Documents
needed:
- 1.
Instructions for candidate (including
briefing pack)
- 2.
Instructions for the actor
- 3.
Instructions & marking sheet for OSPHE
examiner (including national screening committee recommendations)
1.
Instructions for candidate
You have 8 minutes to prepare for this
OSPHE
During this time, read the following scenario and prepare for an 8 minute
discussion.
You are not required to present material using any visual aids. Use your
own experience of the issue and the documents in the briefing pack to prepare
your response and the reasons for it.
The station is designed to assess all of the OSPHE competencies.
Scenario
You are the Public Health Specialist with
responsibility for cancer services in the PCT. Your PCT does not screen for
prostate cancer and discourages GPs from carrying out routine PSA tests.
It is Monday morning. Over the weekend a non-executive board member of the PCT
read an article in the Sunday Telegraph describing the results of a study of
prostate cancer screening by blood PSA testing. The newspaper reports that the
study provides evidence that all men aged 45-80 should be screened for prostate
cancer and appeared under the headline “Prostate cancer screening saves lives”.
The Board Member requests an urgent meeting with you before the next Board
Meeting as they want the Board to consider introducing prostate cancer screening
based on the approach described in the research paper. You ask your secretary to
track down the report of the trial and any local figures on PSA testing. Just
before you go into your meeting with the non-exec you are passed the attached
abstract (Appendix I) and local data (Appendix II).
The Task
When you enter the examination room you will
be talking face to face for 8 minutes with an actor playing the role of the
non-executive board member.
The briefing pack contains:
Screening
Decreases Prostate Cancer Death:
First analysis
of the 1988 Quebec Prospective Randomised Controlled Trial
Modified
from Labrie et al. The Prostate 1999; 38: 83-91
BACKGROUND: 46,193 men aged 45 to 80 years and
registered on Quebec’s electoral role were randomised between screening and no
screening in a study assessing the impact of prostate cancer screening.
METHODS: At first visit, screening consisted
of measurement of serum prostate specific antigen (PSA) using 3.0 ng/ml as the
upper limit of normal. Biopsy was then done if PSA was raised.
RESULTS: Randomisation was on a 2:1 basis
(screen : no screen) - 30,956 men were invited for screening and 15,237 were
randomised to the unscreened group. 7,155 of the men invited for screening
attended screening clinics and 982 of the control men also underwent screening
at their own request despite not being invited. Thus a total of 8,137 men were
screened and 38,056 remained unscreened. 137 deaths due to prostate cancer
occurred between 1989 and 1996 in the 38,056 unscreened individuals while only
5 deaths were seen among the 8,137 screened men. The prostate cancer death
rates during the 8-year follow-up period were 48.7 and 15.0 per 100,000
man-years in the unscreened and screened groups, respectively, yielding an odd
ratio (OR) of 3.25 in favour of screening (p<0.01).
CONCLUSIONS: This approach demonstrates, for the
first time, that early diagnosis and treatment permits a dramatic decrease in
deaths from prostate cancer.
Appendix II - Local data on prostate cancer
DRAFT
Preliminary findings from study
carried out at Puddletown District General Hospital
All 1597 men attending clinics over a
12-month period had blood tests for PSA (screening test) and prostate biopsies
(regardless of their PSA level).
We compared prostate biopsy findings against blood PSA results in men with and
without elevated PSA:
-
Sensitivity of PSA value >3.0ng/ml in detecting biopsy proven
prostate cancer:
64% (14 / 22)
-
Positive Predictive Value of PSA >3.0ng/ml in detecting biopsy
proven prostate cancer: 9.2% (14 / 152)
-
Specificity of PSA>3.0ng/ml: 91% (1437 / 1575)
2.
Instructions for the actor
The actor should be given:
-
Section 1
– Instructions for the candidate
-
Appendix I
– Abstract from the study reported in the newspaper
-
Appendix II
- Local data on prostate cancer
Additional information for the actor
Read through the instructions and appendices given to the candidate. They know
you are a non-exec board member but do NOT know you are non-medical or
that your father has prostate cancer. They know you’ve read an article about the
potential benefits of prostate cancer screening in a Sunday Paper. The newspaper
article suggested the research study found the benefits of screening were clear
cut and the newspaper report did not include comments from any experts who were
more cautious about its findings.
You are a non-executive PCT board member. Your background is in management – you
are the chief executive of a local aircraft manufacturer with no detailed
medical knowledge.
As the candidate enters the room / your office say
“Thank
you for seeing me at such short notice” and then say
“My
interest in prostate cancer screening has been sparked by a newspaper article,
which particularly interested me because my father has recently had late stage
prostate cancer detected and he is just about to undergo radical surgery.”
Give the candidate time to respond to this information (eg. express sympathy or
find out more information about your father). If the candidate asks, say your
father is 70 and has been told his chances of surviving the cancer more than 5
years are 50:50. The cancer was detected when your father started passing blood
in his urine.
Ask the candidate “What does the PCT currently do to screen for prostate
cancer?”
They will answer saying that the PCT does not undertake routine screening for
prostate cancer.
Then ask the candidate
“Have you read the research paper and does this or any other
information you have suggest the PCT should change its position on offering
prostate cancer screening”.
The candidate should then present their interpretation of the abstract and the
local data.
At the end of their presentation say confrontationally
“But
the newspaper article categorically states that screening will lead to a
three-fold reduction in prostate cancer deaths – such a programme may have saved
my father and others like him – surely it is unethical for us not to set a
programme up?”
The candidate should then explain to you their interpretation and misgivings
about the research.
After the explanation say (again confrontationally)
“Even
if the research was flawed surely it makes sense to detect cancer early with
these tests as early detection will lead to better survival chances.”
If the candidate does not volunteer information from the local study say
“I
understand there is some local research into blood testing for prostate cancer –
can you tell me what it showed?”
If the candidate does not mention problems with high false positive test results
ask
“Do
we have any idea about how often false positive test results occur?”
The candidate should
-
identify the level of the board
member’s medical knowledge
-
identify the level of
information and inclusion of any critique given in the newspaper article
-
communicate without using
jargon ensuring explanations make sense to the board member
-
explain the pre-requisites for
establishing a screening programme
-
express their own views of the
research paper
-
make sure that the board member
understands all points and arguments
-
closes the meeting
appropriately
-
identify that the research
summarised in the newspaper article was flawed
-
explain sensitivity with
consideration of local data
-
explain positive predictive
value with reference to local data
-
explain that most men with
raised PSA do not have cancer and that further testing may lead to unnecessary
pain and anxiety
-
deal with the board member’s
anger without losing their temper
-
admit that there is a need for
more information before definitive advice can be given
3.
Instructions
& marking sheet for OSPHE examiner
The examiner should be given:
-
Section 1
– Instructions for the candidate
-
Appendix I
– Abstract from the study reported in the newspaper
-
Appendix II
- Local data on prostate cancer
Additional
information for the examiner
The candidate
should
-
identify the level of the board
member’s medical knowledge
-
identify the level of
information and inclusion of any critique given in the newspaper article
-
communicate without using
jargon ensuring explanations make sense to the board member
-
explain the pre-requisites for
establishing a screening programme
-
express their own views of the
research paper
-
make sure that the board member
understands all points and arguments
-
closes the meeting
appropriately
-
identify that the research
summarised in the newspaper article was flawed
-
explain sensitivity with
consideration of local data
-
explain positive predictive
value with reference to local data
-
explain that most men with
raised PSA do not have cancer and that further testing may lead to unnecessary
pain and anxiety
-
deal with the board member’s
anger without losing their temper
-
admit that there is a need for
more information before definitive advice can be given
Marking
guide
Points to consider in order
to grade C (satisfactory) or above:
|
|
Exce-llent |
Good |
Satis-factory |
Bare Fail |
Clear Fail |
|
1.
Communication Skills (presenting
to a person or audience)
§
Maintains
good eye contact
§
Makes sure
the board member understands every argument
§
Closes the
meeting appropriately eg. offers to find out more information and to get
back to the board member in a fixed time period |
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2.
Communication Skills (explaining
appropriately key public health concepts)
§
Explains
about the pre-requisites for establishing a screening programme (see
attached Screening Committee criteria). A satisfactory answer should
include at least 4 of the points highlighted.
§
Use lay terms
to explain their views of the research paper eg. ‘I need to read the
whole paper, but on the basis of the abstract the analysis is flawed as it
has not been analysed on an intention to treat basis’.
§
Avoids use of
jargon
§
Explains
sensitivity
§
Explains
positive predictive value |
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3.
Communication Skills (listening
and ascertaining key information)
§
Expresses
sympathy with the board member over their father’s condition
§
Identifies
the board member’s level of medical knowledge
§
Establishes
what level of information was given in the newspaper article and whether
the report identifies any critics of its findings |
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4.
Demonstrating
ascertainment of key public health points from the material provided and
using it appropriately
§
Identifies
that the research summarised in the newspaper article was flawed ie. it
was set up as a trial but it was not analysed as a trial (no intention to
treat analysis)
§
Clarifies
that a PPV of 9% means that most men with a raised PSA do not have cancer
and so further testing may lead to unnecessary pain and anxiety
§
Clarifies
that sensitivity of 64% means about 2/3 of cases will be identified and
1/3 of the cases will be missed |
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5.
Appropriately
and sensitively handling uncertainty or conflict and responding
appropriately to challenging questions
§
Deals with
the board member’s anger without losing temper
§
Acknowledges
the board member’s views throughout the interview
§
Expresses
frankness over the need for more information before definitive advice can
be given |
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TOTALS |
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GLOBAL SCORE |
YES |
BORDERLINE |
NO |
Appendix for the
examiner
National Screening Committee -
Criteria for appraising the viability, effectiveness and
appropriateness
of a screening programme
The condition
§
The
condition should be an important health problem.
§
The epidemiology and natural
history of the condition, including development from latent to declared disease,
should be adequately understood and there should be a detectable risk factor,
disease marker, latent period, or early symptomatic stage.
§
All
cost-effective primary prevention interventions should have been implemented
as far as practicable.
The test
§
There should be a simple,
safe, precise, and validated screening test.
§
The
distribution of test values should be known and a suitable cut off level defined
and agreed.
§
The test should be acceptable
to the population.
§
There should be an agreed
policy on the further diagnostic investigation of individuals with a positive
test result and on the choices available to those individuals.
The treatment
§
There should be an effective
treatment or intervention for patients identified through early detection, with
evidence of early treatment leading to better outcomes than late treatment.
§
There should be agreed evidence-based
policies covering which individuals should be offered treatment and the appropriate
treatment to be offered.
§
Clinical
management of the condition and patient outcomes should be optimised by all
health care providers prior to participation in a screening programme.
The screening programme
§
There should be evidence from
high quality randomised controlled trials that the screening programme is effective
in reducing mortality or morbidity.
§
There should be evidence that
the complete screening programme (test, diagnostic procedures, treatment) is
clinically, socially, and ethically acceptable to health professionals and the
public.
§
The benefit from the screening
programme should outweigh the physical and psychological harm caused by the
test, diagnostic procedures, and treatment.
§
The opportunity cost of the
screening programme (including testing, diagnosis, and treatment) should be
economically balanced in relation to expenditure on medical care as a whole.
§
There should be a plan for
managing and monitoring the screening programme and an agreed set of quality
assurance standards.
§
Adequate
staffing and facilities for testing, diagnosis, treatment, and programme management
should be available prior to the commencement of the screening programme.
§
All
other options for managing the condition should have been considered (eg. improving
treatment, providing other services), to ensure that no more cost-effective
intervention could be introduced or current interventions increased within the
resources available.
§
Evidence-based
information, explaining the consequences of testing, investigation and treatment,
should be made available to potential participants to assist them in making
an informed choice.
