Informed choice and navigating the gray areas

Clearly physicians want to help patients and take their oath to “do no harm” very seriously. But what happens when the proper course of action is not so cut and dried?

Questions about these gray areas abound throughout medicine, and one that’s a source of constant debate is mammography screening. Any two well-meaning and sincere physicians could differ significantly in their opinion of the optimal time to start a screening program and the proper interval of scans.

While doctors may be the experts, patients ultimately live with the consequences, and one of this week’s top stories featured a study that looked at what happens when women were given additional information about the risk of overdiagnosis as it relates to mammography screening. As you might expect, it caused some to reconsider the decision to screen.

Published online in The Lancet, the study from Jolyn Hersch, MApplSc, of the University of Sydney, and colleagues, included more than 800 women, half of whom were randomized to an intervention group that received an informational booklet containing data on overdection and overdiagnosis in addition to info on breast cancer mortality and false positives. The other half formed a control group that also received a booklet, but theirs did not have the data on overdiagnosis.

While the decision aids did not raise the reported anxiety levels among the participants, fewer women in the intervention group maintained a positive attitude toward screening, and only 74 percent of this group indicated intention to screen compared with 87 percent of the control group.

An accompanying editorial from Minna Johansson, postgraduate student at the University of Gothenburg in Sweden, and John Brodersen, PhD, of the University of Copenhagen, lauded the study for its refreshing change from the typical “paternalistic discourse” that pervades screening research. While physicians often push hard to recruit patients to screening programs, an honest discussion of possible harms must be included as well.

“This shift of perspective, from paternalism to respect for women's autonomy, is one important step towards an approach consistent with contemporary ethical values,” wrote Johansson and Brodersen.

Total transparency isn’t a panacea that always leads to an informed choice, however. Even after being given the informational booklet, Hersch and colleagues found only 24 percent of the participants in the intervention group could adequately answer a set of specific numerical knowledge questions related to the benefits and risks of mammography screening. Even when the bar was set lower to having a more general understanding of the concepts, only half of participants could exhibit broader conceptual knowledge. In both cases, however, the intervention group performed better than the control group.

“Although the absolute rate of informed choice seems low, we believe the understanding participants showed after reading the short booklet indicates success in communicating information about overdetection and other screening outcomes,” wrote Hersch and colleagues. “Widespread public enthusiasm for cancer screening can cause resistance to information about harms, which have not been well communicated in the past.”

It will take more research to understand how best to effectively communicate with patients, to provide them with medical expertise while respecting their autonomy. But work like that of Hersch et al is certainly a step in the right direction.

-Evan Godt
Editor – Health Imaging