Reinvigorating Cochrane

In a recent package of articles The BMJ confirms current guidance on prostate cancer screening (doi:10.1136/bmj.k3702; doi:10.1136/bmj.k3519; doi:10.1136/bmj.k3581). Our Rapid Recommendations panel pooled data from five randomised trials and concluded that PSA testing doesn’t reduce deaths but increases detection of lower risk cancers. Increasing detection without reducing mortality is a hallmark of overdiagnosis. Many men with a cancer diagnosis would never have experienced symptoms or died from prostate cancer but will risk unnecessary harm from prostate biopsy and treatment.

These findings put PSA testing firmly in the camp of shared decision making, as already recommended by NICE and the US Preventive Services Task Force. Doctors should not routinely raise screening with their male patients of any age, says the panel. If a patient asks, or if there are risk factors such as family history or African descent, the dangers of a false positive diagnosis should be explained. The panel believes that most informed men considering screening would decline it.

High quality systematic review is key to this recommendation and to all good evidence based decisions. No organisation has contributed more to this approach than Cochrane, previously the Cochrane Collaboration, now in its 25th year. So it is sad to hear of the public row erupting among its members (doi:10.1136/bmj.k3945). The situation is still evolving, and details are still emerging, but the governing board’s vote to expel one of its founders and most vocal internal critics, Peter Gøtzsche, brings to a head years of growing tension between the collaboration’s radical academic roots and its more recent corporate identity. The board’s statement cites bad behaviour, but beyond the personalities lies a deep seated difference of opinion about how close to industry is too close.

On BMJ Opinion two of evidence based medicine’s most influential voices call for calm. “I am not convinced that Cochrane is experiencing a crisis of either morality or democracy,” writes Trish Greenhalgh (https://blogs.bmj.com/bmj/2018/09/17/trish-greenhalgh-the-cochrane-collaboration-what-crisis). “We should cut it some slack while it gets its house in order.” Meanwhile Ray Moynihan agrees that this is “not about who is right . . . but the rightness of the giant global collaborative project that is Cochrane” (https://blogs.bmj.com/bmj/2018/09/17/ray-moynihan-lets-stop-the-burning-and-the-bleeding-at-cochrane-theres-too-much-at-stake). But he calls for a ban on financial conflicts of interest among Cochrane reviewers. The BMJ supports this call. It would mean fewer but better systematic reviews.

Cochrane has always been a broad church. As with all churches as they consolidate and encounter internal dissent, a schism was perhaps inevitable. We must hope that Cochrane remembers its roots, and that it comes through this episode reinvigorated, independent, and committed to holding industry and academia to account.