Do good, and fear no one?GP and Cancer Screening, an ethical perspective

Veerle Piessens General Practitioner – Ghent- BelgiumAssistant Dpt. General Practice and Primary

HealthCare, Ghent University

Imagine a health problem…

Imagine a serious health problem Every year (in the UK)

• > 2000 deaths• 25000 people with serious morbidity

Preventive intervention Avoids 99%

Intervention – 99% effective?Stop people from driving cars and motorized vehicles.

Background

Belgium: 1 screening programme: breastcancer High opportunsitic screening cervical

cancer and prostate cancer. Almost no colorectal cancer screening

Fee for service Very little regulation on content of

the job

Background

Positive attitude towards cancer screening

In general In medical school

4 basic ethical priciples

Do good Do not harm Autonomy Justice

Do good“The principle of beneficence refers to a statement of moral obligation to act for the benefit of others.”Beauchamp & Childress, Principles of Biomedical Ethics.

What is good?

What are ‘the benefits’? Do we have evidence? How do we communicate the

benefits?

Benefits of cancerscreening? Early detection of cancer? Disease-related mortality-reduction. Less morbidity < less agressive

therapy

… and the patient?

Patients view on ‘benefits’? Mortality Reduction

Strongly overestimated (x10) More cure/less agressive therapy Reassurance of negative tests 1

Prevention of cancer 2

Silverman E, Woloshin S, Schwartz LM, Byram SJ, Welch HG, Fischhoff B. Women'sviews on breast cancer risk and screening mammography: a qualitative interviewstudy. Med Decis Making. 2001 May-Jun;21(3):231-40.

1. Silverman E e.a. Women's views on breast cancer risk and screening mammography: a qualitative interview study. Med Decis Making. 2001 May-Jun;21(3):231-40.

2. Domenighetti G e.a. Women's perception of the benefits of mammography screening: population-based survey in four countries. Int J Epidemiol. 2003 Oct;32(5):816-21.

Patients expectations of screening… … are not similar. … are not always realistic. … some can impossibly be met

Evidence of benefit?

Screening is an intervention with healthy people.

Strong evidence is needed. Randomized Clinical Trials (RCT)

Do we have evidence of benefit? Screening cervical cancer started

without evidence. Prostate cancer screening started

without evidence. Good quality RCT’s for colorectal

cancer screening with FOBT. Plenty of RCT’s for breast cancer

screening with mammography, but …

Evidence for breast cancer screening? Questions about quality of the trials Best quality no evidence of benefit. Mediocre quality evidence of

mortality reduction

How much benefit?

Relative Risk Reduction

Enough information?

RRR

Breast Cancer 1 15-20%Cervical Cancer 2 60%Colorectal Cancer 3 15-20%Prostate Cancer 4 20%

1. Gøtzsche PC, e.a. Screening for breast cancer with mammography. Cochrane Database of Systematic Reviews 2011, Issue 1. Art. No.: CD001877. DOI: 10.1002/14651858.CD001877.pub4

2. Raffle AE e.a. Outcomes of screening to prevent cancer: analysis of cumulative incidence of cervical abnormality and modelling of cases and deaths prevented. BMJ. 2003 Apr 26;326(7395):901.

3. Hewitson P e.a. Screening for colorectal cancer using the faecal occult blood test, Hemoccult. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD001216. DOI: 10.1002/14651858.CD001216.pub2

4. Schröder FH e.a. ERSPC Investigators. Screening and prostate-cancermortality in a randomized European study. N Engl J Med. 2009 Mar 26;360(13):1320-8. Epub 2009 Mar 18. PubMed PMID: 19297566.

Relative Risk Reduction

What does it mean in ‘real value’ ‘Natural frequencies’

Prostate Cancer Screening 10000 men

▪ 36 die without screening▪ 29 die with screening

7 of 10000 men profit from screening.

RRR Mortality WITHOUT screening

MortalityWITHscreening

Who profits?

Breast Cancer 15-20% 4/1000 3/1000 1/1000

Cervical Cancer

60% 25/10000 15/10000 1/1000

Colorectal Cancer

15-20% 100/10000 85/10000 1-2/1000

Prostate Cancer

20% 36/10000 29/10000 <1/1000

DO GOOD

What are “the goods” we are aiming for?

Do our patients have the same expectations?

Is there reliable evidence? What is the magnitude of the

benefit?

Do not harm“The principle of nonmaleficence imposes an obligation not to inflict harm on others.” Beauchamp & Childress, Principles of Biomedical Ethics.

DO NOT HARM

Fear appeal and other emotional recruitment strategies.

False positive results False negative results Overdiagnose en overtreatment

Emotional recruitment strategies:

Woloshin S, Schwartz LM. Numbers needed to decide. J Natl Cancer Inst. 2009Sep 2;101(17):1163-5. Epub 2009 Aug 11. PubMed PMID: 19671771.

FROG PERSPECTIVE

Put it in at top-10:Cervical cancer is one of the top-10 cancers in women between 15 and 45

Put it in a worldwide perspective:Wordlwide there are every year 500 000 cases of cervical cancer.

Put it in a time perspectiveIn Europe every 18 minutes a woman dies of cervical cancer

In Belgium each year 1/10000 woman 600 are diagnosed with cervical cancer.

False Positive Results

Fear, anxiety, other psychological side-effects. 3 years after the test

Extra medical procedures Sometimes dangerous

Risk of FP result: Mammo: ¼ - ½ Colorectal: 1 person ‘saved’ – 125 pp

with FP

(False) Negative Results

Delay in diagnosis and treament Loss of confidence in own clinical

judgement and in health care system.

Getz L, Brodersen J. Informed participation in cancer screening: the facts arechanging, and GPs are going to feel it. Scand J Prim Health Care. 2010 Mar;28(1):1-3.

Overdiagnosis

Welch HG, Black WC. Overdiagnosis in cancer. J Natl Cancer Inst. 2010 May5;102(9):605-13. Epub 2010 Apr 22. Review.

The balance – 1000 women

Respect patients autonomyDit 3e ethische basisprincipe stelt dat mensen zelf vrij, zonder dwang, beslissingen mogen nemen aangaande hun gezondheid en medische interventies, voor zover deze beslissingen geen anderen schaden.

Respect patients autonomyBeauchamp & Childress, Principles of Biomedical Ethics.

Do we respect our patients autonomy? What is our role as GP

Are all conditions fullfilled? Are our patiens aware of the

existence of cancer screening? Do patients have correct knowledge?

About cancer? About benefits? About harms?

Patients screening – behavior Overscreening Underscreening

What is our role as GP

Information: Lower socio-economic classes/minority-

groups Worried-well

Population – individual Benefit exceeds harm on population-level. Individual level: value of benefits, value of

harm. Threats for autonomy

Targets

Balance GP’s have the opportunity – nobody else has. But…

Do GP’s have balanced information? Is this our priority? Won’t it distract us from the questions our patients

consult for? But…

If we don’t make a choice, choices will be made for us.

Lobby for more balanced information by other channels

What to do when…

… when principles seem to be conflicting?

… when patients have not enough mental capabalities to decide?

… when patients prefer not to decide and leave it to you?

Justice A group of norms for fairly distributing benefits, risks and costs

Justice Is there a problem?

Cancer screening is often free. Available for everybody.

Important socio-economic health disparities, also for cancer: Higher cancermortality Less ‘state of the art’ follow-up Less participation in cancer screening Benefits of cancer screening are not fairly distributed

Justice

Access to healthcare? Not for everybody Screening is free, but follow-up isn’t

financial barrier. Underscreening in lower SE classes

Less informed Long term perspective No priority in daily struggle for life

Justice

Overscreening in higher SE classes No extra benefit More harm Using publicly funded resources

Justice as ‘guide’ for the GP Everybody has a GP.

We see those people who are not reached by PH campaigns.

We see those who are overscreened Opportunity:

to inform them about screening. to stand by our patients

Unequal treatment of unequal people more intensive for those who need

more

Access to healthcare

GP: high accessibility Cherish it, promote it, expand it

Advocate for our patients

conclusion

4 principles

Broader perspective: Tunnel panoramic

Used in a comprehensive way Justice – autonomy

Motive to fullfill our role Harm – Good

Basis for the content

Thank you very much!