“Our screening sacred cows”

On The Guardian’s website in the UK, Dr. Margaret McCartney makes a clear, compelling case for balance in public information about screening in a piece entitled, “Patients deserve the truth: health screening can do more harm than good.” And she charges that the British National Health Service “fails to inform patients that health screening often leads to unnecessary and risky treatments.”

“It is this failure of communication that has led several prominent UK doctors to say publicly that they have chosen not to have breast cancer screening, including Fiona Godlee, the editor of the BMJ, Iona Heath, a London GP and former president of the Royal College of GPs, and Susan Bewley, professor of complex obstetrics at King’s College London. As Heath writes in the BMJ, “My worry is that I have made my decision on the basis of information that is not readily available to my patients.”

patients may not know if their screening test has caused them harm. This leads to the “popularity paradox” where a bad screening test creates many false positives, and much unnecessary treatment, but people end up feeling that they “owe their life” to screening when, in reality, they have been subjected to unnecessary treatments – and the resultant risks.

It is precisely because screening is a mixed bag of benefit and harm that no one should impose their own values onto another person. Yet at present, NHS screening programmes are judged by how many people attend, and not by how many people make an informed choice to attend – or not. Similarly, GPs are paid according to how many screenings are done, not by how well informed their patients are.

In addition, patients are often misled into thinking that invitations to NHS screening come from their trusted GP rather than where they actually come from – a central NHS Screening office. Apparently this increases uptake.

We need a debate about the cost-effectiveness of our screening sacred cows, but we also need a debate about how to give autonomous adults fair information about screening that respects their right to decline. Until patients are given unbiased information – including that screening can maim as well as help – we will continue to fall short of the ideal of patient consent, “no decision about me – without me.”

McCartney is a leading voice for rational, balanced discussion of screening tests and the tradeoffs involved therein.  I’ve written about her work in the past:

Before the week is over, I’ll have two more articles on imbalanced screening test promotions.


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Comments (1)

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Elizabeth (Aust)

January 30, 2014 at 11:15 pm

Dr McCartney and a few others are doing a great thing, challenging these programs and the unfair way they treat women. (that’s putting it politely) In many cases there is no consent at all, we’re bullied into screening or misled, told it’s “necessary” if we want the Pill or even any non-emergency medical care.
This is not screening, which legally and ethically requires informed consent, it’s medical abuse.
Try being a woman and declining pap tests, you’re likely to be scolded, insulted or dismissed as a patient.
You have to know your stuff if you don’t want screening, a simple “no” is rarely accepted. Women are just expected to act like ignorant sheep and screen, no questions asked.

Here in Australia not much is said about our programs, they’re closely protected (not women), we have an outdated population cervical screening program that seriously over-screens women resulting in high over-treatment/excess biopsy rates, but no one seems to care. The lifetime risk of referral for colposcopy/biopsy is a whopping 77% for a cancer with a 0.65% lifetime risk.
Women here are still told they must or should have 26 (or even more) pap tests, very bad medical advice.
So many women have been left worried sick after false positives and harmed by over-treatment, most of this damage was avoidable with ethical and evidence based screening.

I doubt we’ll see that anytime soon here, the new Dutch program is, in my opinion, one of the best in the world for those who wish to test, women there will be offered 5 HPV primary tests (or they can self-test for HPV with a Dutch-invented device) at ages 30,35,40,50 and 60 and ONLY the roughly 5% who are HPV+ will be offered a 5 yearly pap test. (until they clear the virus)
Most women cannot benefit from pap testing, but they can be harmed.
The new Dutch program will save more lives and take most women out of pap testing and harms way.

Our program maximizes risk for no additional benefit to women. This is, IMO, the result when you allow vested interests to influence these programs, millions is made from over-screening and over-treatment, I doubt they’d be happy to adopt the new Dutch program and see their profits plummet.
I consider our program harmful and operating in the interests of others, not women.

It shakes your faith in the medical profession when you know the evidence and listen to the misinformation being fed to trusting women. Where are our medical leaders, ethical doctors? The medical associations here have been silent except to urge women into serious over-screening.
I think our program and the attitudes we see here show a deep disrespect for women, our bodily privacy, legal rights, health and quality of life.
After menopause this test can be very painful and it’s hard to get a decent sample, yet they persist with pap testing when almost all of these women would be HPV-and cannot benefit from pap testing, these women could even test themselves for HPV with the self-test device with no speculum required, but no, they prefer to put women through frequent distressing, painful and futile pap testing that often leads to false positives and more unnecessary procedures.
Two senior male doctors at the AMA have recently publicly linked the Pill with pap testing, when these things are completely unrelated, no one corrected this misinformation, one even seemed to be assuming all doctors practice medical coercion. Yet they have no problem when it comes to men, no one is suggesting men “need” a prostate exam or colonoscopy before they can have Viagra. It seems unhealthy/sexist attitudes exist at the very top of the AMA, no wonder women are treated so badly. These men, of course, do not want to see the Pill off script or give pharmacists more power, anything that reduces their ability to control women is out of the question.

Breast Screening, more of the same, zero respect for women and informed consent, no real information is provided to women, just celebrity endorsement, a scary “story” or a one-sided sales pitch.
It should be a scandal, how insulting to treat women like idiots, children or mere numbers/bodies on the way to screening targets and payments.
Naturally, I don’t participate in either program, informed decisions, and I doctor-shopped and found a decent and respectful doctor. So many women avoid medical care because of the insane pressure to screen, ignoring more serious risks to our health and taking up valuable consult time. Every woman is entitled to respectful and ethical medical care.
Men are treated differently here, real information came out quickly for prostate screening (no program and not recommended) and doctors were reminded to obtain informed consent if men choose to test.
Women are still waiting for the same respectful treatment. I live in hope…