Currently there is an intriguing concept in medicine,
especially in oncology, which suggests that physicians have a tendency to
over-diagnose. The argument goes that because of the amplified diagnostic
abilities we as physicians are able to make diagnosis of a disease such as
cancer earlier. And that is projected to be bad thing? A correlated
argument forced as causality states that over-utilization of the diagnostic capabilities leads to
“harm.” What would be considered a
laudable form of care provided to the patient in terms of early diagnosis,
intervention and potential cure from the malady (cancer in this case), the
experts go to extreme length, to define that as harm (1). This “over-diagnosis” in their minds is the
same as early diagnosis and therefore by using their statistical correlates it
is considered a travesty. Usually the authors of these articles are policy-wonks
or involved in policy making. They cite psychological harm as well as physical
harm behind the reasoning for their premise. The “psychological” harm is a
subjective methodology steeped in questions whose answers are created to evoke
emotions. The physical harm cited however is real and are the complications
related to the surgical procedure, which unfortunately is the unintended
consequence of any surgical intervention.
The question arises whether we as oncologists think that
Early diagnosis is the same as Over diagnosis?
The consequence of such a thought process if followed
through brings us to the conclusion that we should wait till potential cancer
related symptoms become apparent and then intervene, even though as the saying
goes, “The cat is out of the bag.” Is that ethical reasoning? What is even more
puzzling is the use of lead-time-bias that is being used to further the
argument that if intervention is done early and survival is shown to increase
that is nothing more than the biology of a slow growing tumor and that the lead
time in diagnosis gave the false representation of increased survival. This
purported argument has been very strong in the field of uro-oncology especially
with the use of the PSA screening methodology. The problem that arises here is
that we are nowhere close to determining the aggressiveness of the cancer
except by obtaining multiple biopsies and evaluating the Gleason’s score.
Arriving at this juncture then, the argument suggests that “Watchful waiting’
would be a good measure rather than subjecting patients to a radical surgical
prostatectomy or a brachytherapy +/- external beam radiation therapy as a
curative intent. Yet recent studies have shown that upfront intervention saves
lives over the “Watchful waiting!” (2)
Given the controversy that surrounds prostate cancer, is
watchful waiting the right approach in oncology care for a patient with
prostate cancer?
The current data-driven analytical mind-set of correlations
assumed as causations is behind a lot of these illogical thought processes and
is borne of the meaningful use objectives. Unfortunately some of these data
analytics give enormous weight to the cost factor in their analysis and tend to
forget the individual patient. Scientific literature is replete with such
cost-to-care articles especially since the global economic downturn of 2000. A
more reasoned approach would be to use hard empiricism borne of a well thought
out hypothesis and validated through repeatability before using the power of
media blitz.
The Jeremy Bentham utilitarian concept, through the eyes of
the epidemiologists has created a tall mountain to climb for the individual
with cancer. The defining art of oncology care remains that each patient is an
individual who has specific needs and comes with his or her set of
co-morbidities that confound the unified pluralistic ideology driven motive of
“one size fits all.”
Kant’s “Reason” then must be applied to the medical care we
deliver to each individual patient rather than the broad brush strokes of the
multitudes that have been sampled into the Bell curve and bounded confines of
the 95% Confidence Intervals to yield the biased p-value paradigm of the
“truth.”
There is a fine line between menace and utility. Where upon
we as physicians must decide how to shape the destiny of oncological care. Soon
there will be algorithms that will drive medical care and through the rigors of
data crunching a holographic representation of a “healthcare provider” will
render the physician moot. When that day comes, let us hope not too soon, age
and cost hopefully do not drive utility and need to become the technological
menace for humanity.
2a. Radical Prostatectomy or Watchful Waiting in
Early Prostate Cancer — NEJM http://nej.md/1jWzJ02
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