Health screening needs independent regular re-evaluation
BMJ 2021; 374 doi: https://doi.org/10.1136/bmj.n2049 (Published 27 September 2021) Cite this as: BMJ 2021;374:n2049
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Dear Editor
I welcome this initiative and carry the wounds of my past attempts to slow down the juggernauts of the screening enthusiasts.
Their mantra, "catch it early and save a life" has lead to the wastage of huge human and technical resources, delayed the introduction of more valuable public health initiatives and harmed countless asymptomatic individuals by over-diagnosis and over-treatment. As the ultimate reductio ad absurdum there has been a very high profile of a screening programme using liquid biopsies to identify 30 different cancers in the last week. (see this link; https://www.annalsofoncology.org/article/S0923-7534(21)02046-9/fulltext ). It reaches the point of farce when they claim the highest sensitivity for metastatic cancers with unknown primaries. I hate to think how much damage was done to the patient in the frantic research for the primary. I would humbly suggest that the first agenda item for this new committee would be to nip this in the bud.
Competing interests: No competing interests
Dear Editor
I welcome the authors' call to keep health screening under regular re-evaluation by independent arbitrators.
The WHO document (ref 1) on population screening is replete with examples on how an idea of population screening does not necessarily work similarly in an international context.
One of the important premises of population screening, assuming it fulfils Wilson & Jungner's WHO criteria, is that "the benefits of screening outweigh any potential harms".
The issue here is then what are the "potential harms".
Many clinicians advocate various screening programmes based on the focus upon potential harms caused by the disease being screened, often in the form of mortality rates from the disease.
Others (myself included) and much of the public looked at overall mortality and morbidities of the screening programme, including deaths from the diseases as well as of other causes including complications of screening.
This is particularly relevant when the act of screening on an asymptomatic population is a medical intervention by itself and most screening tests are not the final gold standard tests used to confirm the condition; more invasive tests (with associated morbidity and mortality rates from the procedure) are often required.
This discrepancy is the reason for the recent furore over mammography for breast cancer screening.
Whose perspectives matter more, the clinicians' focused on case finding or the public's more interested in overall mortality and morbidity?
Reference
1. https://apps.who.int/iris/bitstream/handle/10665/330829/9789289054782-en...
2. http://apps.who.int/iris/bitstream/handle/10665/37650/WHO_PHP_34.pdf?seq...
Competing interests: No competing interests
Re: Health screening needs independent regular re-evaluation
Dear Editor,
How welcome it is to see well thought out proposals for a workable system of regular independent re-evaluation of health screening! [1] The multidisciplinary international authorship brings a wealth of wisdom and experience, offering a cool appraisal of ongoing methods of updating preventative medicine in a world that is trying to cope with immediate suffering and increasing backlogs. Looking for potential disease in healthy citizens at this particular time of stretched resources, both human and financial, identifying people`s propensity for developing this or that condition, would be restrained and tempered by such level-headed means as are suggested here.
Refreshing, too, to see not just well-reasoned justification but also workable proposals for ways to vault the barriers that they identify: action based on thoroughly reasoned reflection. The importance of deliberative involvement of ALL stakeholders, together with ideas about how to achieve that, is, at last genuine and heartfelt, not mere tokenistic acknowledgement but embraced as a vital and necessary contribution. Unnecessarily turning citizens into patients-before-their time is now fully recognised as a potential harmful consequence of well-meaning but poorly thought-through intentions in screening programmes that continue well past their sell-by date without scrutiny or modification.
It is good to see this detached, practical approach emerging from past turmoil and tribulations experienced by many who have struggled against the odds for so long. May it come to fruition and prosper!
[1] Ropers FG, Barratt A, Wilt TJ, Nicholls SG, Taylor-Phillips S, et al. Health screening needs independent regular re-evaluation. BMJ 2021;374:n2049
Competing interests: No competing interests