Editor's Choice

What’s the point?

BMJ 2011; 342 doi: http://dx.doi.org/10.1136/bmj.d3620 (Published 08 June 2011) Cite this as: BMJ 2011;342:d3620
  1. Trish Groves, deputy editor, BMJ
  1. tgroves{at}bmj.com

In Anke Steckelberg and colleagues’ randomised controlled trial in Germany, comparing the effect of evidence based information about screening for colorectal cancer with that of standard information, the primary outcome was “informed choice” among nearly 1500 people eligible for screening (doi:10.1136/bmj.d3193). This outcome, adapted from a validated instrument and assessed by questionnaires, was a composite of knowledge + attitude + uptake of screening (actual and planned uptake). Unsurprisingly, more participants in the intervention group made an informed choice (44% v 12.8% in the control group, 99% confidence interval 25.7% to 36.7%; P<0.001). But, counterintuitively, the intervention had no direct effect on uptake of screening (actual and planned), evaluated separately as a planned secondary outcome (72.4% (568) v 72.9% (577); P=0.87).

“What is the point of going to great lengths to provide patients with information if it is not going to make a difference?” asks James Penston, gastroenterologist, in a rapid response to this paper (www.bmj.com/content/342/bmj.d3193/reply#bmj_el_261670). He calls the lack of effect on uptake “extraordinary”, not least because the trialists provided good, evidence based information that reported absolute risk reductions. Compare that with the NHS bowel screening programme, whose current leaflet for the public states only that “regular bowel cancer screening has been shown to reduce the risk of dying from bowel cancer by 16%”, as James Penston points out in a separate letter this week (doi:10.1136/bmj.d3369). To be fair, that relative risk reduction (RRR) comes from a Cochrane review that buries the absolute risks deep in its discussion section “the reduction in colorectal cancer deaths over the following 10 years for each of these age groups [for a 16% RRR] would be 0.8, 3.5 and 11.2 respectively, per 10 000 invited” (doi:10.1002/14651858.CD001216.pub2). That’s surely no excuse, though.

So what is the point? Hilary L Bekker argued, in an editorial accompanying two BMJ papers on decision aids in colorectal screening last year, that perhaps information about screening should focus on informed uptake rather than informed decision making, as long as the effectiveness of screening is well established (BMJ 2010;341:c5407). Anke Steckelberg and colleagues revisit that debate and land firmly on the side of the dismayed responses to Dr Bekker’s editorial, concluding that “such information has to target informed choices. Campaigns using misleading presentations of information are delusive and should be abandoned.”

Des Spence’s opinions have been called many things in the BMJ, but perhaps not “delusive” … yet. His recent “Bad Medicine” column questioned the value of routine digital rectal examination in the absence of data on its sensitivity and specificity (BMJ 2011; 342:d3421). This has prompted such strong responses that the question “Are digital rectal examinations performed in primary care a waste of time?” now forms this week’s bmj.com poll. What do you think? Is there any point?


Cite this as: BMJ 2011;342:d3620


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