June 2012 - American Association for Clinical Chemistry

Clinical
Laboratory
News
eDiTorial sTaff
editor—Nancy Sasavage, PhD
senior editor—Genna Rollins
senior editor—Bill Malone
editorial assistant—Laura Kachin
contributors—Hubert W. Vesper, PhD,
and Julianne Cook Botelho, PhD
boarD of eDiTors
chair—Amy Saenger, PhD
Mayo Clinic, Rochester, Minn.
members—Lorin M. Bachmann, PhD, DABCC
VCU Health System, Richmond, Va.
Andrew Don-Wauchope, MD
Juravinski Hospital and Cancer Center,
Hamilton, Ontario
Jacqueline Fisher
Children’s Hospital Boston, Boston, Mass.
Steven Goss, PhD
Siemens Healthcare Diagnostics, Newark, Del.
Pamela Steele, PhD
Covance, Inc., Indianapolis, Ind.
aacc officers
President— W. Greg Miller, PhD, DABCC,
FACB
President-elect—Robert H. Christenson, PhD,
DABCC, FACB
Treasurer—D. Robert Dufour, MD
secretary—Elizabeth L. Frank, PhD, DABCC,
FACB
Past-President—Ann Gronowski, PhD
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Nancy Sasavage, PhD, Editor
Clinical Laboratory News
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4 CliniCal laboratory news June 2012
Few Understand the Evidence
screening Tests, continued from page 3
and patients had completely ignored the
USPSTF recommendation.
Patients’ enthusiasm alone may not be
to blame for such a discrepancy between
recommendations and practice. There also
is reason to doubt that physicians themselves
can comprehend or communicate
even the basic facts about evidence when
it comes to screening tests. A nationally
representative survey of internal medicine
physicians found that a majority were easily
stumped by questions about basic statistics
and would recommend a screening test
to save lives based on irrelevant evidence
(Ann Intern Med 2012;156:340–349).
The researchers expected that physicians
would understand that in screening
tests, survival statistics are susceptible to
lead-time and overdiagnosis biases. In fact,
more than 20 years ago the National Cancer
Institute concluded that reduced mortality
in a randomized trial could be the
only reliable evidence that a screening test
saved lives. However, when presented with
evidence about two hypothetical screening
tests, physicians in the study overwhelmingly
favored a test backed by evidence of
improved 5-year survival over one with an
improved mortality rate.
The inability of some physicians to interpret
data about screening tests appears
even more dire considering how USPSTF
and other groups have leaned toward optional
shared decision-making in their recommendations.
This concept emphasizes
the importance of doctor-patient collaboration
to arrive at healthcare decisions and
puts greater emphasis on patient autonomy
and choice. The concept gained momentum
especially with PSA testing after
USPSTF’s 2008 “I” recommendation for
prostate cancer screening in men younger
than 75, which suggested that these men
“should be assisted in considering their personal
preferences before deciding whether
to be tested.”
Many opinion leaders in healthcare
expressed deep frustration with this strategy,
questioning shared decision-making
for controversial screening tests for which
the evidence perplexes both doctors and
patients. For example, Allan Brett, MD, is
among those who welcomed USPSTF’s
more conservative 2011 draft recommendations
against using PSA tests to screen for
prostate cancer.
After those draft recommendations
were published, Brett, a professor of medicine
at the University of South Carolina
School of Medicine and member of the
university’s Center for Bioethics and Medical
Humanities, wrote an editorial praising
USPSTF for giving physicians clearer guidance
(N Engl J Med 2011; 365:1949–1951).
“For two decades, primary care physicians
have been expected to present a flawed
online extra
low-value scenarios
for lab Tests
go to the June issue
of CLN at
www.aacc.org
screening test to patients, cloaking the flaws
in an elaborate ritual of informed decision
making. In turn, men have been expected
to make sense of a confusing mix of hypothetical
outcomes,” he wrote. Due to the
difficulty of digesting the data on screening,
these patient-physician discussions about
PSA testing were “essentially a charade,”
and their decisions “reflected their general
concerns about cancer or their general inclination
to accept or resist medical interventions.”
Brett is also the editor-in-chief of
Journal Watch General Medicine.
Brett also recently wrote about coping
with patient pressure for unnecessary tests
and procedures more generally (JAMA
2012;307:149–150). Physicians have been
overcorrecting for their traditionally paternalistic
tendencies since the 1980s, he
argued. Now the pendulum has swung too
far, with physicians’ intellectual authority
routinely questioned. “Yes, there should be
a partnership between doctors and patients
in decision-making, but when it crosses the
boundary into things that don’t plausibly
confer medical benefit, physicians should
be able to say no,” he told CLN.
These pressures on physicians are one
reason that Harris advocates the use of outcomes
tables that do a better job of capturing
all of the potential benefits and harms
of a particular screening test. “If you don’t
lay it out for people, it’s hard for them to
see what is meant by harms,” he said. “We
need to help people see that the benign
blood test that you agree to when you have
a doctor visit can end up being the first step
in a cascade of events that, after a while, you
won’t be able to control. And that cascade
can end up with your being helped, but it
might also result in your being hurt.”
But is it possible that giving patients
more choices can boost screening where
underutilization is a problem? New evidence
suggests that in the case of colon
cancer screening, offering patients choices
about the type of test boosted compliance
(Arch Intern Med 2012;172:575–582). The
researchers viewed these results as particularly
significant because patients frequently
avoid recommended colon cancer screening.
They found that patients for whom
colonoscopy was recommended were less
likely to complete colorectal cancer screening
than either those for whom FOBT was
recommended or those who were given
a choice between FOBT or colonoscopy.
Only 38.2% of the participants in the colonoscopy
group completed that procedure,
compared with 67.2% in the FOBT group
and 68.8% of those allowed to choose their
own screening method.
In an invited commentary on the study,
Theodore Levin, MD, urged physicians to
See screening Tests, continued on page 6
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2011.09 CLN Immunoassay.indd 1 8/5/2011 5:05:28 PM