Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
PARAMOUNT BIAS IN “ALL” CANCER SCREENING.
- Sergio Stagnaro (11 July 2003)
-
Information on expected mortality reduction from attending screening needs to be factually correct
- Roger Graham Blanks (11 July 2003)
-
Breast Screening - THE FACTS
- Julietta Patnick (11 July 2003)
-
Presenting risk information
- Tom P Marshall (12 July 2003)
-
informed consent for screening
- Hilary S Cooling (12 July 2003)
-
The population impact of mammography
- Richard F Heller (17 July 2003)
-
Breast Cancer-The facts
- John Nottingham (18 July 2003)
-
Half truth is no truth
- Mitzi AJ Blennerhassett (20 July 2003)
-
Grammar does matter
- Peter C Arnold (20 July 2003)
-
Unrealistic Expectations
- Graeme Mackenzie (22 July 2003)
-
Do women really have choices?
- Éva Rásky, Willibald-Julius Stronegger (22 July 2003)
-
THANK YOU
- maryanne larsen (25 July 2003)
-
Conflicts in health screening
- Marwan A Habiba (11 September 2003)
|
|
|||
|
Sergio Stagnaro, Specialist in Blood, Gastrointestinal, and Metabolic Diseases. Researcher in Biophysical Semeiotics. Via Erasmo Piaggio 23/8. 16037 Riva Trigoso (Genoa) Italy.
Send response to journal:
|
Sir, I cannot agree with all authors, who state accordingly that mammographic screening nowadays is well established in the United Kingdom and elsewhere. In fact, all around the world authors ignore or overlook the existence of Oncological Terrain (See HONCode site 233736, http://digilander.libero.it/semeioticabiofisica) as well as bed-side recognizing breast cancer “real” risk, in a quantitative way (2,3,4). Consequently, all authors think "wrongly" that “all” women must urdergo to mammography and other screening measures, therefore spending uselessly NHS money, and physician’s energy and time. As a matter of fact, a woman can be involved by Oncological Terrain, even with or without precise location in a well defined breast quadrant (“ab posse ad esse non licet illatio”, Kant, Kritik der reinigen Vernunft) (5). I think that because congenital functional mitochondrial cytopathology is overlooked--a "conditio sine qua non" of the most frequent and dangerous human disorders, including malignancies--all current clinical research is fundamentally biased. In other words, it does not consider the existence or assess the seriousness as well as the location of Congenital Acidosic Enzyme-Metabolic Histangiopathy (in my site), conditio sine qua non also of Oncological Terrain. In fact, both environmental risk factors and every drug, including oestrogens, suggested as a risk factor for breast cancer, "could" influence some human biological functions and/or bring about different disorders, such as cancers, exclusively in relation to both the presence and intensity of CAEMH in a well-defined biological system. For instance, despite the well-known negative influence of oral contraceptive use on breast oncogenesis (1-5) and/or arterial disorders we have to consider the importance of the “genetic predispositions” , as far as the onset of a lot of disorders is concerned, including breast cancer (See above-cited site). In conclusion, we need at first (i.e., starting whatever screening or research) to investigate the presence and intensity of CAEMH in the "tested" population, i.e. in "every", "single" patient, and soon thereafter assessing presence, intensity, and precise location of the "Oncological Terrain", which always develops on the basis of the above -mentioned congenital mitochondrial cytopathology. In fact, without this alteration of psycho-neuro-endocrine-immunological system, oncogenesis is not possible, as allows me to state a 46-year-long clinical experience with Biophysical Semeiotics, Single Patient Based Medicine theory is based on (6). The importance of the above-mentioned congenital constitution should not be overlooked, particularly when we assess a "possible" risk factor for cancer and then for cancer screening. 1)Thornton H., Edwards A., Baum M. Women need better information about routine mammography. BMJ 2003;327:101-103 (12 July) 2) Stagnaro S. Terreno Oncologico e Oncogenesi http://digilander.libero.it/piazzettamedici/professione/professione.htm 3) Stagnaro S. An overlooked, usefull, reliable, and bed-side screening of breast cancer.http://www.biomedcentral.com/1471-2458/3/9/comments#2601 4) Stagnaro S. Il Terreno Oncologico: contributo clinico semeiotico- biofisico alla lotta al tumore: 5) Stagnaro-Neri M., Stagnaro S. Cancro della mammella: prevenzione primaria e diagnosi precoce con la percussione ascoltata. Gazz. Med. It. – Arch. Sc. Med. 152, 447, 1993 6) Stagnaro S. Single Patient Based Medicine versus EBM. http://bmj.com/cgi/eletters/326/7398/1048#32299, (16 May 2003). Competing interests: None declared |
|||
|
|
|||
|
Roger Graham Blanks, Epidemiologist Institute of Cancer Research, Sutton, Surrey, SM2 5NG
Send response to journal:
|
Thornton et al suggest that claims for the reduction in relative risk of death from breast cancer among women who are screened have ranged from 63% to 6%. This is clearly vital information for women considering attending. Unfortunately the lower limit,attributed to our paper in the BMJ in 2000 is no such estimate. The 6% refers to the reduction seen in breast cancer mortality rates for invited women(including screened and non -attenders) in 1998 from a programme which started between 1988 and 1995. For reasons we explained in great detail in the paper (including the fact that many many deaths in the 1990s will have been from women diagnosed with breast cancer before any invitation to screening) this is most likely to estimate the beginnings of an effect - not the full effect. It is therefore inaccurate and extremely unhelpful to quote this figure to women as an estimated relative risk reduction from attending screening - it is not. Competing interests: None declared |
|||
|
|
|||
|
Julietta Patnick, Director NHS Cancer Screening Programmes
Send response to journal:
|
I would like to make the following points in response to the paper – Women need better information about routine mammography – by Hazel Thornton, Adrian Edwards and Michael Baum (BMJ volume 327 12 July 2003). In October 2001 we produced a leaflet – breast screening THE FACTS. Designed to ensure that women are told what screening can and cannot achieve, it includes an explanation about false positive and false negative results, and addresses the need to inform woman about the use made of their personal information for audit, as set out in the General Medical Council guidance on confidentiality. This means that women should be able to make a genuinely informed choice based on an understanding about why they are attending for screening, and what happens to their records after being screened. The leaflet was extensively researched and tested to ensure that it is easy to understand. Produced in conjunction with the Cancer Research Campaign’s Primary Care Education Research Unit, the research included working with focus groups drawn from a diverse range of women. It was clear from the research that women wanted the right information at the right time, when it actually meant something to them. For example, women in the focus groups did not find information provided on Ductal Carcinoma In Situ (DCIS), which appeared in original drafts of the leaflets, helpful. The women suggested that the subject of DCIS should only be dealt with in information provided if a woman was recalled for further investigation. In a similar way, women did not want too much numerical data, particularly about risk. We do accept that some women may want further information which is why we have included our website address in the leaflets: www.cancerscreening.nhs.uk The leaflet is being kept under constant review and the Cancer Research UK Primary Care Education Research Group is currently undertaking a study to assess women’s understanding of breast screening based on the leaflets. The results will be fed into the next edition of the leaflet, as will other information and comments received. We are confident breast screening is saving lives, and so we very strongly encourage women to accept their invitation for a mammogram, but in the end it is not our choice, it’s up to the individual woman. Yours sincerely Julietta Patnick
Competing interests: None declared |
|||
|
|
|||
|
Tom P Marshall, Lecture in Public Health Birmingham University B15 2TT
Send response to journal:
|
There is a great deal of evidence on how risk should be presented to facilitate understanding. [1] Absolute risks should be given more prominence than relative risks. The effects of the decision over the individual's lifetime should be presented rather than the effects in the next few years. The way information is framed also influences the decisions people reach. Reductions in losses (e.g. "screening decreases mortality from 6% to 4%") are more persuasive than increases in gains (e.g. "screeniing increases survival from 94% to 96%"). Unless our aim is to manipulate the influence of framing should be minimised by presenting risks of both gains (survival) and losses (mortality). Individuals tend to find it easier to understand data presented in the form of integers (3 in 10 people) rather than probabilities (30% of people). Any attempt to present risk information to women should make use of decision aids. [2] Current breast cancer information leaflets do not contain information on absolute reduction in mortality or absolute risk of further investigation over the course of a screening career and do not use any decision aids. [3] There are now published decision aids for breast cancer screening that meet at least some of these requirements. [4] Hopefully they will soon be found in future leaflets. REFERENCES 1. Edwards A., Elwyn G., Mulley A. Explaining risks: turning numerical data into meaningful pictures. British Medical Journal 2002;324:827-30. 2. O'Connor AM, Stacey D, Rovner D, Holmes-Rovner M, Tetroe J, Llewellyn-Thomas H, Entwistle V, Rostom A, Fiset V, Barry M, Jones J. Decision aids for people facing health treatment or screening decisions (Cochrane Review). In: The Cochrane Library, Issue 2, 2002. Oxford: Update Software. 3. Breast Screening - the facts. Published by Health Promotion England in association with the NHS Cancer Screening Programmes, with advice and support from the Cancer Research Campaign Primary Care Education Research Group. Crown copyright, London 2001. 4. Marshall T. Adab P. Informed consent for breast screening: what should we tell women? Journal of Medical Screening 2003; 10(1):22-26. Competing interests: None declared |
|||
|
|
|||
|
Hilary S Cooling, SCMO Central Health Clinic, Bristol, BS2 0JD
Send response to journal:
|
I recently declined a birthday present from the NHS – an invitation to attend for my first routine mammogram, the appointment nicely timed for my 51st birthday! As a doctor specialising in reproductive and sexual health I was in the fortunate position to be able to make a realistic assessment of my own risk factors, as advocated by Thornton et al (BMJ 12.7.03). This led me to the conclusion that for me the risks of screening on this occasion outweighed the benefits, so I politely declined the invitation. Thornton et al are correct in their assertion that all women need to be able to make this choice, based on information they can understand. The challenge is how to achieve this, but a commitment to this ideal would be a good place to start. Competing interests: None declared |
|||
|
|
|||
|
Richard F Heller, Professor of Public Health Evidence for Population Health Unit, University of Manchester, M13 9PT.
Send response to journal:
|
The paper by Thornton et al, BMJ 2003;327:101-3 reinforces the need to take a population perspective to the measurement and communication of risk. The Population Impact Number (PIN) is defied as “the number of those in the whole population amongst whom one event will be prevented by the intervention”1;2. I have calculated PIN from England and Wales mortality data for 2001, assuming that mammography leads to an 24% and 18% relative risk reduction of breast cancer mortality among women aged 50-59 and 40-49 years respectively, and that 70% of women attend for screening. A policy of screening among a population of 164,773 women aged 50-59 years will lead to one less death from breast cancer per year, the figure for women aged 40-49 years being 470,312. This extends the number needed to screen quoted by Thornton et al, and allows the health gain to the population from a policy of mammography to be compared with the health gain from alternative interventions. Whether the presentation of information in this format will help individual women to make a choice about accepting an invitation for screening remains to be tested. References 1. Heller RF, Dobson AJ. Disease impact number and population impact number: a population perspective to measures of risk and benefit. British Medical Journal 2000;321:950-2. 2. Attia J, Page JH, Heller RF, Dobson AJ. Impact numbers in health policy decisions. Journal of Epidemiology and Community Health 2002;56:600 -5. Competing interests: None declared |
|||
|
|
|||
|
John Nottingham, Consultant histopathologist Northampton General Hospital, NN1 5BD
Send response to journal:
|
I read the paper by Thornton et al with interest and the reply by Julietta Patnick. Both the National Health Service Breast Screening Programme (NHSBSP) and cervical screening programme have made great efforts to improve the understanding by women of the principles of screening since Dr. Mary Anderson and I wrote a paper critical of the information given, back in 1999. Unfortunately there is clearly someway to go. According to a recent report from the Cancer Research UK Psychosocial Oncology Group at the University of Sussex patients remain confused. The BBC, quoting from the report, states that: "They were also flummoxed by terms used to describe screening procedures for breast and bowel cancer." and "More than half of the study group either didn't know or showed partial understanding of breast cancer screening techniques such as mammography." (http://news.bbc.co.uk/1/hi/health/3071937.stm). It is also disappointing that the leaflet to which Mrs. Patnick refers (Breast Cancer: the facts) omits to mention the potential consequences of being screened, namely invasive biopsy procedures or even mastectomy, with their attendant morbidity. Whilst these eventualities may only affect a minority of those being screened, they are surely worthy on mention in a pamphlet to purporting to telling it how it is, especially since most of these women are healthy before undertaking the screening test. Given the time and effort spent in ensuring that bereaved relatives are given appropriate information prior to their next of kin undergoing a post-mortem exam, surely it is time truly informed consent was given to participants in screening programmes so they exactly what it is they are signing up to. 1. Anderson CM. Nottingham J. Bridging the knowledge gap and communicating uncertainties for informed consent in cervical cytology screening; we need unbiased information and a culture change. Cytopathology. 10(4):221-8, 1999 Aug. Competing interests: None declared |
|||
|
|
|||
|
Mitzi AJ Blennerhassett, Chair, member, Medical Royal College Patient Liaison Groups York YO62 4AQ, London
Send response to journal:
|
Not only do women need to be offered better information (and access to full information) about harms and benefits of routine mammography, the public needs honest information about all screening tests and, indeed, all tests, in order to give informed consent. Few patients would realise that risks of ear syringing vary from perforation (common) to aural polyps (rare), yet complications of this procedure are the commonest cause of litigation against GPs.(1) Men who request testing for prostate cancer and are told explicitly about the advantages and disadvantages are then likely to change their minds (cost effective information giving). Women who refuse an invitation to breast screening and are offered discussion on the issue by their GP (as well as those invited for cervical smear taking) need to know the minus as well as the plus side of acceptance. Good written information aids transparency and protects against accusations of coercion. Any payment linked to numbers of people screened creates a vested interest in compliance. The public no longer wants doctors to "manage uncertainty by fibbing". (2) The government and the public want patients to have more control over their own healthcare. Bland reassurance is no longer acceptable; the public wants truth. Health services need to wake up and catch up. (1) Gillett D, Lewis N, Patel H, Wareing M.GP Clinical.16.06.03. (2) Farrell L.GP Opinion.9.06.03. Competing interests: None declared |
|||
|
|
|||
|
Peter C Arnold, Former GP Sydney, Australia
Send response to journal:
|
Thornton, Edwards and Baum want women to be able to make "true informed choices". Do they mean: "truly informed choices" (choices made after being informed – according to a protocol - about the risks of benefits and harms, such that they are assumed capable of choosing); or "true, informed choices" (truthful - and valid – choices, after having been informed of the risks); or "truthfully informed choices" (choices made after being told the "truth" about the risks)? If the first, the adverb "truly", to modify "informed", would have clarified the authors' meaning. If the second, a comma would have achieved their purpose. If the third, "truthfully" might have been clearer than "true". In an area so fraught with misunderstanding, bedevilled by trying to relate statistical information to one individual’s fate, the phrase "true informed choices" can, like statistics, mean different things to different people. Further, the authors believe that "women need to fully understand both the benefits and the potential harms". Undoubtedly, doctors’ obligation is to explain as best we can. Increasingly, in this "information age", patients will come to understand more, but to generalise that women "need" (as an absolute) "full" (as an absolute) understanding is, with respect, unrealistic. I suggest that the only patient possibly capable of such understanding is a medically trained statistician who is not feeling nauseated. Competing interests: None declared |
|||
|
|
|||
|
Graeme Mackenzie, GP Whitehaven CA28 7RG
Send response to journal:
|
I accept that breast screening saves the occasional life. I accept that screening is with us and here to stay and that it is vital part of the health economy if not the wider economy. This article was good in that it points out the lack of warning of potential harm. However any attempt to screen an entire population (albeit the cohort 50-64,)I would have thought, needs to have a test which is quick, easy, relatively objective and probably done with minimal patient "consent". The vast majority of women have probably neither the time not the inclination to take on board the complexities of mammography screening as discussed in Journals. They need and want to assume "having an X-ray prevents me dying of cancer". Most probably do not want to, or to be more brutal probably are unable to, take on any discussion beyond that level. That goes for most screening we do including opportunistic BP measurement and PSA (to avoid any accusations of sexism). The fact that discussion about breast screening continue to rage suggests that the benefits are marginal and need large studies to show them. While we screen healthy women and subject most to an anxiety provoking test which for most of them will prove to be a waste of time, we increasingly live in a society which stresses everbody out considerably increasing obvious disease. Screening by imposing a burden on society to get to every patient to check them out increases that stress. In addition screened diseases become somebody's fault. As GP I suspect I will be the fall guy in the future for many screening failures. Adding in the need for complex discussions with every patient on the pros and cons is just a ridiculous idea which is doomed to fail and consume vast amounts of NHS time in a task which must already be mind numbingly tedious and where the benefits are marginal. Expecting staff to robotically discuss the complex issues of screening with every patient when even the academic world are unable to agree seems bizarre! But then the whole screening business does provide a lot of jobs so maybe the benefits do outweigh the costs Screen breasts: yes but make it patient choice so that only patient willing to enter these discussions come forward. Oh and of course make it private so that the NHS illness service can get some more resources and screening can rightly assume its place in the wider economy. Competing interests: None declared |
|||
|
|
|||
|
Éva Rásky, Institute of Social Medicine and Epidemiology Universitaetsstrasse 6/I, Austria, A-8010 Graz, Willibald-Julius Stronegger
Send response to journal:
|
Dear editor, we would like to raise issues around informed decision making by women on screening mammography. We absolutely agree with supporting the autonomy of women/patients. We would like to take into consideration that decisions of women are not made in empty space but in a social context. The decisions are framed by class and gender specific acceptance of prevention in society. Women apply these preventive principles to themselves according to believed positive health behaviour and not by the latest scientific evidence. Therefore, we think it is unethical not to consider these aspects of decision making related to screening mammography. We want to point out that there are inconsistencies in information gathering and transmission in screening mammography. Intervention aiming at a healthy population presupposes estimating scientifically, potential benefits and harms of the methods applied. The systematic review of Olsen & Goetzsche (2001) shows that the benefit of screening mammography is not evident, particularly not for all age groups of women. In their review, the authors found no evidence in favour of screening mammography programmes. To the contrary, mammography leads to more biopsies on women. As a consequence, only very few important organisations in the preventive field changed their guidelines (Humphrey et al., 2002). Why is it so? Information on changes in breast density under hormone replacement therapy relevant in this age group is mostly missing in guidelines (Kavanagh et al., 2000). Why is it so? If evidence was the only criterion, women under 40 should not be eligible to join mammography screening programmes. In Austria however, in general, patient information recommends baseline mammography (Rásky et al., in press). How could this happen? Breast cancer is a cancer of ageing. Is it sensible generally to stop screening mammography at 69 years of age when this measure is considered scientifically proven? And if there are doubts, why does the scientific community not aim at initiating randomised trials evaluating the benefit of screening mammography for older women? In general, research information provided to the general public, at least in Austria, does not present all aspects of mammography, in particular, presenting benefits outweigh the presentation of harm. This is true for information given in scientific publications, newspapers, and leaflets (Slaytor et al., 1998). Thornton et al. (2003) referring to the publication of Tabar et al. (2003) and Otto et al. (2003), present a 44% mortality reduction in the screening group without presenting exact numbers for the estimates of the group not screened. The most positive presentation on the benefit of screening mammography so far (obtained from a meta-analysis of randomised trials) is a 30% reduction of mortality (Nyström et al., 1993). Both Tabar et al. (2003) and Otto et al. (2003) can not clarify the causal effect of this screening intervention on breast cancer mortality since they do not meet the methodological standards required to this end. With the exception of randomised trials, residual confounding as well as bias remain a potentially serious problem, even after elaborate adjustments have been made in the data analyses (Egger et al., 1998). The two cited studies may have scientific merit but they are not providing evidence justifying the implementation of screening mammography programmes. Why do media cite these results more often than those of the systematic review of Olsen & Goetzsche (2001)? It took twenty years of practising screening mammography to start discussing the autonomy of women. In the case of prostate cancer, men, in contrast, from the very beginning of campaigns for screening have had options, and a very accessible website offers pros and cons of the test (www.cancerscreeing.nhs.uk/prostate/index.html). We get the impression that screening for men is considered on a broader evidence base and with more freedom of choice for the men concerned. In the case of screening mammography with a population based preventive strategy, we need more than 70% of women participating (Perry et al., 2001). It is not yet understood in which way women decide whether to accept screening mammography and how they apply all available information (Curry et al. 1993; Schwartz et al. 2000; O´Sullivan et al. 2001). And what if too many women decide against mammography and thus jeopardise the programme? We consider it unethical to shift the responsibility of decision making onto women without straightforwardly naming the scientific evidence for benefit and harm of mammography. We fear that the autonomy of women might be supported only at a point at which their physicians withdraw from their responsibility. Is it really responsible to allow and demand women´s informed decision making at a point at which not even scientific medicine can make an evidence based recommendation? Commenting on the picture illustrating the article by Thornton et al. (2003): the picture does not follow the guideline of the General Medical Council (1999) to allow patients sufficient time to reflect information given by health providers. The woman shown is already half dressed and prepared for the screening, a bad position in which to decline. References Curry SJ, Taplin SH, Anderman C, Barlow WE, McBride C. A randomised trial of the impact of risk assessment and feedback on participation in mammographic screening. Prev Med 1993; 22: 350-60. Egger M, Schneider M, Davey Smith G. Spurious precision? Meta-analysis of observational studies. BMJ 1998; 316: 140-44. General Medical Council. Protecting patients, guiding doctors. Seeking patients´ consent: the ethical considerations. London: GMC, 1999. Humphrey LL, Helfand M, Chan BKS, Woolf SH. Breast Cancer Screening: A summary of the evidence for the U.S. Preventive Task Force. Ann Intern Med 2002; 137: 347-60. Kavanagh AM, Mitchell H, Giles GG. Hormone replacement therapy and accuracy of mammographic screening. Lancet 2000; 355: 270-74. Nystrom L, Rutqvist LE, Wall S, Lindgren A, Lindqvist M, Ryden S, Andersson I, Bjurstam N, Fagerberg G, Frisell J, et al. Breast cancer screening with mammography: overview of Swedish randomised trials. Lancet 1993; 341: 973-978. Olsen O, Goetzsche PC. Screening for breast cancer with mammography (Cochrane Review). In: The Cochrane Library, Issue 4, 2001. Oxford: Update Software. Sullivan I, Sutton S, Dixon S, Perry N (2001). False positive results do not have a negative effect on reattandance for subsequent breast screening. J Med Screen 8: 145-48. Perry N, et al. European guidelines for quality assurance in mammography screening. Luxembourg: European Commission, 2001 (http://www.euref.org/FOLDER_GUIDELINES_NW.PDF, last accessed 21th July, 2003). Otto SJ, Fracheboud J, Looman CWN, Broeders MJM, Boer R, Hendriks JHCL, Verbeek AML, de Koning HJ, and the National Evaluation Team for Breast Cancer Screening. Lancet 2003; 361: 1411-17. Rásky É, Groth S. Informationsmaterialien zum Mammographiescreening in Österreich – Unterstützen sie die informierte Entscheidung von Frauen? (Information materials on mammography screening in Austria – do they help women with informed decision?). Soz Praventiv Med (in press). Schwartz LM, Woloshin S, Cox HC, Fischhoff B, Welch HG. US women´s attitudes to false positive mammography results and detection of ductal carcinoma in situ: cross sectional survey. BMJ 2000; 320: 1635-40. Slaytor EK, Ward JE. How risk of breast cancer and benefits of screening are communicated to women: analysis of 58 pamphlets. BMJ 1998; 317: 263- 64. Tabar L, Yen M-F, Vitak B, Chen H-H T, Smith RA, Duffy SW. Mammography service screening and mortality in breast cancer patients: 20-year follow- up before and after introduction of screening. Lancet 2003; 361: 1405-10. Thornton H, Edwards A, Baum M. Women need better information about routine mammography. BMJ 2003; 327: 101-103. Competing interests: None declared |
|||
|
|
|||
|
maryanne larsen, n/a 08873
Send response to journal:
|
Thank you so much for your article. As a woman who has put through an ordeal by the "breast care" industry, I wish someone had gone over the risks and benefits of breast cancer screening. What I learned is that patients are not allowed to ask questions and try to do their own cost benefit analysis. If they do, they get shunned. I was told I was meanspirited in the same breath that I was told I had breast cancer. I was told to have a partial mastectomy to comfort my doctor. I was told that it was "best." Ultimately the conclusion was that I had fibrocystic breasts. After a year and 1/2 of sleepless nights and anxiety, thousands of dollars and lost time from work, the last breast surgeon I consulted with could not even look me in the eyes. The best she could do was to tell me to reduce my caffeine intack. The medical industry lost a whole lot of credibility and trust in my eyes. I will never go for screening again for breast cancer or any disease. Competing interests: None declared |
|||
|
|
|||
|
Marwan A Habiba, Senior Lecturer in Obstetrics and Gynaecology Clinical Sciences Building, University of Leicester, LE2 7LX
Send response to journal:
|
In their article, Thornton et al. explore some of the many uncertainties surrounding breast cancer screening, and allude to the fact that much of the information provided to patients in the context of screening mammography is biased towards increasing uptake, even without women acquiring substantial understanding of the process.1 These are indeed significant problems which interfere with patients’ ability to make truly informed choices. However, despite being important confounders, the argument in favour of informed choice in relation to screening should not rest on any inherent uncertainty or bias. The difficulty with screening is that, despite its prominence in modern medicine, it resides distinctly outside the traditional patient- doctor framework, and as such raises unique ethical concerns. Screening programmes utilize familiar health-care resources to achieve end points determined elsewhere, away from the individual patient. Yet these programmes require the participation of those targeted, who themselves are presumed healthy. Given this, conflicts will remain inevitable in population-wide health programmes unless unanimity can be achieved; but this is precluded by the evaluative nature of health, disease and illness. And whilst agreement is possible on health as being valuable, it is less so on its desirability or priority. Furthermore, screening cannot be justified on grounds of its being either moral or universally rational to pursue, nor on the grounds of its being collectively rational in the pursuit of a generally agreed, and hence aggregated, good. Indeed the legitimacy of the notion of ‘collective’ choice is open to question. Thus, despite protestation that at least some screening programmes might be beneficial, the notion itself necessarily risks conflict.2 Indeed, similar arguments could be made in relation to immunisation and many other public health programmes, and the failure of professionals and policy makers to appreciate this, risks alienating the increasingly critical public. This calls for an inclusive debate aimed at defining the conceptual framework for these programmes. 1- Thornton H, Edwards A, Baum M. Women need better information about routine mammography. BMJ 2003; 327:101-3. 2- Habiba M. Health screening: a libertarian perspective. PhD thesis, University of Wales, 2000. Competing interests: None declared |
|||