Controversy in managing patients with prostate cancer

BMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7149.1919 (Published 27 June 1998) Cite this as: BMJ 1998;316:1919

Banish dogma, get more data

  1. Albert G Mulley Jr, Associate professor of medicine,
  2. Michael J Barry, Associate professor of medicine
  1. General Medicine Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114-2696, USA

    Life is uncertain, and never more so than when a serious illness like prostate cancer strikes and a decision must be made about how to proceed. Ideally, the clinician would find (or remember) the relevant research, interpret the findings as they apply to the patient at hand, estimate prognosis, and discuss treatment options objectively and with compassion and support. Even then, life remains uncertain; for any particular patient, no matter how good the evidence and precise the probability estimates, there can be no guarantee.

    This irreducible uncertainty is confronted routinely by doctors and patients and is rarely a source of clinical controversy. Trouble begins when experts reach different conclusions from the same piece of evidence. The poorer the evidence, the more discretionary the interpretation, and the more controversial the conclusion. When available evidence is totally inadequate to inform decisions that must be made, then clinical controversy may border on chaos. Savage and others have shown that in Britain and elsewhere controversy and chaos reign in the management of prostate cancer.1-3

    For early prostate cancer, there have been no controlled trials good enough to show whether survival is increased by active intervention with radical prostatectomy, radiation, or hormonal therapy. For men …

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