Panorama. The Hospital That Failed Women

Editor

Nigel Bundred’s critical review of the Panorama programme about
breast cancer care in Bradford illustrates the dangers of judging
performance of doctors and hospitals from a sensationalist television
programme rather than a balanced analysis of health care quality.

When Bradford Hospitals Trust was first made aware by the Yorkshire
Cancer Registry in 1995 of the low referral rate for radiotherapy
following breast cancer surgery it took its duty to patient care extremely
seriously. Radiotherapy rates were low in the 1980’s and early 1990’s
and the Trust has clearly and repeatedly acknowledged this historical
under-referral during a period when there was no evidence about the
benefit of radiotherapy on survival and concern about side effects.

The Yorkshire Cancer Registry report also showed wide regional
differences in the use of chemotherapy (>10 fold differences between
the highest and lowest districts) and in all aspects of surgical practice
(e.g. 2 fold difference in lumpectomy rate). This was in a period pre-
dating national or regional evidence-based guidelines. Guidelines were
introduced as Bundred points out in 1995 (and 1996) in response to the
“lottery” of cancer care widely debated by the public and profession at
that time.

The issue regarding how much information to give individual patients
who may have received historical suboptimal treatment is important but
complex. The group of patients in question were already being closely
followed up by the breast team and would not have benefited from
radiotherapy several years after treatment. It is clear that guidelines
should be followed after their introduction but should these standards by
applied retrospectively? Should all patients who had previously received
too little (or too much) chemotherapy, radiotherapy or surgery by the
standards of new guidelines be informed? Should this apply to patients
who were treated 5 years before the introduction of the guidelines, or 10
or 15 years? If so should this principle be applied equally to the
treatment of other cancers or indeed all medical conditions where
widespread medical practice variation is well described?

The Trust’s response in 1995 was to implement major changes in
clinical practice including the development of weekly multidisciplinary
meetings of the breast team to plan each patients care. When the first
regional guidelines were produced by the Leeds Cancer Centre in 1996 which
for the first time clearly defined criteria for selection of patients for
radiotherapy following breast cancer surgery, they were enthusiastically
adopted by the team. Since that time all patients have been referred in
accordance with the guidelines.

Two leading national experts were asked to review the statistical
evidence from the Panorama. Professors Trevor Sheldon and Richard Lilford,
felt strongly enough about the flaws in the statistical interpretation to
volunteer to appear on camera to dispute this evidence. We asked the
Panorama team to interview them. However this request was refused and
neither expert was approached for comment by the Panorama team. As a
result, the viewers were not made aware of the fact that survival data for
example, were not adjusted for patient case mix such as cancer stage and
that the survival rate for patients treated by the surgeon in question was
average for the region and only raised in one time sub-period when
compared with a small subset of experienced surgeons. The viewers were
also misled about the changes in radiotherapy practice because the
Panorama analysis chose to show average performance over a 4 year period
(during which practice changed considerably).

Clinicians at the Trust invited the Panorama team to discuss the
implications of the differences in expert opinion. All requests for
dialogue were refused and so we agreed to be interviewed on camera. We
spent nearly four hours acknowledging historical underperformance,
describing in detail the changes in the clinical service in 1995 and
discussing the flaws in the statistical analyses. The editing of the final
content made no attempt to provide a balanced reflection of these
interviews.

In contrast the Panorama team gave lengthy and sympathetic coverage
to three former employees at the hospital, two doctors and an anonymous
manager. Bundred is right to be critical of Panorama for using the
testimony of one of the doctors who had been suspended for serious
professional misconduct. However Panorama failed to report that the other
doctor is presently under investigation by the General Medical Council
following a serious complaint about his competence, and the manager had
resigned when subject to disciplinary action for sexual harassment of a
member of staff. It is astonishing that the Panorama team did see fit to
inform viewers or question the professional credibility of their
witnesses.

Clinicians at the Trust were ultimately so frustrated about the
confrontational behaviour of the Panorama team that we wrote to the Lancet
and made the background evidence available to the public on the Lancet
website.1 We hope that this provides some balance to the debate.

Bundred is quite correct in questioning the lack of a patient voice
in the programme. The Panorama team approached local patient groups and
local general practitioners in Bradford in 2005. They were unsuccessful in
identifying any patients who would support their prejudice and so none
were included in the broadcast.

The adversarial and one-sided manner in which the Panorama team have
conducted their investigation is a lesson to all doctors and patients
about the presumption of guilt in trial by media. A balanced report would
have described the genuine divergence of expert opinion on the
interpretation of the medical statistics, debate about the implementation
of national guidelines and the evidence from clinical audit.

The public have a right to expect the highest standards of care. In
cancer this has been closely monitored since 1997 by regular detailed peer
-review of the quality of the service.
This review has repeatedly praised the quality of care provided by the
Bradford team and the overdramatic attempts by the Panorama team to instil
fear and anxiety in local patients is unwarranted.

We welcome appropriate review of standards of clinical practice in
the breast cancer care. We would encourage further public debate about the
interpretation of the medical statistics and agree completely with the
comments from Michel Coleman that the spotlight of a TV documentary is not
the best way to do this. We will pursue redress over the partial and
selective reporting by the Panorama team through official BBC complaints
procedures. The Panorama programme discredits investigative journalism and
is a reminder about not believing all that you see on television.

John Wright
Consultant in Clinical Epidemiology

Chris Bradley
Consultant in Medical Oncology

1. Wright J, Bradley C, Sheldon T, Lilford R. Trial by media: dangers
of misinterpretation of medical statistics. Lancet 2006;367:1139-40.

Competing interests:
None declared