Maximising benefit and minimising harm of screening
BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39470.643218.94 (Published 28 February 2008) Cite this as: BMJ 2008;336:480
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Giuseppe Lippi, Mario Plebani, Giancesare Guidi
We read with interest the recent article of Gray et al. on maximising benefit and minimising harm of screening. It was stated that all screening programmes do harm; some do good as well, and, of these, some do more good than harm at reasonable cost (1). Although we agree in principle with these conclusions, it is also to mention that there are some exceptions to this rule, since not all screening programs do an effective harm. The U.S. Preventive Services Task Force (USPSTF) strongly recommends that clinicians screen men and women 50 years of age or older for colorectal cancer, since studies clearly indicate that screening is likely to be cost -effective regardless of the strategy chosen, which includes periodic fecal occult blood testing (FOBT). Proven methods of FOBT screening use guaiac-based test cards prepared at home by patients from three consecutive stool samples and forwarded to the clinician, a simple and non invasive strategy that is associated with reductions in risk of death from 15 to 33 percent (2). Besides FOBT, there are additional screening programmes based on laboratory testing (e.g. the National Cholesterol Education Program for reducing illness and death from coronary heart disease or fasting plasma glucose for diabetes screening), that balance the little harm from a venipuncture with an unquestionable benefit in terms of reduced morbidity and mortality for these pathologies. Screening is a mean of detecting disease early in asymptomatic people; concluding that all screening programmes do harm is inappropriate and may be negatively perceived by both patients and clinicians.
References.
1. Gray JAM, Patnick J, Blanks RG. Maximising benefit and minimising harm of screening. BMJ 2008;336:480-483.
2. [No authors listed]. Colon cancer screening (USPSTF recommendation). U.S. Preventive Services Task Force. J Am Geriatr Soc 2000;48:333-335.
Competing interests: None declared
Competing interests: No competing interests
screening for breast cancer: ?political expediency masquerading as public healthcare
I was disturbed by this paper on a number of levels. It comes under the analysis section in the BMJ but wasn't an analysis in any real sense but seems to be more of a PR exercise lauding the achievements of managing a national screening programme in terms of some quantifiable systems based outcomes. It skated over the still existing controversy surrounding the efficacy of such screening, and in so doing subtly assumes that such screening must be good for the nation's health (1). It assumes that mortality (length of life) is the most important outcome. It makes value judgements on the relative balance of harm vs good - making the assumption that the authors know the nature of the harms caused, the amount of this harm and how individuals feel about such harms.
Surely such mass screening affects the psyche of the nation, we become pathologised, encouraged to believe that we must extend life at all costs, fearful of our ticking cancer time bombs, morally bullied into submitting to the fear, pain and inconvenience of the screening process, and made to feel guilty if we refuse. People remain poorly informed of the risks and benefits, the chances of unnecessary surgery, the diagnosed cancers that would never kill (2).
Given that the evidence base is still uncertain why did the government impose a national screening programme? Was the medical profession morally justified in implementing such a mass programme in the absence of greater certainty? Why has the BMJ given this programme such publicity?
In the BMJ in an analysis section I would have hoped for an analysis of the evidence behind such screening programmes. Ironically some of the increase in cancer diagnosis was due to the increased incidence of cancer due to HRT, another international tragedy where a mass preventitive programme was introduced by enthusiastic government and researchers despite a lack of sufficient evidence of net benefit.
(1) The mammography dilemma: a crisis for evidence based medicine Goodman SN, editorial Ann Intern Med 2002;137:363-365
(2) Mammography screening: Are women really giving informed consent Baines C.J Ntl Ca Inst 2003 vol 95; No 201; 508 1510
Competing interests: None declared
Competing interests: No competing interests