Cancer screening review diminishes informed choiceBMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l6224 (Published 31 October 2019) Cite this as: BMJ 2019;367:l6224
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McCartney’s warning against the latest NHS review into adult screening programmes is welcome.(1) Pledging financial incentives to increase cancer screening uptake encourages coercion which diminishes informed choice, among other potential drawbacks.(2)
However, the issue goes deeper: Who conceived this review and why? What is the purpose of expensively screening people for potential risks when more obvious, well-known and major causal risk factors (obesity, alcohol or tobacco use) are inadequately addressed? Only 75% of oncology clinicians assess tobacco use at intake visit, 60% advise patients to quit, and substantially less recommend cessation treatment despite smoking worsening outcomes of cancer treatment effectiveness, overall survival, risk of second primary malignancies, and quality of life.(3)
Why pay bonuses to healthcare practitioners and systems to scare healthy people when the quality of care for those suffering actual diseases is inadequate? Well citizens ought to be frightened that there’s no evidence that screening programmes improve quality of life or mortality. They are not adequately funded for quality assurance, so accordingly, despite accumulating evidence of relevant effects from serial robust trials colorectal cancer, screening effectiveness is not achieved in the real life setting. The number of colorectal cancer deaths in the US is 1.45/10,000 per year, a rate that has fallen steadily from 2.45 in 1990, well before screening was implemented.(https://seer.cancer.gov/statfacts/html/colorect.html). In France, as elsewhere, a wrong indicator is used: the uptake for one round faecal test. It is a poor surrogate as early RCTs in the 1990’s showed that mortality was reduced at best after 8-13 years of screening in two trials and not until after 15-18 years of screening in another two trials, under optimal compliance conditions. Effectiveness in France is a fantasy when the uptake for one round is only one third.
Why does the NHS enduringly refuse a scientific debate on the screening issue?(4,5). Here, the Pay for Performance scheme is most comprehensive and copies a French approach to decision making. In 2007, the “Journal Officiel de la République Française” demanded “the general practitioner draws the patient’s attention to the benefits of (breast cancer) screening … produces positive information about screening … which naturally falls within the scope of mere monitoring … in order to remove his patients’ reticence.” (https://www.legifrance.gouv.fr/affichTexte.do?cidTexte=JORFTEXT000000649...)
1 McCartney M. Cancer screening review diminishes informed choice. BMJ 2019;367:l6224.
2 Barr B, Taylor-Robinson D, Whitehead M. Impact on health inequalities of rising prosperity in England 1998-2007, and implications for performance incentives: longitudinal ecological study. BMJ 2012;345:e7831.
3 Ramaswamy AT, Toll BA, Chagpar AB, Judson BL. Smoking, cessation, and cessation counseling in patients with cancer: A population-based analysis. Cancer 2016;122:1247-53.
4 Bewley S, Rose L, Gøtzsche P et al. Time to halt an out of control trial with ineffective oversight. BMJ 2014;349:g5601.
5 Braillon A, Bewley S, Pisinger C, Fisken RA, Richmond C. NHS health checks are a waste of resources. BMJ 2015;350:h1006.
Competing interests: No competing interests