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

Veerle Piessens General Practitioner – Ghent - Belgium Assistant Dpt . General Practice and Primary HealthCare , Ghent University. Do good , and fear no one ? GP and Cancer Screening , an ethical perspective. Imagine a health problem …. Imagine a serious health problem.

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

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  1. Veerle Piessens General Practitioner – Ghent- Belgium AssistantDpt. General Practice and PrimaryHealthCare, GhentUniversity Do good, and fearnoone?GP and CancerScreening, an ethicalperspective

  2. Imagine a healthproblem…

  3. Imagine a serioushealthproblem • Everyyear (in the UK) • > 2000 deaths • 25000 peoplewithseriousmorbidity • Preventiveintervention • Avoids 99%

  4. Intervention – 99% effective? Stop peoplefromdrivingcars and motorizedvehicles.

  5. Background • Belgium: • 1 screeningprogramme: breastcancer • High opportunsiticscreeningcervicalcancer and prostate cancer. • Almostnocolorectalcancerscreening • Fee for service • Verylittleregulationon content of the job

  6. Background • Positive attitude towardscancerscreening • In general • In medical school

  7. 4 basicethicalpriciples • Do good • Do notharm • Autonomy • Justice

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

  9. What is good? • What are ‘the benefits’? • Do we have evidence? • How do we communicate the benefits?

  10. Benefits of cancerscreening? • Earlydetection of cancer? • Disease-relatedmortality-reduction. • Lessmorbidity < lessagressivetherapy

  11. … and the patient?

  12. Silverman E, Woloshin S, Schwartz LM, Byram SJ, Welch HG, Fischhoff B. Women's views on breast cancer risk and screening mammography: a qualitative interview study. Med Decis Making. 2001 May-Jun;21(3):231-40. Patients view on ‘benefits’? • MortalityReduction • Stronglyoverestimated (x10) • More cure/lessagressivetherapy • Reassurance of negativetests 1 • Prevention of cancer2 Silverman E e.a. Women'sviews on breast cancer risk and screening mammography: a qualitative interviewstudy. Med Decis Making. 2001 May-Jun;21(3):231-40. 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.

  13. Patientsexpectations of screening… • … are notsimilar. • … are notalwaysrealistic. • … somecanimpossiblybe met

  14. Evidence of benefit? • Screening is an interventionwithhealthypeople. • Strong evidence is needed. • RandomizedClinical Trials (RCT)

  15. Do we have evidence of benefit? • Screeningcervicalcancerstarted without evidence. • Prostate cancerscreeningstarted without evidence. • GoodqualityRCT’sforcolorectalcancerscreeningwith FOBT. • Plenty of RCT’sforbreastcancerscreeningwithmammography, but …

  16. Evidenceforbreastcancerscreening? • Questionsaboutquality of the trials • Best quality noevidence of benefit. • Mediocre quality  evidence of mortalityreduction

  17. Howmuch benefit? • Relative Risk Reduction • Enoughinformation? • 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 • 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. • 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 • Schröder FH e.a. ERSPC Investigators. Screening and prostate-cancermortalityin a randomized European study. N Engl J Med. 2009 Mar26;360(13):1320-8. Epub 2009 Mar 18. PubMed PMID: 19297566.

  18. Relative Risk Reduction

  19. What does itmean in ‘realvalue’ • ‘Naturalfrequencies’ • Prostate CancerScreening • 10000 men • 36 die without screening • 29 die withscreening • 7 of 10000 men profitfromscreening.

  20. DO GOOD • What are “the goods” we are aimingfor? • Do ourpatients have the sameexpectations? • Is therereliableevidence? • What is the magnitude of the benefit?

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

  22. DO NOT HARM • Fearappeal and otheremotionalrecruitmentstrategies. • Falsepositiveresults • Falsenegativeresults • Overdiagnose en overtreatment

  23. Emotionalrecruitmentstrategies: WoloshinS, Schwartz LM. Numbersneeded to decide. J NatlCancerInst. 2009 Sep 2;101(17):1163-5. Epub 2009 Aug 11. PubMed PMID: 19671771.

  24. FROG PERSPECTIVE Put it in at top-10: Cervicalcancer is one of the top-10 cancers in womenbetween 15 and 45 Put it in a worldwideperspective: Wordlwidethere are everyyear 500 000 cases of cervicalcancer. Put it in a time perspective In Europeevery 18 minutes a woman dies of cervicalcancer In Belgiumeachyear 1/10000 woman 600 are diagnosedwithcervicalcancer.

  25. FalsePositiveResults • Fear, anxiety, otherpsychologicalside-effects. • 3 yearsafter the test • Extra medical procedures • Sometimesdangerous • Risk of FP result: • Mammo: ¼ - ½ • Colorectal: 1 person ‘saved’ – 125 pp with FP

  26. (False) NegativeResults • Delay in diagnosis and treament • Loss of confidence in ownclinicaljudgement and in health care system. Getz L, Brodersen J. Informed participation in cancer screening: the facts are changing, and GPs are going to feel it. Scand J Prim Health Care. 2010 Mar;28(1):1-3.

  27. Overdiagnosis WelchHG, Black WC. Overdiagnosis in cancer. J NatlCancerInst. 2010 May 5;102(9):605-13. Epub 2010 Apr 22. Review.

  28. The balance – 1000 women

  29. Respect patientsautonomy Dit 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.

  30. Respect patientsautonomy Beauchamp& Childress, Principles of BiomedicalEthics.

  31. Do we respect ourpatientsautonomy? What is ourrole as GP • Are all conditionsfullfilled? • Are ourpatiensaware of the existence of cancerscreening? • Do patients have correct knowledge? • Aboutcancer? • Aboutbenefits? • Aboutharms? • Patientsscreening – behavior • Overscreening • Underscreening

  32. What is ourrole as GP • Information: • Lowersocio-economic classes/minority-groups • Worried-well • Population – individual • Benefit exceedsharmonpopulation-level. • Individual level: value of benefits, value of harm. • Threatsforautonomy • Targets

  33. Balance • GP’s have the opportunity – nobodyelse has. • But… • Do GP’s have balancedinformation? • Is thisourpriority? • Won’titdistractusfrom the questionsourpatients consult for? • But… Ifwe don’tmake a choice, choiceswillbe made forus. • Lobby for more balancedinformationbyotherchannels

  34. What to do when… • … whenprinciplesseem to beconflicting? • … whenpatients have notenough mental capabalitiesto decide? • … whenpatientsprefernot to decide and leaveit to you?

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

  36. Justice • Is there a problem? • Cancerscreening is often free. • Availableforeverybody. • Important socio-economichealthdisparities, alsoforcancer: • Highercancermortality • Less ‘state of the art’ follow-up • Lessparticipation in cancerscreening  Benefits of cancerscreening are notfairlydistributed

  37. Justice • Access to healthcare? • Notforeverybody • Screening is free, but follow-up isn’t financialbarrier. • Underscreening in lower SE classes • Lessinformed • Long term perspective • No priority in dailystruggleforlife

  38. Justice • Overscreening in higher SE classes • No extra benefit • More harm • Usingpubliclyfunded resources

  39. Justice as ‘guide’ for the GP • Everybody has a GP. • We seethosepeoplewho are notreachedby PH campaigns. • We seethosewho are overscreened • Opportunity: • to informthemaboutscreening. • to stand byourpatients • Unequaltreatment of unequalpeople • more intensive forthosewhoneed more

  40. Access to healthcare • GP: high accessibility • Cherishit, promoteit, expandit • Advocate forourpatients

  41. conclusion

  42. 4 principles • Broaderperspective: • Tunnel  panoramic • Used in a comprehensiveway • Justice – autonomy • Motive to fullfillourrole • Harm – Good • Basis for the content

  43. Thankyouverymuch!

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