Correspondence
Arguments about Tossups
N Engl J Med 1997; 337:638-639August 28, 1997
- Article
To the Editor:
You and Dr. Pauker (April 24 issue)1 completely miss the point in focusing on the negligible difference in outcomes between screening and not screening for breast and prostate cancer. The difference is negligible only in large populations. For one person, the difference in outcomes can be and frequently is fatal. Each year in this country, thousands, if not tens of thousands, of lives are affected by the decision whether to screen, and for each of these persons, the decision can be crucial. Factoring in patients' preferences and autonomy is well and good, as long as patients' denial and inability to confront mortality, along with simplistic ideas such as the notion that disease does not exist unless you know about it, are also factored in.
To state that “the patient cannot make a bad decision” is simply not true. More accurately, if the difference between the expected outcomes of two screening policies is truly small, then only a large population cannot make a bad decision. An individual person may make a catastrophically bad decision.
Therefore, the clinician is obligated, more times than not, to screen, especially when the risk of screening is small. The focus should be, as it has been with the move toward lumpectomy and radiation therapy for breast cancer, to select the least disabling cure. Allowing tens of thousands of men and women to die of these two diseases unnecessarily is ethically and medicolegally wrong. When one is sitting at the bedside of a patient dying of metastatic cancer, what does one say to the patient and family about the preventability of the death or the “negligible” differences of two screening policies?
No one can be right all the time, but we can certainly be right more often by helping our patients avail themselves of screening tests for potentially fatal cancers. There is plenty of resistance in the general population to testing without enhancing it by confusing patients about the difference between outcomes for populations and outcomes for individuals.
1 ReferencesAbe Levy, M.D.
Mount Kisco Medical Group, Mount Kisco, NY 10549-34121
Pauker SG ,Kassirer JP . Contentious screening decisions. N Engl J Med 1997;336:1243-1244
Full Text | Web of Science | Medline
To the Editor:
I appreciate the effort you and Dr. Pauker have made to remind us of the existence of tossups, as you initially described them in the Journal 16 years ago.1 Since that initial description, it has been clear that many of the most intensively debated issues in medicine and clinical health policy have involved decision making in which the expected outcomes of the available options are, on average, quite close.
However, the mammography issue highlights important differences between the arena of individual clinical decision making and the arena of public policy. It is relatively straightforward to state that individual women in their 40s and their physicians should be free to choose between regular screening and no screening. This choice should be based on an individualized assessment of the various important outcomes (e.g., anxiety, discomfort, and the burden associated with doctor's appointments, as well as the morbidity and potential mortality associated with breast cancer).
The implications of a tossup change, however, when one moves to the arena of public policy. For example, I believe that one of the reasons for the vehemence of the debate is the belief by those in favor of screening that unless it is strongly recommended by authoritative groups, it will not be financially available to many women, because third-party payers will choose the lower-cost option of not screening. A fundamental basis of rational, individualized patient care is that individual utilities should influence treatment decisions. It is not as clear, however, how individual utilities should affect the allocation of resources for a population.
The mammography decision is not a tossup for those who must pay for it. Even if we decide to preserve an area of choice when decisions are tossups on average, what about other decisions? For example, it may be reasonable for a health plan to choose a medication that is more likely to cause dry mouth but is much less expensive than an equally effective alternative. However, what if an individual patient feels strongly that he or she wants to avoid having a dry mouth? Would it matter if that patient were an opera singer?
The question that must therefore be addressed is how our profession can preserve the option of reimbursement for a treatment that may be better in important ways for some persons but that, on average in a population, is no better than a less costly treatment. These issues require further debate, but they should not lead us to avoid stating clearly what the risks and benefits are for particular treatments.
1 ReferencesDeborah A. Zarin, M.D.
American Psychiatric Association, Washington, DC 20005To the Editor:
I agree with the points that you and Dr. Pauker make in your editorial. As a junior attending physician in clinical cardiac electrophysiology at an institution different from the one in which I trained, I find myself questioning not only contentious screening decisions but also many treatment strategies that I initially viewed as dogmatic. As I acquire more knowledge and gain experience, I am better able to assess the risks and benefits of individual patients' treatment options and have realized that there are many more tossups than I ever imagined. Many visits with patients have become opportunities for discussions about data from recent studies, the risks and benefits of treatment options, the consequences of no treatment, and foresight with regard to future therapies. The choices of antiarrhythmic-drug therapy to maintain sinus rhythm or simply rate control for atrial fibrillation, catheter ablation or drug therapy for supraventricular arrhythmias, and even beta-blockers or no therapy for symptomatic premature ventricular complexes are frequent topics of discussion with my patients.
I eagerly await the results of ongoing clinical trials to answer some of these questions but realize there will continue to be some element of a tossup for each patient, regardless of the study results. Data analysis and risk assessment are essential elements in the science of medicine, but the process of informing, explaining, and advising, as well as supporting the patient's decision, is the real art of medicine.
Ralph J. Verdino, M.D.
University of Chicago Hospital, Chicago, IL 60637Author/Editor Response
The authors reply:
To the Editor: We believe that Dr. Levy makes two errors. First, he confuses a decision with its outcome. Patients can make good decisions but nonetheless — by virtue of chance — have bad outcomes and then regret their choices. By not informing our patients when the alternatives they face carry similar risks and benefits, we can make a bad result even worse if the patients believe that they somehow made a mistake. Second, Dr. Levy's analysis is misleading because he looks only at one side of the decision — namely, the adverse consequences of not screening. On the other side are patients who are screened for prostate cancer, have positive tests, and undergo radical surgery for a cancer that never would have caused them harm. If such a patient has incontinence and permanent impotence postoperatively, he and his family may have just as much (and perhaps even more) regret as the man who was not screened and is now dying of painful metastatic cancer. One can mount a similar argument for screening for breast cancer. Disclosure of the outcomes of both alternatives allows patients to make rational choices and to better accept the consequences of their decisions.
Dr. Zarin's thoughtful comments raise ethical questions that are particularly important now that medical decisions have become so influenced by short-term market forces. But should policy analysts or physicians exaggerate the benefits of a test (or a treatment) to preserve that option for patients who might benefit from it? We think not. Rather, when the choice of two options is a tossup, we believe physicians should say so. At the same time, we must argue strenuously to preserve funding for those patients who may benefit substantially and for those who choose to exercise their individual judgment.
Stephen G. Pauker, M.D.
New England Medical Center, Boston, MA 02111Jerome P. Kassirer, M.D.
