Smear tests and seat beltsBMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7295.1188 (Published 12 May 2001) Cite this as: BMJ 2001;322:1188
Will cervical cancer screening survive media misunderstanding?
The Times editorial (4 May) got it right: “A collective panic over cervical cancer screening errors will achieve nothing.” The headline writers did not quite see it that way. If they had, the Times' front page headline would have read: “Cervical tests successful for two thirds of cancers.” Instead, they went for “Cervical tests fail to detect cancer in a third of cases.” By not including the words “shock” or “fears,” the Times' coverage of the audit of the Leicestershire cervical screening programme was slightly less alarmist than that of other broadsheets.
In an unfortunate coincidence, the report into the locum work of the retired pathologist James Elwood—“who misread the cancer tests of more than 250 patients” (Daily Mail, 4 May)—was published on the same day as the Leicestershire audit. The Elwood case seems less one of mistaken pathological diagnosis—when his case came to light, expert opinion was that his error rate was well within normal limits—than of poor regulation of NHS locums. However, it was all taken as evidence, yet again, of the failing NHS.
The stories had broken the previous day. They formed the lengthy lead item of BBC Radio 4's Six o'clock News on 3 May and set the pattern for the next day's newspapers: “shock horror” of varying degrees followed by considered comment and interviews with pathologists. Professor Mike Richards, the “cancer czar,” emphasised that the Leicestershire report was neither a surprise nor exceptional. It was the first such audit in the country, and other areas would likely produce the same findings. Screening was not and could never be infallible, and there was no suggestion that Leicestershire was failing. These and similar comments appeared in every newspaper that covered the story. The Daily Mail had Professor Richards “confessing” that screening was fallible, as if no one had ever suggested it before. The Daily Mail was the only paper to lead with the story. It carried the headline: “A betrayal of women,” and featured the words “blunder,” “scandal,” and “devastating.”
In December 1998 the then health minister Baroness Hayman sensibly but far too belatedly likened the smear test to a seat belt: it would lessen the chances of dying but was no guarantee. Presumably the Express's next scandal will be seat belts. It opined (4 May) that misdiagnosis in Leicestershire “goes way beyond what can be considered an acceptable margin of error.” However, it did not say what would be “acceptable” or how, if worldwide false negative rates were 15-40% (Times, 4 May), the NHS could “find ways to eradicate [the] high level of mistakes.” It accused Professor Richards of “having the nerve to claim that no mistakes were made but that results were interpreted incorrectly.”
And that is the biggest single difficulty faced by the NHS at the moment. In all branches of medicine in which decisions are taken the decision can be wrong; whenever a treatment is given it may fail or may cause more harm than the disease. Mistakes and poor practice make these outcomes more likely but are not a necessary trigger. Has the Express thought through its strident populist cry that “women and their relatives who suffered so badly must be compensated for their trauma”? If there is negligence then compensation is due. The NHS must not start paying compensation for irreducible uncertainty.
Cytology screening is hard, poorly paid work. The Times included a full column article under the heading “Poor pay for a highly skilled worker.” The wonder is that there are any screeners still willing to work. Pathology services are further hampered by unfilled pathology consultant posts, which brings us back to Dr Elwood: if the choice is a locum or no service at all, what are trusts supposed to do?
There are still some doctors who doubt the clinical utility of screening. If by their analyses screening services are proved to cause more harm than good, then the Department of Health must have the courage to dismantle them (or, for those services not yet introduced, to abandon them). But it would be tragic if screening services that truly prevent disease and suffering were forced out of business because the Express's and Daily Mail's illogic and misunderstanding prevailed over the Times' cool sense.
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