TRANSPARENCY ABOUT BENEFITS AND HARMS IS UNCOMMON IN RECOMMENDATIONS ON CANCER SCREENING & PREVENTION
Candidate for the Lee B. Lusted Student Prize Competition
Structured review to examine how groups recommending cancer prevention services present the benefits and harms of the services they recommend.
We reviewed all recommendation statements related to cancer prevention from the United States Preventative Services Task Force (USPSTF), excluding ‘I’ statements and pediatric or counseling guidelines. Next, we searched within the National Guidelines Clearinghouse (NGC) for all discrete guidelines developed by US organizations on the same topics. We also searched a widely-used point-of-care clinical resource that makes recommendations [UpToDate© (UTD)]. Finally, we identified recommendations for the use of the preventive service in a particular population (positive recommendations) for analysis. Two coders independently abstracted basic guideline demographic data and information about how benefits and harms were presented. We gave a transparency rating for each positive recommendation based on benefit-harm presentation (Green, Yellow, or Red transparency rating as below).
49 guidelines were included (11 from USPSTF; 27 from NGC; and 11 topics from UTD). 55 positive recommendations were identified within these guidelines. Among the positive recommendation statements, 24% (n=13) received a green rating -- presenting absolute risks for both benefits and harms so that the trade-offs could be directly compared. 18% (n=10) received a yellow rating because they did not quantify the potential benefit – thus, the chance benefit and harm could not be directly compared. 58% (n=32) received a red rating due to an inadequate or imbalanced presentation of benefits and harms: 14 because they made a recommendation for a service without even mentioning what the potential benefit might be; 5 because they mentioned the benefit but did not mention the possibility of any harms; 7 because they quantified the benefit and mentioned but did not quantify the harms; and 6 because they quantified the benefits in terms of a relative risk reduction (larger number) while quantifying the harms in terms of absolute risk increase (smaller number), a practice known as mismatched framing.
Transparency is uncommon in guidelines recommending cancer screening and prevention services. Groups recommending cancer screening and prevention interventions for asymptomatic individuals should be obligated to clearly present absolute estimates for the chance of benefit and harm. Transparent risk information would enable clinicians and policy-makers to better understand the trade-offs and support shared decision making.