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Physicians suggest expert recommendations ignore vital issues for patients
Date:9/12/2012

BOSTON In the medical world, where decisions invariably involve risk and uncertainty, two Beth Israel Deaconess Medical Center physicians note that experts generally base their recommendations on the outcome of death, which is "readily determined, easily quantified, concrete."

"There is more to life than death," Pamela Hartzband, MD, and Jerome Groopman, MD, write in the Sept. 12 edition of the New England Journal of Medicine. "Basing decisions on the outcome of death ignores vital dimensions of life that are not easily quantified."

For example, death has been the outcome at the bottom of two recent and controversial recommendations from the US Preventive Services Task Force involving the use of the PSA test to screen for prostate cancer among men and the value of mammography in women ages 40 to 49 to screen for breast cancer.

In each instance, Hartzband and Groopman note, Task Force members presented their conclusions with absolute certainty, declaring it was a "no-brainer" that the harm from the treatment in men and the screening in women outweighed any benefit.

But, the doctors' note, epidemiological data show a 75 percent decrease in the number of men presenting with advanced prostate cancer since the introduction of PSA screening. And mammography increases the likelihood of identifying breast cancers that are small enough to be treated with conservative therapies such as a lumpectomy, rather than a mastectomy and chemotherapy.

"How do we balance that possibility of a later life with prostate cancer marked by bone pain, pathological fractures and urinary obstruction against the more immediate symptoms of incontinence and impotence that often follow surgical or radiation treatment of early stage prostate cancer," Hartzband and Groopman ask.

"For a woman in her '40s, how do you balance the anxiety and discomfort of a biopsy for a false positive mammogram against the possible need for more extensive
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Contact: Jerry Berger
jberger@bidmc.harvard.edu
617-667-7308
Beth Israel Deaconess Medical Center
Source:Eurekalert

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