Commentary: controversies in NICE guidance on prostate cancer

BMJ 2008; 336 doi: (Published 13 March 2008) Cite this as: BMJ 2008;336:612
  1. Timothy J Wilt, professor of medicine1
  1. 1Minneapolis VA Center for Chronic Disease Outcomes Research, 1 Veterans Drive (111-0), Minneapolis, MN 55417
  1. Tim.wilt{at}

    The NICE guidelines on prostate cancer provide comprehensive advice on best practice for diagnosis and treatment of prostate cancer. They are based on systematic reviews of the evidence, incorporate multidisciplinary opinions, and try to balance the values of healthcare providers and patients for various outcomes while emphasising a patient centred approach. Their conclusions are generally consistent with other reviews and guidelines evaluating similar evidence.1 2 3 4 5 If followed, these recommendations will likely improve prostate cancer outcomes while reducing unnecessary, ineffective, harmful, and costly care.

    Paucity of randomised controlled trials

    Although NICE’s recommendations are generally appropriate, any guidelines on prostate cancer are going to be hampered by the lack of high quality information available. The paucity of randomised trials limits the quality of data used for informed decision making, particularly regarding detection and treatment of localised disease. Even where randomised trials have shown benefits, the absolute magnitude of benefit is generally small, requires many years to accrue, and must be weighed against accompanying harms and costs. Few studies enrolled men with disease that had been detected as a result of measuring the level of prostate specific antigen (PSA) or were adequately powered to assess survival outcomes. Individual patients and providers may place different values on a particular outcome or have clinical and tumour characteristics that have not been adequately assessed by the trials providing the evidence used for drafting …

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