding for informed discussion. But we and our patients should use the offered evidence-based guidelines, and perhaps assume some costs, within a personalized context. Guidelines are only guidelines.
Medical screening consists of trying to detect an occult disease at a point in its course—earlier than if diagnosed by clinical manifestations—when treatment offers a meaningful benefit to the patient. If the cost is acceptable, one would think that most care providers and patients would embrace the concept. So why are there such heated controversies surrounding screening for breast, prostate, and lung cancer?
The answer to that question is interpretive and philosophical and depends in part on the frame of reference. Are we looking at screening from the perspective of the health care system or from the perspective of the individual patient who is contemplating being screened?
The US Preventive Services Task Force (USPSTF), whose guidelines on screening are reviewed by Dr. Craig Nielsen in this issue of the Journal, went to great lengths to generate evidence-based guidelines based on rigorously conducted trials. They did not consider observational information or the emotional contextual biases of individual patients. Since their guidelines carry great weight, they have a big impact, sometimes including effects on insurance reimbursement for certain screening tests.
As with all “evidence-based” decisions, when applying guidelines or trial data in the clinic, we weigh the effect of our recommendations on individual patients, not on populations. Is a test worthwhile if it offers a 1 in 250 (or fill in your own number) chance of prolonging a specific patient’s life but is expensive and uncomfortable and poses the possible stress of a false-positive result that will warrant more testing? Which is actually more stressful: undergoing additional testing (with expense and discomfort) or not knowing whether you have a potentially lethal tumor? What is a reasonable cost to the patient and to a financially failing health system in attempting to delay the end of life to some time in the future when the patient may well be frail and perhaps even incapacitated?
People may differ in how they answer these questions, some of which may not even be answerable. The USPSTF guidelines, I believe, offer solid scaffolding for informed discussion. But we and our patients should use the offered evidence-based guidelines, and perhaps assume some costs, within a personalized context. Guidelines are only guidelines.
Medical screening consists of trying to detect an occult disease at a point in its course—earlier than if diagnosed by clinical manifestations—when treatment offers a meaningful benefit to the patient. If the cost is acceptable, one would think that most care providers and patients would embrace the concept. So why are there such heated controversies surrounding screening for breast, prostate, and lung cancer?
The answer to that question is interpretive and philosophical and depends in part on the frame of reference. Are we looking at screening from the perspective of the health care system or from the perspective of the individual patient who is contemplating being screened?
The US Preventive Services Task Force (USPSTF), whose guidelines on screening are reviewed by Dr. Craig Nielsen in this issue of the Journal, went to great lengths to generate evidence-based guidelines based on rigorously conducted trials. They did not consider observational information or the emotional contextual biases of individual patients. Since their guidelines carry great weight, they have a big impact, sometimes including effects on insurance reimbursement for certain screening tests.
As with all “evidence-based” decisions, when applying guidelines or trial data in the clinic, we weigh the effect of our recommendations on individual patients, not on populations. Is a test worthwhile if it offers a 1 in 250 (or fill in your own number) chance of prolonging a specific patient’s life but is expensive and uncomfortable and poses the possible stress of a false-positive result that will warrant more testing? Which is actually more stressful: undergoing additional testing (with expense and discomfort) or not knowing whether you have a potentially lethal tumor? What is a reasonable cost to the patient and to a financially failing health system in attempting to delay the end of life to some time in the future when the patient may well be frail and perhaps even incapacitated?
People may differ in how they answer these questions, some of which may not even be answerable. The USPSTF guidelines, I believe, offer solid scaffolding for informed discussion. But we and our patients should use the offered evidence-based guidelines, and perhaps assume some costs, within a personalized context. Guidelines are only guidelines.