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CMAJ
CMAJ - April 6, 1999JAMC - le 6 avril 1999

Guidelines — not always an easy answer

CMAJ 1999;160:983

See response from: F. Tudiver, et al; R. Gallagher, N. Fleshner
Fred Tudiver and colleagues discuss the reasons why family physicians fail to comply with clinical practice guidelines for cancer screening [full text].1 As an example, they present data illustrating the rapid increase in screening for prostate-specific antigen (PSA), despite the fact that the Canadian Task Force on the Periodic Health Examination [now the Canadian Task Force on Preventive Health Care — Ed.] recommends its exclusion as a screening manoeuvre.2 An important reason why family physicians do not follow the task force guidelines in this and other areas is the dissemination of conflicting recommendations by various expert interest groups.

Conflicting recommendations for the same cancer screening manoeuvre are well illustrated in the issue in which the editorial by Tudiver and colleagues appears. In the Clinical Basics article appearing a few pages after the editorial, Richard Gallagher and Neil Fleshner [full text]3 describe individual risk factors for prostate cancer in men, ending their article with the following unreferenced statement: "Although there are no firm guidelines regarding screening, the American Urological Association recommends that digital rectal examination and testing for prostate-specific antigen begin at age 40." Hence my confusion about which recommendation on PSA screening is based on the best available evidence and which I should follow in my own practice.

Although there are many reasons why family physicians perform cancer screening that is not recommended by expert organizations, a discussion of possible noncompliance is incomplete without acknowledging the systemic issues that result in diverse recommendations about the same screening manoeuvre.

James Goertzen, MD, MClSc
Northwestern Ontario Family Medicine
  Residency Programme
Health Sciences North
Thunder Bay, Ont.
JGoertzen-HScN@oln.com

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References
  1. Tudiver F, Herbert C, Goel V, for the Family Physician Study Group, Sociobehavioral Cancer Research Network, National Cancer Institute of Canada. Why don't family physicians follow clinical practice guidelines for cancer screening? CMAJ 1998;159(7):797-8.
  2. Canadian Task Force on the Periodic Health Examination. The Canadian guide to clinical preventive health care. Ottawa: Health Canada; 1994.
  3. Gallagher RP, Fleshner N. Prostate cancer: 3. Individual risk factors. CMAJ 1998;159(7):807-13.