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OBSERVATIONS: Iona Heath It is not wrong to say no BMJ 2009; 338: b2529 [Full text]

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Sense at last

Susan M Dovey   (25 June 2009)

Who really decides?

susnne stevens   (26 June 2009)

Clear communication about risk is the key

stephen black   (7 July 2009)

Tell women the truth

Deborah L. Brown   (23 July 2009)

Agreed - and the spin of risk

David G Taylor   (25 July 2009)

Sense at last 25 June 2009
Susan M Dovey, general practice researcher University of Otago, Dunedin School of Medicine, Dunedin 9016, New Zealand Send response to journal: Re: Sense at last	Thank you so much for writing such an articulate and coherent article. For a few years now I have repeatedly declined invitations to breast cancer screening myself, having a vague understanding of the literature and having generated from occasional scanning of breast cancer research the feeling that the risks of breast cancer screening would, for me, far outweigh any potential personal benefits. I lacked the time to develop a good argument to explain my reservations to my GP and I felt bad about disappointing her by declining her invitations. In New Zealand as in the UK (when I lived there) there is a strong expectation that women will do as they're told and submit to screening programmes. A very paternalistic attitude, if you think about it - in New Zealand we call it the "Nanny State" approach. Now here, in this article, you have captured all the reasons that I would like to give to my GP for not wanting to risk being diagnosed with breast cancer while I remain in robust good health. I hope all GPs (and public health doctors) read this. Competing interests: None declared
Who really decides? 26 June 2009
susnne stevens, retired wales Send response to journal: Re: Who really decides?	Iona Heath is incorrect in saying that all women in UK are sent a leaflet outlining the 'facts' about breast screening. Unless things have changed recently the breast screening service itself sent out standard letters 'out of the blue'instructing women that an appointment had been made for them to attend an appointment. Their names had been forwarded from GP lists but without any prior consultation or discussion which would allow women the right to decide whether to have it or not. Nobody tells women that they can have their names dleted from lists. Leaflets are available sometimes, mainly from folders hanging off walls, but it is questionable how many are read unless they are specifically handed out. These are as Iona Heath points out, worded in one direction only and so contravene the right of individuals to make informed choices about accepting medical procedures. As another correpondent also points out sometimes it is the arrogance of unwanted advice or the way people are approached which contributes to a decision. But it is not the case that 'uneducated' women make different choices simply from lack of knowledge or skills. They may be less gullible than someone contantly bombarded with health warnings. Very often they make wise choices based on life experience or passed down knowledge...not least they can be amused and cynical about the sort of unhelful health advice given over the years. There is also a difference in the level of pressure on people to take unasked for health advice. It much less possible to be exposed to it in rural areas. However Iona Heath and other health workers do have another advantage which women also take into account. They can keep themselves on the data base for screening whilst declining to attend, or take themselves off it altogether 'just in case'. But they know if they do develop a concern they have priveledged knowledge and finances to access the best treatment. Most women cannot guarantee this and it may tip their decision into having the procedure despite reservations. Competing interests: None declared
Clear communication about risk is the key 7 July 2009
stephen black, management consultant london sw1w 9sr Send response to journal: Re: Clear communication about risk is the key	Iona Heath raises some important issues in her courageous comments about breast screening. But she understates one important one: the systemic illiteracy of medics, epidemiologists and other health professionals when it comes to communicating statistical results. Gerd Gigerenzer pointed out (see, for example, his book "Reckoning With Risk", Penguin, 2003) just how badly professionals misinterpret risk when given the data as conditional probabilities. He contrasted this with the (much improved) results when the facts are communicated as natural frequencies. Despite this we continue to use the format that doesn't work. I have used the statistics around screening for HIV, prostate cancer and breast cancer when explaining to decision makers why the way you communicate the facts makes a huge difference to people's ability to make sense of them. Surprisingly, public health people in the NHS are often shocked at the implications of the statistics on breast cancer screening once they understand them (they often seem to start with a belief that mass screening programmes are an effective public health intervention). We need to stop assuming that the problem is people's inability to comprehend statistics and recognize that the problem is statisticians' (and other experts') inability to communicate. Let us change the way we communicate risk so people don't keep making the same errors. Competing interests: None declared
Tell women the truth 23 July 2009
Deborah L. Brown, Lawyer 3000 Send response to journal: Re: Tell women the truth	It has been a concern of mine for many years now...the ethics or lack thereof of the screening programs. The focus is recruitment of women at all costs. The attitude seems to be...we don't care how many women we harm, as long as we can show a reduction in the death rate from this cancer. Cervical and breast cancer screening is supposed to be "offered" to healthy women and informed consent is "supposed" to be obtained... The tactics adopted to push women into screening programs are unethical and improper. No women (apart from a privileged handful) is able to give informed consent for either test at the moment. The brochures are simplistic and provide an exaggerated upside with no mention of the limitations and risks of screening. Words like "should" and "must" and "strongly recommend" are a feature of their campaigns. How can this be permitted to go on? Women are quite capable of making their own decisions about screening - give us ALL the information - and drop the scare campaigns, misleading statistics, overstatements and payments to doctors to reach high screening targets. Women who choose not to participate in screening are not irresponsible and reckless with their health, rather they have exercised their right to refuse the screening test and that should be respected and accepted. Women who decline screening are not defaulters or refusers. I've watched with alarm for many years the harm being done by these screening tests and sadly, it continues.... I understand the cervical screening authority in this country is currently combing through electoral records to identify women who aren't having cervical screening. It sounds like a rounding up of the strays... It would never cross their minds that these women may well have made an informed decision not to have screening. I think these screening programs are enormously disrespectful to women and it's about time something was done to bring them in line with legal and ethical requirements. Competing interests: None declared
Agreed - and the spin of risk 25 July 2009
David G Taylor, GP Principal Birmingham B31 Send response to journal: Re: Agreed - and the spin of risk	Thank you so much for articulating this well. I was led to your article when reading this week's Des Spence jottings. Can I comment on the problem of explaining risk by pointing to David Misselbrook's excellent paper in the BJGP? We should all be aware of how to draw pictures of risk, and try to tailor this to our patients. BJGP 2001, 51, 276-279 Patients’ responses to risk information about the benefits of treating hypertension - David Misselbrook and David Armstrong Competing interests: None declared