Commentary: Overstating overtreatment?BMJ 1994; 308 doi: http://dx.doi.org/10.1136/bmj.308.6941.1413 (Published 28 May 1994) Cite this as: BMJ 1994;308:1413
Women in prison are at high risk of diseases of the reproductive tract. In an independent review of one high security prison for women serving long sentences Lester and I found a high hysterectomy rate (on average nearly three a year over six years in a stable population of about 35 women), which seemed to reflect genuine physical disease.1 Cervical carcinoma was cited as a reason in only one case, but as Downey et al point out, women in prison are at particular high risk of this potentially fatal disease. The immediate reaction to their paper must be that it represents an important advance for the health of these women. The only ripple of concern is created by their description of low voltage diathermy loop excision of suspected cervical tissue as overtreatment.
The concept of overtreatment is deceptively simple. It implies giving more treatment than would be required to produce a desired effect. The authors seem to take a strictly physical view on both counts. The treatment consists of excision of suspect cervical tissue under local anaesthesia, a procedure which generally takes about four minutes and only rarely more than 10 minutes. Morbidity after treatment is minimal,2 but cervical carcinoma has serious morbidity and mortality, and this intervention is important in preventing its emergence. Arguably, then, the main desired effects are treatment of existing disease and prevention of more serious disease.
The authors perhaps should have emphasised that, just as the procedure is not 100% specific, it is not 100% sensitive - some true positive results will be missed. It does, however, offer a much better prospect of prevention than more conservative repeat smear examinations, not least because it is well documented that a substantial minority of women attending any clinic will not keep attending for the duration of repeat tests or other interventions necessary. The drop out rate for the high risk group of women in prison in this paper was nearly 40% at first follow up, and over three quarters failed to follow advice.
Best treatment for women
The problem of attending for follow up may, then, affect any woman. Though women are unlikely to be concerned whether a slightly larger or smaller number of cells is removed from their cervix, since healthy tissue will almost invariably regenerate within weeks, they are likely to be concerned about how much time and misery it is going to take to restore themselves to health and safety. Most women likely to need such interventions, including former prisoners, are likely to be busy with children, paid employment, or domestic work and often all three. A desired treatment is thus one that does not require repeated, long, wearisome journeys and probably even longer waits in outpatient halls. These women might argue that, in the circumstances, overtreatment is that which requires them to commit, say, four or five afternoons rather than two.
A related issue is the fact that most women dislike vaginal examinations, but some of the most potentially vulnerable women - for example, those who have been sexually abused in childhood or adulthood - experience not just anxiety, but panic under gynaecological examination. They do their best to avoid examination, putting their longer term health at risk. Wilkins and Coid noted that of a sample of 74 women from the same prison, 15% reported being incest victims, 24% other sexual abuse in childhood, 34% sexual assault in adulthood, and nearly one third current evasion of sexual activity.3 These are likely to be underestimates but do give some indication of the risk of phobic avoidance of repeated gynaecological procedures.
The balance of considerations might be different if the proposed intervention were to carry a risk of serious side effects, or if it was destructive and irreversible. But for the situation presented here, it seems to me that there is hardly a dilemma at all, provided that the women have given informed consent. A recent survey of psychiatric disorder among women serving a prison sentence showed that, although rates of psychiatric illness were high, few women had illnesses likely to impair their competence for making decisions about medical treatment.4 They will, however, need information about the physical nature of the procedure, its physical consequences, and the population adjusted physical risks of not attending to the warning signs found in the cervix; they also should have information about the time commitments that the different approaches will entail and the risk that, whatever their intentions at the time of discussion, they may not return for follow up. If despite this the woman chooses a conservative approach her doctor must accept that. Only if the woman were mentally incapable of making such a decision would there be any case for medical paternalism (or maternalism), although it would require careful legal consideration. There is no ready procedure for cover against a possible suit for battery in treating a patient with incapacitating mental disorder for a physical disease if that patient has not given real or valid consent. The Law Commission has provided useful guidance through the maze.5
In summary, while commending the caution of Downey et al and acknowledging that there are issues of principle that would have to be addressed if the procedure recommended were more destructive or less reversible, I believe that the real issue for service purchasers and providers is whether it is ethically defensible not to have this treatment available in every NHS gynaecological clinic and particularly in all closed institutions that house women. For the individual doctors and patients the issue is almost exclusively of real consent.