How the NHS failed me and mine.
What it did, to the most important person
in my life and how it could happen to you unless
we do something about it!

Thursday, 10 May 2012

An 'Ambiguity of Evidence'.

So says Dr. Edward Stefanek with regards to Cancer Screening in an article in Medscape Today. He cites the 'summoning' of women for mammography, contrasting with the 'informed choice' paradigm that exists for men with possible prostrate cancer. He suggests too that this is paternalistic, I would say more likely misogynistic as well, because men are viewed as being participants in some sort of  'club' by simple virtue of their sex, when it comes to honesty in health care. In fact the first rule of misogyny (just like 'fight club') is that we don't talk about misogyny.

Well, I for one don't want to belong to any such club, fraternity or organisation. I do not want to labelled as a feminist either, because I do not wish to 'steal' the term from women. I want to be known as an equal, and one who is just as vulnerable, fallible and more importantly human as is any woman. I am not strident (except in this view) aggressive or demanding of any submission (from women) and feel some men are 'spoiling' it for the rest of us, and the greatest of these are the those who lurk in Medicine, and within that cohort those who continually ram home the message that 'screening saves lives'. Well, patently it does not. It may facilitate an intervention that may do so, but screening per se cannot save any life.

Screening for all cancers is constantly on the rise, despite the fact of the paucity of evidence that exists to support it's continued promotion by the NHS. Medscape also featured Carole Schroeder  who has an interesting blog that provides good information for men about prostrate cancer, but the main thread is that for far too long, women in general (and occasionally men) have been subjected to a constant tirade that they are taking "unacceptable" risks with their health unless they submit to screening. Mammography leads the way despite the fact that recent studies have clearly shown that it is not effective for most and can be catastrophic for some as I detailed in a previous post. There is now a groundswell of opinion rising to ensure that all those who participate are fully informed of the risks, benefits and harms of the process, instead of the current paradigm of inflating the the risks of breast cancer and concealing the harms of mammography. The the BMJ highlighted this last July and I wrote about the innate misogyny displayed in many of the testing regimes, aimed at women, only recently.

A recent development however, is the call for younger women to be 'screened' for cervical cancer, which to be frank is bordering on the dangerous, but when a young Nottingham woman was diagnosed with cervical cancer the pressure was applied both at local and National level for this cohort to be screened. This is despite the fact that only ten deaths from this form of cancer in 20-24 year olds was recorded in the whole of England and Wales in 1988-1989 and it has subsequently 'fallen of a cliff in mortality terms down to 3.7 deaths per 100,000 by the turn of the century (overall mortality). So despite the fact that Natalie Carney did actually have cancer, which is appalling, should we then create a whole new subset of tested women because of one isolated case? Women in this age group often have abnormal cells but it is well known that virtually all of these regress spontaneously without intervention, which is largely why young women are not screened. In fact most screened abnormalities are either benign or regress generally but 'over-diagnosis', just as in mammography, dominates cervical screening. But there is a bigger issue, as always and that is Coercion.

Persuasive tactics predominate all cancer screening testing. The NHS and it's GP's in particular values it out of any proportion to the benefits, but it is a political imperative, maybe to show that they care (sic). 'List and chase' was the tactic employed in the 90's along with 'hit that target', all to encourage GP's to recruit women to the Cytology Screening Programme so they could get their target payments. Yes, they get paid substantial sums for achieving an 80% uptake of testing in the 25 to 64 yr old practise cohort. In fact until payments were commenced uptake was quite low, but once the money was there that all changed. One GP is alleged to have said, "We are afraid of missing our targets, not missing a cancer" (Journal of Medical Ethics 1998;24:151-157). I think that sums up the position quite nicely.

There is little in the way of information provided to women targeted, just exhortations that 'you put your life at risk, by not complying', or ' REMEMBER - regular smears saves lives' and other such coercive statements that are simply not borne out by the evidence. A balanced view is never given and feminine autonomy is usurped by this type of inflammatory rubbish because experts cannot predict the incidence of abnormal smears nor those that will definitely progress to invasive cancers. Quite large numbers of those tested are then subjected interminable waits to find out if there cancer is real and many go on to be treated with surgery or radiation for no useful purpose other than 'being sure'. Those who try to shun the tests are often singled out for bombardment with 'phone calls, text messages and mail shots that are akin to blackmail, foretelling all sorts of dire consequences if they continue to abdicate their responsibility to their partners and families.

Current leaflets explaining the test and likelihood of cervical cancer outrageously inflate the benefits saying that screening is responsible for the drop in the rate of mortality, when it was falling before the testing system got underway and there is no evidence whatsoever that the fall in incidence or mortality was due to screening. Almost 30% of actual cancers occurred in women who had adhered totally to screening guidelines. There were 6231 women diagnosed with cervical cancer between 2007 and 2010, in a population in England of 14.6 million. 44% of those cancers were classed as 'micro-invasive' and were conservatively treated by cone biopsy or loop excision (and of course may not have been true cancers). So that is approximately an incidence of 14.4 per 100,000. Or approximately 8 per 100,000 for those with Stage 1B+ Cancer or worst. At 1 in 3000, you are considerably more likely to to be hit by a meteorite ( I know I didn't believe it, but I did check) so let's get this into some sort of perspective. Of course as you get older the incidence and mortality increases, as will be seen from the graph. That of course is in accord with the aetiology of this cancer which can take many long years to develop. But it still remains quite rare. So does it warrant all the attention, cost and stress to women?
Numbers of deaths and age-specific mortality rates for cervical cancer in the UK
More important however, is the treatment of women as a whole as incapable of making an informed decision about their lives and the ethically unacceptable tactics employed to persuade them to bow to the dubious manipulation of the State. We all are (or should be) autonomous adults and it's completely unethical to attempt to infiltrate any of us with dubious medical opinions, statistics or advice instead of treating us a agents of our own destiny. It is generally women rather than men that are treated in this way and it is generally men who do it. I am ashamed of my gender, especially those called 'Doctor'.

Perhaps the words of Professor Michael Baum, one of my medical hero's may be the best ones to end with. They are here.