Margaret McCartney's Blog, page 5

The problems with Movember

as facial hair now sprouts forth, let us examine the health advice that Movember is offering on it’s website.

Useful points:

here, they give a good rundown on what you can do to reduce your risk of avoidable premature death or illness; essentially it is this. Don’t smoke, keep to a healthy weight, do some exercise you enjoy, preferably daily, eat a varied diet, mainly plants, and preferably make some social, work, see people.

Not at all useful is this webpage, a ‘health checklist by age’.

Last year, @petedeveson wrote this article about the lack of evidence for the health checks they advocate. I was especially concerned about last years advocating of PSA screening, and took up his offer to speak to the PR department on a joint phone call to Movember about evidence for these. I offered evidence based information, such as the complex nature of most screening tests and the problems of overdiagnosis, overtreatment and the need for fair information. I said I’d be happy to speak to them again. No luck!

They have produced a document suggesting that men aged 40 and above have a baseline PSA test. They do not mention any of the problems with PSA testing, namely that it doesn’t work well as a screening test, and is not part of an NHS Screening programme, and it means that men who would never have been maimed by an indolent prostate ‘cancer’ are, however, harmed by treatment for it. They present PSA testing as something a good citizen would do, not something which performs very poorly. Nor do they link to information such as decision aids (which, incidentally, tend to lead to more men not wanting the test.)

There are lots of other problems with their information. They advise a blood pressure to be measured every 2 years. The NHS says men over 40 should have it checked every 5 years. They say mens’ cholesterol should be checked from age 20; the NHS says from age 40 in someone otherwise well, and even then, cholesterol is only one factor of a cardiovascular risk assessment – which includes things like smoking. I’m think – not sure from their wording – that they are recommending flu vaccination in men aged 20 and above, again, this isn’t recommended by the NHS unless other problems such as asthma. (There is also the additional ‘problem’ of Cochrane but we will leave that meantime). There is good information about what the NHS recommends in terms of vaccination, here. From age 50, they recommend diabetes screening, again, despite the lack of the NHS recommending this and this recent large RCT.) They also recommend annual bowel screening, although the NHS offers it every 2 years from age 60 (not because the NHS is stingy, but because this is where the balance of risk and harm is most favourable.) As for aortic aneurysm screening, they say this is ‘only relevant for men who have smoked’ – in fact the NHS invites all men aged 65, smokers or not.

In other words, their advice is contrary to NHS advice. This is unfair on men, and on the NHS, who have to use their resources to mop up this kind of poor information.

I urge Movember to pull their health check ups page, use evidence based advice, and concentrate on some of the real unmet health needs of men – what about suicide, alcohol, and car crashes, for example. Not as sexy as proactive (unnecessary and potentially harmful) health checkups – but likely to be of far greater benefit if properly addressed.

 

New bmj articles – free links

The doctor won’t see you now: online consulting and prescribing

 

 

  The assault on the Liverpool care pathway 

The Breast screening review is out

 

Here is the press release from the Lancet:

Independent panel concludes that breast cancer screening reduces deaths, but overdiagnoses

**Embargo: 00:01 [UK time], Tuesday October 30, 2012**

An independent panel of experts has concluded that routine breast cancer screening results in a reduced risk of dying from breast cancer compared to when no screening takes place, but that screening also results in overdiagnosis, according to a Review published in The Lancet.

When breast cancer is detected by screening, it generally allows for earlier treatment and an improved prognosis for the patient.  However, concerns have recently been raised about overdiagnosis – where screening identifies a tumour, which is consequently treated by surgery, and often radiotherapy and medication, but which would have remained undetected for the rest of the woman’s life without causing illness if it had not been detected by screening.

The panel, led by Professor Sir Michael Marmot, Director of the Institute of Health Equity at University College, London, UK, was set up by The National Cancer Director for England, Professor Sir Mike Richards, and Dr Harpal Kumar, Chief Executive Officer of Cancer Research UK, to provide an independent review of the evidence for the benefits and harms of breast cancer screening in the UK.

The panel set out to analyse the best existing evidence for the effectiveness of breast cancer screening and the risks of over-diagnosis.  They performed a meta-analysis of 11 randomised controlled trials assessing whether breast cancer screening results in fewer deaths due to the disease, compared to when no screening takes place.   Overall, they found that women who are invited to breast cancer screening have a relative risk of dying from breast cancer that is 20% less than those who aren’t invited to screening.

Although the Panel acknowledged several limitations to these studies – not least the fact that all of them took place more than 20 years ago – they nonetheless concluded that the evidence was sufficient to allow for an overall estimated relative risk reduction of 20%.

Despite a scarcity of reliable studies on overdiagnosis (there were only three randomised trials available), the Panel concluded that for the roughly 307 000 women aged 50-52 years who are invited to begin screening every year, just over 1% will have an overdiagnosed cancer in the next 20 years.

Putting together benefit and overdiagnosis from the above figures, the Panel estimate that for 10,000 UK women invited to screening from age 50 for 20 years, about 681 cancers will be found of which 129 will represent overdiagnosis, and 43 deaths from breast cancer will be prevented.

However, given the uncertainties around all of these estimates, the Panel state that the figures quoted give a spurious impression of accuracy, and further research will be needed to more accurately assess the benefits and harms of breast cancer screening.

According to Professor Marmot, “The reduction in risk of death from breast cancer screening corresponds to one breast cancer death prevented for every 235 women invited to screening, and one death averted for every 180 women who attend screening.  The breast screening programmes in the UK, which invite women aged 50 – 70 years to screening every 3 years, probably prevent around 1300 breast cancer deaths every year.  However, our estimates also suggest that each year around 4000 women are overdiagnosed as a result of screening.”*

“For each woman, the choice is clear.  On the positive side, screening confers a reduction in the risk of mortality of breast cancer because of early detection and treatment.  On the negative side, is the knowledge that she has perhaps a 1% chance of having a cancer diagnosed and treated that would never have caused problems if she had not been screened.  Clear communication of these harms and benefits to women is essential, and the core of how a modern health system should function.”*

A Lancet Editorial, published alongside the Review, concludes that “The Panel’s report, the latest and best available systematic review, shows that the UK breast-screening programme extends lives and that, overall, the benefits outweigh the harms. Dissemination of these findings is now imperative in the media, the NHS screening programme, and between doctors and their patients. Women need to have full and complete access to this latest evidence in order to make an informed choice about breast cancer screening.”

 

For full Review, see: http://press.thelancet.com/breastcancerscreeningreview.pdf

For Lancet Editorial, see: http://press.thelancet.com/breastcancerscreeningeditorial.pdf

 

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)61611-0/abstract

Points;

1) They did not look at all cause mortality, but breast cancer deaths. Yet all cause mortality is very important in screening interventions, see here http://jnci.oxfordjournals.org/content/94/3/167.longY

2) This was not a systematic review.

3) The trials analysed are 20years old. Breast cancer treatment has improved hugely since then. The advantage of finding some tumours earlier may now be outweighed by the fact that treatment is so good.

4) Cancer Research UK have said in the press conference http://press.thelancet.com/breastcancerscreening.mp3 that they will continue to ‘recommend’ that women attend screening.

Sorry, but this is simply wrong. It is paternalistic. CRUK are making a value judgement that they feel it is worth being treated needlessly for breast cancer (overdiagnosis) because there is also a chance that screening might stop your death from breast cancer.

This is unfair. It is not up to them, it is up to the woman in question.

This is what the recommendations say, and it’s important to remember that they have also said “the Panel state that the figures quoted give a spurious impression of accuracy” but estimate then ” that for 10,000 UK women invited to screening from age 50 for 20 years, about 681 cancers will be found of which 129 will represent overdiagnosis, and 43 deaths from breast cancer will be prevented.”

We are no longer in the realm of paternalistic medical decision making, but the irony here is that it’s a charity that’s making a value judgement for you. It is only in screening that we intervene with the potential to do so much harm in an asymptomatic person, and where we do not give people properly informed consent first. Medicine has been at fault in failing to explain the pros and cons of screening from the start; it has never been straightforwardly beneficial.

I await the findings of Informed Choice in Cancer Screening.

 

 

 

 

 

 

 

Lifeline screening/ responses

..have posted this response to http://privatehealthscreen.org/, you can see my response on their page and CEMB’s Carl Henegan’s response here, which is not (yet?) up.

 

 

should Pharma teach students critical appraisal skills?

I think not.

Last week I was very pleased to have been asked to  the Glasgow Evidence Based Medicine Society. I going to talk about the problems of medical headlines in the media. I got there a bit early and so went to a session being run by Pfizer on how to critically analyse a paper. It was all quite standard stuff – apart from the wee Pfizer logo on the bottom of every slide – in terms of how to unpick a paper and analyse it’s flaws.

But what was missing, in an enormous, black-hole kind of way, was a discussion about the way in which pharmaceutical companies can choose not to publish clinical trial data. Despite the APBI claiming that criticism levelled at pharma is ‘fashionable’ they have not addressed the fact that actually, people like Sir Iain Chalmers have said as far back as 2004 that non publication of trials kills people. Not so recent a fashion, then. Ben Goldacre’s recent book Bad Pharma offers spades of evidence that despite assurances from Pharma that this kind of dangerous practice would stop, there is copious evidence that it hasn’t.  The discussion from Pfizer didn’t mention any of this or the way in which this publication bias distorts what we know about the evidence, leads to overestimation of pharmaceutical benefits, and unnecessary risks and harms for patients. Have a look at this paper which details some of the correspondence to and from managers at Astra Zeneca, and cringe.

And so, by the time it came for me to give my talk, I was ridden with angst. This enormous problem hadn’t been mentioned, and if there is to be any discussion about the need for evidence in clinical practice, it has to be about what we don’t get to know about. If we don’t know about all the clinical trials of a drug, we don’t know as much as we should, and any attempts to critically analyse the evidence will thus fail in making a fair judgement.

And so I apologise if I went on a bit, or was overly harsh, but until we start talking about these problems with evidence based medicine, we will continue to do more harm than we need to. Pfizer, if you want to talk to me, am happy to discuss, at margaret@margaretmccartney.com .

 

 

 

 

Young Minds report on self harm behaviour

This weeks Inside Health discussed a report about self harm.

The report (http://www.cellogroup.com/pdfs/talking_self_harm.pdf) was produced by a company, Cello (who are a “a leading global insight and strategic marketing group with a primary focus on the pharmaceutical and health sectors in addition to deep expertise in a range of other high margin sectors” in conjunction with Young Minds, a charity for young people’s mental health.

This is the press release

http://www.youngminds.org.uk/news/news/1117_uk_teenagers_nowhere_to_turn_as_self-harm_spirals

From this, it says

“Almost half GPs feel that they don’t understand young people who self-harm and their motivations”

“In the most comprehensive research undertaken in the UK into perceptions of self-harm amongst young people, parents, GPs and teachers, all respondents agreed that self-harm is more concerning than drug use, binge drinking, bullying and gangs.”

 

From the report, it seems that they interviewed 50 GPs. However the report does not include normal research information such as the number of GPs approached, the response rate, the questionnaires used, the responses to each question. I’ve asked for the full research to be made available, and I’ve been told that someone could talk me through it but I couldn’t see it.

There are lots of issues about the lack of resources for young people in mental distress. But I would question whether this survey actually adds reliable evidence of what GPs think and might even be harmful – I would hate if a young person read the headlines resulting from this report and concluding that they won’t get help from their local surgery.

If organisations want to gather headlines about their research, they should do the decent thing and allow readers full access to their survey techniques and results – otherwise it isn’t possible to take seriously as much more than fodder for publicity.

 

The overselling and lack of evidence for TAMPAP

…in the face of promotion by media doctors.

My blog on the upheld ASA complaint over at the Guardian and a news story also.

Online health checks

BMJ medicine in the media, here.

Functional symptoms

this Inside Health piece - more information via the excellent www.neurosymptoms.org website.

Here’s an job advert I won’t be applying for

“Channel Four television is looking for a Sex In The City style female GP or other Medical Professional to present a new prime time glossy series on Cosmetic Surgery.

The series is currently untitled, but it’s a transformational show that looks at the modern breakthrough’s in beauty and the very latest innovations. Our new medical presenter will help women on the show navigate through all their options on the market, as well as offering advice and help in the world of cosmetic procedures and treatments available.

It would be fabulous to hear from you if you think you fit the bill. You don’t need to be a cosmetic surgery specialist but should be excited about the advances in the areas and the latest procedures on the market. Maybe you’ve had surgery yourself or would never say never to Botox, Chemical Peels or surgery yourself?

We have a tight deadline and looking to chat to possible individuals on the telephone initially as soon as possible. Please don’t hesitate to contact me on the telephone number below between 10am – 5:30pm.”

In short; will the public get fair unbiased information (especially about the lack of positive long term outcomes and higher risk of body dysmorphia in those seeking surgery) from a program set up like this?