Posted by Gary Schwitzer in Screening
(If you were looking for the “Choosing Wisely” campaign article, please click here. In the April 9 email digest that many of you receive, I inadvertently entered the wrong link – which has brought you to the article below instead. Although it’s a good one as well!)
Dr. Margaret McCartney writes in the BMJ with a UK physician’s perspective on “What companies don’t tell you about screening,” questioning whether customers of private screening companies are given information to really understand what they are undertaking. Excerpts:
The full page advertisements in the weekend press are hard to ignore. “Your quick and easy way to help prevent a stroke,” goes the headline, with “Did you know that strokes are the third most common cause of death in the UK?” underneath. Two customers support the company offering the tests, Life Line Screening: “No matter how healthy you might think you are, it could save your life,” and “I had very significant narrowing of both coronary arteries . . . I can’t thank you enough for virtually saving my life.”
Life Line Screening doesn’t just advertise in newspapers; it also sends personal looking letters to people; one that I received started, “Did you know that cardiovascular disease is the #1 killer of men and women in the UK—and a leading cause of permanent disability?” Followed by, “Did you know that the majority of strokes can be prevented?”
Life Line’s business model is to send letters to people in an area before setting up ultrasound scanners and electrocardiography machines in church halls or leisure centres. For around £100-£200 (€120-€240; $160-$320) it will perform Doppler ultrasound examinations of the carotid arteries and abdomen, testing for peripheral artery disease, and electrocardiography. It also has extra packages offering ultrasound assessment of risk of osteoporosis and a “10 year heart disease risk assessment [that] includes a cholesterol and preventable diabetes glucose test.”
“Why doesn’t your GP order these screenings?” asks the company’s letter. “The answer is that typically such preventative screenings are not available on the NHS (National Health Service) for people without symptoms or family history.”
Life Line Screening is one of many companies offering testing to asymptomatic people; this is a competitive field. Lifescan, which operates from 19 UK venues, ran a television
advertisement stating, “There are lots of ways to keep your health in check. Like eating well, taking regular exercise, getting plenty of sleep, and visiting Lifescan. Our highly advanced CT [computed tomography] health checks could help detect signs of serious illness before symptoms appear, including heart disease, strokes, lung or colon cancer, and aneurysms . . . So if you’re 40 or over, keep your health in check with Lifescan.” Other companies offer health checks such as a “head to toe clinical exam,” spirometry, faecal occult blood testing, CT calcium score of the heart, mammography, lung CT, and magnetic resonance imaging of the brain.
It is completely legal for the companies to offer these screening services. But their promotion of these services contrasts with the stance of the NHS, which introduces screening programmes only after a robust review of the evidence against internationally
recognised criteria by the UK National Screening Committee (UK NSC). NHS screening programmes are subject to rigorous controls and quality assurance to ensure they maximise the ratio of benefit to harm, and there is a clear pledge in the NHS constitution to “provide screening as recommended by the UK NSC.”
The committee’s director of programmes, Dr Anne Mackie, says: “Screening tests should be offered only when there is evidence that their use in asymptomatic populations will produce more benefit than harm.” The UK NSC has a database listing all of its policies and stating whether screening for a particular condition is recommended. When no good quality research evidence is available, or research has found that screening for a particular condition causes more harm than good, the UK NSC will recommend that routine screening should not take place. Mackie says that “The UK NSC upholds the right of people to buy these services, but offering screening without explaining fully the risks relating to false positives, which can lead to raised anxiety and further unnecessary diagnostic tests, and false negatives, which provide false reassurance, is unethical.”
Although Life Line and other providers may give full information to their customers at screening, the letters sent to my home address and the recent full page advertisements do not state the risk of false positive results.
At the same time, another “personal view” published in the BMJ by a UK physician, Keith Hopcroft, states, “Routine testicular self examination: it’s time to stop.” Excerpt:
What do Robbie Williams and the Leicester Tigers rugby team have in common? Answer: testicles. Plenty of them. Enough cojones, in fact, to be leading lights in testicle cancer awareness. And they’re not alone. We are regularly bombarded by celebrity exhortations to be “testicle aware,” typically via some attention (and testicle) grabbing stunt.
The specific message that cancer charities and men’s health tub thumpers ram home is that any self respecting bloke should regularly examine his testicles. Or grope his gonads. Or caress his crown jewels. Or whatever the prevailing vernacular might be—so long as it sounds non-threatening and wacky.
It’s easy for the profession and the public to get carried away with earnest health promotion dressed up as fun and assume that routine testicular self examination is self evidently A Good Thing. The trouble is, it isn’t. It’s an activity based purely on well meaning whimsy, with the potential to do harm.
There is no good evidence that routine testicular self examination is of any benefit. Nor will there ever be: a study of adequate power would require millions of men, simply because testicular cancer is so rare. This fact is distorted by all the well meaning evangelism—few consumers of men’s health media would realise, for example, that the average general practitioner will see only one new case every 20 years.
Surely it’s time for sense and science to put the brakes on the men’s health bandwagon? Routine testicular self examination is an activity that is illogical and potentially harmful, and is based not on evidence but on something that, many years ago, simply seemed like a good idea at the time.
In fact, such evidence as there is suggests that a key issue is not so much men failing to notice swellings but men failing to act on them, with one study recording, in over a quarter of patients, a delay of at least three months before presentation. This might be a useful message to convey to men, if there’s one to convey at all. But at present it’s drowned out by the noise from campaigns that succeed only in turning the nation’s blokes into ball watching neurotics.
To be sure, this is not a UK-only phenomenon.
The US Preventive Services Task Force recommends against screening for testicular cancer in adolescent or adult males. Yet, a simple web search will show you how rampant are testicular cancer screening campaigns in this country.
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