Screening propaganda: the television shows that gave harms second billingBMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f7643 (Published 20 December 2013) Cite this as: BMJ 2013;347:f7643
- Margaret McCartney, general practitioner, Glasgow
“Thousands of us who die of cancer could be saved if British cancer diagnosis and screening were up to the standard of comparable countries . . . NHS bowel screening is second rate compared even to what’s available in one of the poorest neighbourhoods in America.”
Too Late To Save Your Life, a recent current affairs programme made for the UK channel ITV’s flagship news series “Exposure” was watched by a million people.1 It argued that the United Kingdom does not do enough screening for prostate, bowel, and lung cancers.
The programme promoted a “cheap and simple” blood test for prostate specific antigen (PSA) to screen for prostate cancer. One now terminally ill patient’s GP was reported to have said that such screening “could cause more problems, psychologically, than it could cure.”
Gordon McVie, oncologist and former director general of Cancer Research UK, said, “We need a screening programme [for prostate cancer].” And the narrator said that the NHS’s reason for not creating one—that testing for PSA is of uncertain benefit—was of “little solace to men who die of the disease because . . . it’s a painful killer.”
Klim McPherson, professor of public health epidemiology at Oxford University, took issue with the programme: “What it was doing was exploiting the strong ‘face validity’ that implies all screening is good because it catches disease earlier, and you can benefit from that. But you have got to have treatment that is more effective as a consequence, and levels of overdiagnosis shouldn’t create problems—and PSA screening doesn’t do this. It’s not recommended by the NHS for these reasons.”
The programme also failed to mention that the US Preventive Services Task Force, an independent panel of health experts, recommends against prostate cancer screening.2
McPherson told the BMJ that the programme did not give enough information on the downsides: “I would never have a PSA test, because I know what I’m doing. If people get misleading or biased information then they don’t know what they are doing, especially if it seems so obviously beneficial. And that’s a problem.”
The result of the programme may be that viewers request the test unaware that it may lead to unnecessary treatment and has risks of side effects such as impotence and incontinence. Professor Mike Baum is the chairman of the independent international steering committee for the ProtecT trial, a randomised controlled trial that measures quality of life, prostate cancer deaths, and all cause mortality from PSA screening, which is due to report in 2015. Every year it reviews the current evidence on screening to ensure that it is ethical to continue randomisation. Baum said that, with current knowledge, “We simply cannot say that PSA screening is on balance a good thing. To anticipate the outcome [of ProtecT] would be foolish in the extreme, and to promote PSA screening without adequate evidence is completely irresponsible.”
Cancer Research UK, unlike its former director general, was not invited to take part in Too Late To Save Your Life. It reported that based on current evidence it does not support a national PSA screening programme.
The programme included only sparse mention of the hazards of bowel screening, such as false positives and negatives, and it did not explain that no reduction in all cause mortality through bowel screening has been proved.3 It presented lung cancer screening rosily without any discussion of caveats or uncertainties about benefits and harms, including false positive findings and radiation risks.4 ITV told the BMJ that it thought the programme was accurate and fair and had no further comment.
Screening was also the subject of BBC One’s programme earlier this year Long Live Britain, which offered a “one-off, record breaking televised event” of “Britain’s biggest ever health screening,” presented by the celebrity doctor Phil Hammond.
The press release said that it aimed to screen 1000 people in Manchester for diabetes, cardiovascular, and liver disease, but in the end 384 participated, and 79% were referred to their GP because of “increased risk.” If each one of these people was prevented from developing a health condition, the press release declared, “the project could have saved the people of Manchester 4090.5 years of life.”5 That’s a big assumption, and not an outcome that current evidence about behavioural interventions would suggest possible.
Hammond explained that screening tests or scans may be justified if they “motivate people to change their behaviour.” He told the BMJ, “The problem of television is that it always likes to have pretty pictures and high tech investigations to make it more interesting. People know when they’re overweight; they know when they smoke; they usually know when they drink too much; and it doesn’t take much to point out the problems with their diet.
Hammond said that he saw the programme as an opportunity to promote personal responsibility. But how do we know whether the people who went to their GP to discuss their results were simply the most healthy with the least to gain?
The health screenings were promoted to participants as straightforward, with no mention of the problems of overtreating blood pressure or cholesterol. Hammond added, “Broad sweep health promotion programmes are meant for everyone and do not debate the subtle nuances of screening and overdiagnosis. Whether they do more harm than good is hard to say, as they need to be scientifically evaluated themselves as an intervention.” That’s a research project that hasn’t been done.
It has taken a long time for autonomy and choice to be clearly crystallised in the NHS’s invitations to cancer screening.6 7 8 We know not only that screening can detect conditions that are harmless but also that unnecessary treatments as a result of positive screening can cause harm. The General Medical Council says that doctors must “work in partnership with patients, sharing with them the information they will need to make decisions about their care.”9 Television programmes may have other competing priorities but in suggesting that more screening is better for us they do their viewers a disservice. Hyping the benefits of screening without full and fair disclosure of potential harms is bad for us all.
Cite this as: BMJ 2013;347:f7643
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.