Director's Message: Dilemmas in Cancer Decision-Making

My approach to best care has always been to think of a clinical trial first and use best available evidence next. That approach was unnerved by this week's excellent Perspective in the NEJM by Robert Aronowitz and Jeremy Greene.

Aronowitz and Greene's perceptive and moving account of an all too common cancer decision-making dilemma regarding the management of Gleason 7 prostate cancer in a 66-year-old is riveting. Based on best-available evidence at the time - 2006 - a recommendation of surgery led to an apparent cure, with incontinence and impotence and a decline in quality of life. Yet, later evidence might have led to a "watch and wait" approach or no diagnosis at all.

I bring this to your attention because the authors reflect on the Heisenberg uncertainty principle with the statement that the study of prostate cancer management and detection has resulted in changes in practice and in decision-making, noting that, "The resulting instability of medical knowledge will not be solved by medical progress."

Most of us will shudder at that conclusion, but there is wisdom in it. As they describe, the study of medicine necessarily leads to, "contingent knowledge and looping effects." We change what we study and our affirmation of eureka moments will be followed by ever-changing interpretations and modulation, if not outright recognition of failure of our premature proof. QED does not appear in the medical lexicon for a good reason. This Perspective is really worthwhile for all to read, as it will inform your next discovery, your next interpretation, your next question of a cohort study, interpretation of a clinical trial and your support for a Prevention Task Force recommendation.

Use your knowledge wisely.