Raising Awareness – Do We Know What We Are Doing?

There was an interesting discussion on Radio 5 Live recently between Glasgow GP Dr Margaret McCartney and Kris Hallenga, the founder of the CoppaFeel breast cancer awareness charity. The interview was arranged in relation to an article Dr McCartney wrote for the BMJ in the first of her new weekly column for the journal, which criticised The Sun newspaper’s rather hypocritical Page 3 campaign to encourage young women to regularly check their breasts for lumps. Whatever you might think of the piece, you have to admire Dr McCartney’s boldness for taking on both a national daily newspaper and the emotive power of the Pink Ribbon for her induction to the column!

The interview exposes how screening for disease and responding to symptoms are so often blurred in the media and by health campaigners – whether this is due to simple ignorance or a deliberate ploy to increase the power of the campaigns is uncertain, but that it is helpful is without doubt. The Sun’s campaign calls for the screening of asymptomatic women through regular breast self-examination, and Dr McCartney’s assertion is that the benefits and harms of this strategy are not sufficiently understood to be able to promote such advice, and what evidence we do have suggests it may do more harm than good. Ms Hallenga, on the other hand says that she ‘ignored her symptoms for so long’; ignoring the symptoms is not the same as failing to remember to check yourself when you don’t have symptoms – there is something more going on here, which brings me to a fundamental problem with ‘awareness raising’ health campaigns.

The logic of raising awareness goes like this: people aren’t seeing their doctor quickly enough about a certain disease – this must be due to a lack of knowledge, understanding and awareness of the condition – there should be a campaign to raise awareness – people will be better informed and see their doctor more quickly – lives and money will be saved. If we were all computer programmes and responded in a predictable way to data input this would work a treat, but people are far more complicated than that.

There are many reasons why someone may choose not to see their doctor when they have significant symptoms. Ignorance may be one of them, but in this day and age of instant health information courtesy of Google, it is surely less of a factor than it used to be – the danger is now the converse, that too much information may be having a detrimental effect. If a woman finds a breast lump – whether by chance or through a belief that she should check herself – she is unlikely to be unaware that breast cancer is a possibility, and yet some will delay seeing their GP despite this knowledge. Other factors must play a part: fear of what might happen next; complex self-denial as we convince ourselves that ‘this can’t be true’; embarrassment; business and the attitude that ‘I haven’t got time to be ill’ are all reasons why someone may not see a doctor – attitudes that might be improved by an awareness-raising health campaign, or might just be hardened by it.

Awareness raising is usually championed by politicians whose motive is to improve a statistic or – for understandable reasons – by those with an emotional connection with the disease in question. The problem with this is that the focus is heavily biased towards those with the disease, with little consideration given to the potential harm to others who may be caught up in the campaign. The justification for this is often that it brings reassurance to those who are checked out and found to be ok – but we should question the merit of a campaign which brings peace of mind to those who have been made anxious by the very same campaign in the first place.

The ‘cough for three weeks could be cancer’ strategy is a good case in point. As with all GPs I have seen more patients with a cough since the adverts appeared – usually non-smokers who are very conscious of their health and would never ignore symptoms for very long – while I am aware of smokers who have been put off seeing their GP by this very campaign because they don’t want to be given bad news. There is rarely any attempt to see how people will respond to these health messages – little consideration given to the fact that the same message might harden the resistance of those who should seek advice while unhelpfully altering the health-seeking behaviour of those who should not. We need to be bolder in challenging this, even if, like Dr McCartney, we end up being accused of acting ‘dangerously’.

Sometimes, though, if you can’t beat them you have to join them, and so I would like to launch my own awareness raising campaign. It’s very simple and it goes like this: ‘Health Awareness Campaigns can do more harm than good – use with caution, apply common sense, and trust your instincts’.

This post was originally posted in Pulse magazine (free subscription required)

Would We Have the Nerve?

It will remain to be seen whether or not the release of 25 year follow-up data from the Canadian National Breast Screening Study will prove to be a game changer, but what if it did? What if its findings – that regular screening mammograms have no impact at all on mortality from breast cancer, and result in harm from an overdiagnosis rate of 22% – were proved to be irrefutably true? What then? Would we have the nerve to act? Could we ever give up the UK screening programme?

There can be no doubt that if the Canadian study were the only research available then mammography could not be recommended – we would conclude that it does more harm than good and be done with it. We should never rely on one study, of course, and other studies have shown routine mammography in a more favourable light. It is, however, the only study of significant size to be undertaken in the modern context of more effective breast cancer treatment and it is not the only time in recent years that mammography has been brought into question. So what if we were to believe its results?

What would happen if the UK National Screening Centre (UKNSC) were to withdraw its support for breast screening? We are used to new programmes being introduced, but not an established one being cancelled; after 35 years of endorsement and public health advice exhorting women to take part in screening, it would be quite an about-face to tell the population that it wasn’t such a good idea after all.

There would be all the mobile screening units for starters – what would we do with them? Replace the x-ray machines with ultrasounds and expand the aortic aneurysm programme? Cut our losses and sell them off to a haulage company? What about all the staff involved in delivering the programme? Or the expertise the NHS has acquired in reading mammograms? There would still be a role for the x-ray in symptomatic women, but there would be huge over-capacity if the screening programme were to be stopped in its tracks. I’m certainly not rushing out to buy shares in a company that makes mammography equipment.

More of an issue, though, is the political challenge that any change in policy would encompass. It is well-known that no matter how compelling the argument might be for closing a hospital, trying to actually do such a thing is usually akin to political suicide – would the same be true for whichever unfortunate cabinet minister was left to announce the cessation of screening mammograms? Would the move be seen as anti-women? What would the pro-screening lobby have to say? There are enough men who are angry about being ‘denied’ a national prostate screening programme despite the evidence that it would do more harm than good. The belief that early is always better, and knowledge is always good are so deeply ingrained that they are often maintained despite any amount of evidence to the contrary.

Any woman who has had to endure the rigours of treatment for a breast cancer picked up on a mammogram can be expected to believe wholeheartedly that the whole process has saved her life – how else could anyone face going through such difficult treatment? What, then, is she to think if she hears of other women being denied the same chance to live? Can we expect everyone to make a clinical assessment of the evidence on such an emotive issue as breast cancer?

Perhaps the biggest hurdle of all, however, will be the NHS Mandate. Enshrined within this document is a drive to bring down five-year cancer survival rates; those figures that are thrown at the NHS from time to time as the UK is told how poorly we compare with the rest of Europe. The best way to keep five-year survival figures low is to concentrate on screening – catch it earlier, survive longer – and not to worry too much about mortality rates. If the Government ever sanctioned the cessation of the breast screening programme we would slip even further down the league tables and the goals of the Mandate would be harder to reach – even if it was better for the health of the nation, this could be too much for those in power to stomach.

I don’t know where the evidence will move from here – more studies perhaps? Another Cochrane review? Perhaps the UKNSC will deliver a verdict. What really matters, though, is whether we could ever act on the findings; if we have been doing the wrong thing for the last 35 years, could we ever find the nerve to change?

This past was originally posted in Pulse magazine (free subscription required)

Plain Cigarette Packaging – Does the Government Really Care About Health?

So today is the Queen’s Speech, and the promised legislation on plain packaging for cigarettes has been shelved – put on hold, maybe, hopefully, but probably left to flounder in the long grass until it is somebody else’s problem.

I have no doubt that it takes great courage to take on the might of the tobacco industry – but Australia has paved the way for the rest of the world to follow, it has taken the hit of lengthy legal battles and proved victorious. Our own Government just needs to follow in this lead, and that it has refused to do so does not show a lack of political mettle, but a fundamental problem with political ideology: When it comes to the health of the nation or the health of business, business wins every time.

 

This decision makes a mockery of Government rhetoric on health – promises such as:

These are worthy goals, and it is good to hear the Government talking about them – but they have shown no willingness to play their part in tackling these problems. All of these health outcomes are closely linked to smoking. In response to a recent report on international mortality data, Jeremy Hunt derided the UK health service for ‘shocking underperformance.’

Hunt said the UK was a long way behind its global counterparts and called for action by local health commissioners to tackle the five big killers – cancer, heart disease, stroke, respiratory and liver diseases. He will on Tuesday announce a strategy to tackle cardiovascular disease, which he says could save 30,000 lives a year.

I have blogged my views on this report, and Hunt’s response to it, elsewhere, and so won’t repeat them here. It is not good enough, however, to tell local health commissioners to do better if the Government is not willing to play its part. Many of the biggest health benefits in the history of medicine have come in the area of public health – vaccination, health and safety at work, sanitation and the smoking ban to name a few. Plain packaging could have been the next big public health policy to have an impact. I don’t believe anyone thinks it would be bad for the health of our nation to move to plain packaging; undoubtedly most smokers won’t care what the packet looks like, but it is hardly likely to increase smoking rates.

There are arguments being made against, of course – from the ludicrous notion that small shops will implode because of the extra time it might take shop-keepers to find the right packet, to more reasonable concerns about job losses and counterfeit packets. Suzie Gage has looked at the (lack of) evidence for some of these claims – and as for job losses, well wouldn’t that apply to any strategy to reduce smoking? What should really worry us are the conflicts of interest behind the scenes that may be influencing decisions – like ministers enjoying hospitality from tobacco companies and lobbyists failing to declare their links to the industry.

Instead of doing what it can to prevent disease in the first place, the Government prefers that we wait for it to happen, and then catch it in its earliest stages through screening. This is the thinking behind the NHS Health Check (about which I have blogged here), a hugely expensive programme which may have benefits for a few individual, but where the evidence that it will improve the health of a population is very limited indeed.

And the most frustrating aspect of the whole thing is that the Government’s favoured statistic for measuring our health will actually be best improved by encouraging smoking and then screening for disease. Again, I have already blogged about the unhealthy obsession with 5 year survival data. The truth is that you don’t improve 5 year survival by reducing the number of smokers – because you can’t survive something like lung cancer if you don’t get it in the first place. No, far better to keep people smoking, scare them about cancer enough so that they undertake one of our screening programmes and then cure them – that way we can really make a difference to the statistics and give ourselves a lovely congratulatory slap on the back.

Choices, Choices , Choices

Choice has become a mantra within the public sector, a sine qua non, an indisputably good thing. Politicians are so entranced by its allure that they are blind to both the inherent paradoxes and blatant inequities that are frequently the close companions of choice. The result is that we are often left feeling let down and oddly disempowered.

There are three main types of choice within healthcare: Those that are promised to all but only available to some; those we don’t like to talk about, because the reality is that they aren’t available at all; and those we could all have, but that the powers that be prefer not to tell us about – because they don’t trust us to make the right choice.

The first type of choice we might call the big slice of cake choice. When my teenage son and I cut two slices of cake, inevitably one is larger than the other. With equal predictability, since we are rather partial to cake, we both choose the larger piece – but the reality is that only one of us can have it. Similarly in healthcare – the best surgeon cannot operate on everyone, but who would ever choose the second best? Or I might like to choose the beautiful new hospital on the other side of town, but I have no car and the bus only goes to the tired old DGH down the road.

The result of these big slice of cake choices is that only those with the wherewithal to navigate their way through the confusion of options, and are both savvy and mobile enough to take advantage of the range if choices on offer, will actually benefit – which usually equates to the better off and the less unwell, yet another example of the inverse care law in action.

The second type of choice is the one we like to brush under the carpet – the unpalatable lack of choice that we have to face due to the reality of rationing. The NHS can no longer afford to say ‘yes’ to every health choice we would like to make. The latest, most expensive drug may not be available to us, and our varicose veins may not be deemed worthy of treatment. We are getting used to this in the NHS, and should not be embarrassed by a degree of rationing – although the decisions about what we can and cannot choose need to be made ethically and carefully, and not just by a board of panicked managers frantically trying to balance the books.

The third type of choice is the one that really interests me. It could and should be given to us all, and yet it is rarely talked about – because it has little political value, and involves actually trusting patients. If you are going to trust patients, you have to accept that they can be irrational, unpredictable, and sometimes make foolish choices – and here I speak not as a doctor frustrated by his patents, but as a member of the human race celebrating our glorious diversity.

The choices I am talking about here are these: Should I take a tablet for my mildly raised blood pressure? Should I have a mammogram? How do I feel about statins? These are the sort of health choices many of us are faced with when we visit the doctor, or receive a letter in the post inviting us to engage in a health screening programme. And yet it is rarely presented to us as a choice. We are told to take this tablet, made to feel irresponsible if we ignore the invitation letter, and risk being branded as non-compliant if we disagree – as though it is our duty to bend to the will of the medical profession.

This lack of choice is enshrined in the fabric of the GP contract, as GPs are given an ever-increasing number of targets to aim for – including achieving tight blood pressure control, prescribing anti-coagulants or performing cervical smears. Pressure to deny patient choice comes in the form of prescriptive guidelines, which are frequently dictatorial in the manner in which they tell doctors what they should be done in a particular situation. While evidence-based guidance has been an invaluable tool in helping to achieve excellent standards of care, the words ‘depending on patient individual preference’ appear all too rarely in published guidelines, and doctors are in danger of projecting the pressure that they feel to conform onto their patients.

Many treatment decisions are a complex blend of objective medical evidence concerning risk, and need to take account of highly individual, subjective preferences, priorities and health beliefs. Respecting autonomy is one of the principal pillars of ethical practice, but all too often this is reduced to waiting for the patient to raise objections to the proposed treatment plan, or asking them to become an ‘expert’ in their own health, which can equate to expecting the patient to become the doctor.

True respect for autonomy is a highly active process. It involves creating an environment in which autonomy can flourish, and empowering the patient to make the right choices for their individual situation. It requires that the doctor knows and understands their patient, has a thorough grasp of what matters to them, and is able to distil the available medical evidence into an understandable, personalised format. It may involve supporting the patient when they choose to have treatments or investigations which the doctor would not choose for themselves, or giving licence to opt out of guidelines if they wish to, and turn down treatment without being made to feel like a naughty school child,

This respect cannot be confined to the consulting room, but needs to be enshrined in all aspects of health care – and health promotion in particular. Invitation leaflets for health screening should seek to enable informed choice rather than tell us what to do, and health awareness campaigns should avoid emotional manipulation and never, ever, look like this:

cervical-cancer-poster
Cervical Screening Campaign Poster, Kirklees Feb 2012

Screening for Dementia – Beware the Zeal of an Evangelist

There’s an old joke about a Pastor and an Evangelist going on a bear hunt. Once they have arrived at their log cabin hunting lodge the Pastor starts to unpack their supplies for the week, but the Evangelist announces that he’s going out to explore the surrounding area. Barely twenty minutes have passed before the Pastor is somewhat alarmed to see the Evangelist racing down the path back towards the cabin at breakneck speed. His alarm turns to terror when he catches sight of a large Grizzly Bear in hot pursuit.

The Pastor backs defensively into the cabin, leaving the door wide open for the Evangelist to reach safety. With relief he sees that the Evangelist is going to get there just in time, but at the last moment his friend steps deftly to one side. The Bear charges headlong into the cabin, at which point the Evangelist slams the door shut and shouts to his friend: “You deal with that one, I’ll go and get another!”

Jeremy Hunt is on a crusade to increase the rate of diagnosis of dementia, and has approached the task with all the enthusiasm, energy – and lack of forward planning – of the Evangelist. The hapless Pastor will be our dangerously over-stretched dementia services, which are already at breaking point and unable to offer the sort of service that dementia sufferers require; and the Bear will be all those people newly diagnosed through the Health Secretary’s proposals, trapped within a diagnostic label, but not able to receive the care, support and advice they need because the system will be unable to cope.

I have written an earlier post questioning who the real beneficiaries will be with the drive for early diagnosis in dementia, arguing that what we need is prompt diagnosis for those who need it, rather than an increasing search for ever milder cases. The Government, however, has announced its proposals for what they call ‘Dementia Case Finding’, which amounts to widespread screening for dementia in older people.

The proposal is that GPs should ask all at risk people – deemed to be those over 60 with certain conditions such as stroke or diabetes, and all those aged over 74 – about their memory, and offer them a screening test. This is to happen during routine visits to the doctor – which means that any older person who chooses to see their doctor about, say their arthritis or a skin rash or a blood pressure check, will be asked about their memory. There will be no advanced warning that this is going to happen, no chance to consider the potential benefits and harms of dementia screening, no leaflet in the post explaining the programme, just screening questions, and a referral to the memory clinic if you fail the test.

We need to think long and hard about the implications of this. I have three major worries.

It is a wasteful distraction from the real need in dementia care. While I have such grave concerns about the Government’s proposals, their overall focus on improving dementia care is something to be celebrated. It is long overdue, and is giving this much neglected area within medicine the drive and energy to shape change and attract investment. However, the over-riding need within dementia care is hands-on support for those who are already diagnosed and their families or carers. Currently our system can barely cope with making a diagnosis, starting people on medication and reviewing them about once a year. This is woefully inadequate. People need help understanding their diagnosis and carers need to learn a whole new way of interacting with their loved one who is now behaving in such a different way (see this post for more on that need). Issues such as Advanced Care Planning and Power of Attourney are vital, and yet people are often left to find their own way when they need someone to walk them through these emotive and complex issue. And as for non-drug therapies – such as reminiscence therapy – there is so much that could be done if only we invested in it.

There is a very real danger that older people will be put off seeing their doctor. However much we try to reduce the stigma of dementia (and try we most certainly should), it will always remain a life-changing and very frightening diagnosis. Many older people are quite threatened when I ask them about their memory – how will they feel if they hear that I will be required to do it when they come to see me? Going to the doctor can be a stressful enough experience as it is – I’m already likely to want to check their blood pressure/monitor blood tests/talk about their weight/nag them about smoking etc etc. A serious unintended consequence of this policy could well be that people will avoid seeing their doctor about other serious health issues for fear of being subjected to a memory test.

All the evidence and advice about dementia screening is clear – don’t do it. Screening for any disease is always a balance of benefits and harms, and so all NHS screening programmes are considered and evaluated by the UK National Screening Committee (UKNSC). This committee looked at dementia screening in 2010 and gave a very clear ‘No’ to the idea. The benefits of picking up the very early stages of dementia just do not outweigh the potential harms of over-diagnosis and over-treatment. The Government has neatly sidestepped the UKNSC by calling their proposal ‘Dementia Care Finding’ rather than screening, but you can call a spade a ‘garden digging implement’ if you like – it’s still a spade.

Many other doctors, and dementia campaigners share my concerns, and together some of us have written an open letter to the Prime Minister and the Chief Medical Officer, which has been published in The British Medical Journal. We have also raised an e petition asking the Government to reconsider these proposals. If you share my concerns then please consider signing the petition, and sharing it as widely as possible with others.

Thank you.

The Drive to Improve 5 Year Cancer Survival – an NHS Priority, or Political Folly?

In the original Johnny English film, Rowan Atkinson’s hapless spy performs a flawless daredevil penetration into the heart of a hostile occupied building. Dropped by helicopter onto the roof, his use of grappling irons is exemplary, his ability to move through locked doors and windows – textbook. Flushed with his own success, it is only after assaulting several members of staff that he realises he has inadvertently broken into the local hospital instead of his intended target.

If you are going to invest a lot of time and effort into something important, no matter how good your intentions might be, it is vital to aim for the right target.

When the Government published its NHS Mandate earlier this month, a cornerstone of the proposal was the commendable aim for the NHS to be better at Preventing people from dying prematurely. A key aspect of this is to look at deaths from cancer – so far so good. The details, however, is where there is a problem – the focus is to look at 1 and 5 year mortality rates. It is quite simply the wrong target and will result in bad decisions that will be bad for patients and wasteful of scarce NHS resources. The target should be overall mortality, nothing more and nothing less.

5 year mortality data were originally devised to assess the effectiveness of treatment. Here they are useful – if you want to know how one chemotherapy regime works compared with another then the overall 5 year mortality can be very helpful. The problem comes when we use it to assess overall performance, or start comparing data for different countries. We end up with disturbing headlines such as this from the Daily Mail in 2009. These cause politicians real headaches, and the danger of knee-jerk reactions and bad decisions.

The problem with 5 year survival is that they are so easy to manipulate – and the easiest ways to do this bring little benefit to patients, or even harm. The hardest way to really improve survival from cancer is to genuinely improve treatment and care – this is expensive, requires investment in the people who run cancer services, often relies on medical breakthroughs and has no guarantee of success. There are far easier, much more reliable methods for achieving results if you are so inclined, and two may prove irresistible to politicians so dependent on a quick fix and the next set of statistics.

Technique 1: Diagnose cancer earlier

If you have a cancer that is incurable and you are going to die in three years time despite whatever treatment medicine can offer, then you will fall the wrong side of the 5 year statistic. If, however, I can persuade you to be diagnosed 2 years earlier – through an awareness campaign, or cancer screening for instance, then even if I don’t change your outcome one iota you will have crossed magically into the success side of my statistic – Tada! Of course, for some people an earlier diagnosis may make a difference to their outcome, and we would always want to reduce delays once someone develops symptoms related to cancer, but the evidence is that early diagnosis through screening has a limited impact on overall improvements in survival.

Another, more powerful, lure of early diagnosis through screening is the prospect of picking up cancers that are so early that they would not ever become a problem. If these cancers go completely undetected then they will have no impact on the statistics. If, however, they are diagnosed they will, by definition, be treated successfully, and they will add a rosy glow to the 5 year survival data. To take prostate cancer as an example. If you screen for prostate cancer you will save lives – but for every life you save you will need to treat 48 other men who would never have died from their ‘cancer’. Without screening there would be one man who will enter the data, and may or may not survive 5 years. With screening 49 men become statistics – and they are all on the good side. This is a compelling political argument, but is it good for patients?

Technique 2: Redefine Cancer

Cancers like pancreatic cancer are what we all think of when we use the Big C word – nasty, aggressive diseases that are almost impossible to treat and spread rapidly. If the NHS is to be tasked with improving 5 year survival for pancreatic cancer then it is on a hiding to nothing – medicine needs to move on and make a break-through if that is to happen. So to balance the books, as it were, there is a great temptation to put as many easy to treat cancers on the other side of the scales as possible, and the best way to do that is to redefine what we mean by cancer. Terms like Ductal Carcinoma in Situ, which is really a pre-cancerous change in the breast of an uncertain nature, have come under the cancer umbrella in recent years. Treated like any other breast cancer, the survival is phenomenally good and it is fantastic for statistics, but the evidence is that many women are treated for it unnecessarily as it will not always develop into a true cancer.

The Importance of Mortality Data 

The problem with relying on 5 year survival is that it encourages Governments to endorse screening programmes on the basis that they improve statistics, rather than being good for patients. It is vital that all screening programmes are rigorously evaluated for both benefits and harms before they are implemented. If the NHS Mandate looked at overall mortality from cancer instead then the drive to improve would be free from these pressures to artificially manipulate statistics, and the focus could be on better care, as well as public health initiatives that might really make a difference, such as plain packaging for cigarettes.

The Government might even be pleasantly surprised. In 2008, the most recent year where full data are available, the World Health Organisation database ranks the UK quite favourably – just above Germany and better than most European countries outside Scandinavia. Maybe a pat on the back is in order for the NHS? Or is that not politically permissible these days?

A Hiccup for the Health Check-Up

Scientific data can be a real headache for politicians, especially when it has an irritating propensity to directly contradict flagship Government policy.

This is exactly what happened last week, when a Cochrane review published the results of a meta-analysis on the efficacy of Health Check-Ups, which was widely reported by the BBC and others. The review looked at the effects of health screening in over 180 000 patients, and concluded that while those screened were more likely to be diagnosed with high blood pressure or raised cholesterol than those not offered the check-up, there was no difference in mortality, hospital admission or disability between the two groups. The review concludes:

From the evidence we’ve seen, inviting patients to general health checks is unlikely to be beneficial.

The problem for politicians is that this is undermines a key health policy from the Department of Health which involves inviting all people aged 40-73 to a health check to look for the risk of heart disease, stroke, type 2 diabetes and kidney disease. And this includes politicians of all the major parties – the policy was introduced by the Labour Government and has been continued by the Coalition.

What should we make of this? Aren’t we used to contradictory scientific headlines telling us that something is terribly good for us one week and causes cancer the next? Well, how hard we should listen depends on the quality and type of evidence before us. A small observational study is a very different piece of evidence to a large randomised trial, or a systematic review of all the evidence. I have borrowed an illustration from Margaret McCartney’s book The Patient Paradox which illustrates this well. It is a hierarchy of the quality of evidence, with the most reliable being at the top:

Cochrane reviews are not only at the top of this hierarchy as a systematic review, but they are also renowned in medicine as being among the most reliable, unbiased reviews that are conducted. They are important, and we should listen to them. Which is exactly what a Department of Health spokesman did not do in response to this important research. When questioned by the BBC, the response was to say:

By spotting people who are at risk of heart attacks, diabetes, stroke and kidney disease we can help prevent them.

The NHS Health Check programme is based on expert guidance. Everyone having a health check is offered tailored advice and support to manage or reduce their risk of developing serious health conditions.

So the power of a Cochrane review has been dismissed on the basis of expert evidence. When you look at the above hierarchy it is easy to see how ridiculous this is – it is like pretending that a pair of Jacks can beat a Royal Flush, it just does not work.

So where does this leave us? Well for the Government the situation is clear: Inviting large numbers of healthy people for routine health check-ups has no discernible benefit and the Department of Health programme should be reviewed. The main reason for this is that since it is of no discernible benefit, it is poor use of NHS funds. The checks themselves still need to be better evaluated, but they are not unreasonable – if you are going to have a check-up then to look at the 4 disease areas in question once every 5 years is probably the thing to do.

The organisations that really need to take note of this study (but they are unlikely to do so as they make too much money from health screening) are the private health providers like BUPA, which offer annual health checks that are far more wide-ranging than the NHS scheme – including many tests which are of zero value (such as measuring urate, the waste product implicated in gout which is uninterpretable in a person who does not suffer from gout) and others which are extremely controversial (such as prostate screening).

For individuals, however, we need an individual approach. When the Government first announced the proposal to invite people for check-ups most GPs felt mildly bemused – hadn’t we been doing this for years? You can always see your GP for a blood pressure or cholesterol check and the only thing that was different in the new policy was the invitations. There may be good reasons to assess your risk of conditions such as heart disease or diabetes, especially if there are particular concerns, such as a strong family history.

We must remember, however, that health check-ups are, by definition, performed on people with no symptoms. When we engage in health screening of any sort we cross a line that transforms us, temporarily, into a patient. We hope that this will be the briefest of forays into this alien world and we will soon return to our lives, unscathed, stamped with a clean bill of health and medical approval. We must always accept, however, that we may just remain a patient for longer than we have envisaged if a problem is picked up. This may have real benefits – such as avoiding a heart attack – but will also incur personal costs, including anxiety, more tests and the possibility of unnecessary treatment.

There is still a place for individual health check-ups, but these need to be tailored to individual risk, and also our personal views on how we like to deal with risk. We need to get away from the concept that every upright citizen “ought to have a health MOT”. We are not cars in need of a certificate of roadworthiness, and health screening is a complex issue: Its benefits are often far smaller than we first realise, and its potential for harm far greater than we like to admit.

Healthscans: A Lifeline for Patients, or a Cashline for Private Medicine?

One of the questions I am most frequently asked by patients and friends alike (and I am sure most other GPs would say the same), is what I think about Lifeline Health Screening, and so it is high time I gave the matter some attention. I am not the first to write on this subject (Margaret McCartney has been one of the most effective voices on this issue, and the UK National Screening Committee has produced excellent advice leaflets on private screening), and I hope I will be far from the last. Given the effectiveness of the leafleting and advertising campaign of the company involved, the majority of us will have come across their products several times over, and we need to balance such effective marketing with regular comment from as wide a range of doctors as possible.

I try to retain a sense of balance on this blog, but having come at Lifeline with an open mind, I find it increasingly difficult to find anything in favour of the tests they offer, and am extremely concerned about their approach with regard to how they advertise themselves, and the (complete lack of) support if the test results are abnormal. Their website claims that an “easy and painless package of screenings at £139 can help put your mind at ease.” Well the tests are easy to perform, and painless (they state these facts again and again on the site, and there is no doubting these facts), but the statement is highly misleading. The most significant pain associated with any screening test is related to what you might do if the test is abnormal – for instance, they screen for abdominal aortic aneurysm (an enlargement of the main artery to the legs), and the main treatment for this is major abdominal surgery – not exactly a painless event. The assertion that the £139 will “put your mind at ease” also assumes that the tests are going to be normal. Most of us don’t have sleepless nights worrying that we might have a stroke – but if we are told that the artery to our neck is partly furred up, “at ease” is probably the last thing we will feel.

So what of the tests? Well their main package involves five tests, as well as a lipid profile and blood glucose (which are the most useful tests they offer, but your GP will happily do these when needed anyway). I’ll look at them in turn:

Carotid artery screening The test involves a scan of the main artery to the brain to see if it is narrowed by cholesterol deposits. This is useful in patients who have had a temporary stroke (transient ischaemic attack) as they are at high risk of a second, more permanent stroke. If the artery is sufficiently narrowed then sometimes surgery to remove the narrowing can significantly reduce the risk of further strokes. As you can imagine, though, operating on the main artery to the brain is a risky business, and so you would only want to undergo this if your risk of stroke outweighed the risk of surgery. For people without symptoms this is just not going to be the case. There’s a fair chance your GP would feel obliged to refer you to a surgeon, who would advise that you shouldn’t have surgery! What would be more worthwhile would be lifestyle changes – don’t smoke, a healthy diet, possibly attention to blood pressure and cholesterol – but you don’t need a carotid scan to work this out.

Atrial Fibrillation (AF) and stroke risk The test involves a limited ECG to see if your heart rate is irregular, which would put you at risk of stroke. AF is an irregular heart rate, and is generally worth knowing about (although the risk of stroke is only really a problem in the over 75s or those with other health problems which you and your GP will already be aware of). The main issue here is that you don’t need an ECG to screen for AF – the company are hiding behind technology. Your GP can easily exclude AF by simply taking your pulse and seeing if it is regular (and will then arrange an ECG if it is not).

Peripheral Artery Disease The test involves measuring ABPI, which is basically the blood pressure in your legs. It is useful in people with symptoms, but completely meaningless in people without – like the carotid artery screening it would simply be a pointer towards lifestyle measures and you would never want to consider surgery to improve the circulation to the legs without symptoms.

Aortic Aneurysm Screening This scan looks for a weakness of the main artery to the legs, called an aneurysm. The main concern about aneurysms is that they can rupture, which is a sudden and commonly fatal event. Small to moderate aneurysms are usually left alone, but a large aneurysm can be repaired surgically. This is a major operation with significant risks involved, and the evidence in favour of screening being more beneficial than harmful is only for men over the age of 65 – a screening programme which is being rolled out in the NHS anyway.

Osteoporosis Screening This has all the hallmarks of “We’ve got a scanner, what else can we do with it?” It’s the wrong test (a heel scan, which is only a test to see if you might need another test), being performed on the wrong people. This condition relates to how our bones become more brittle as we get older, and so more prone to fracture. If you are at high risk of fracture (eg you have had a fracture already, have coeliac disease or are a post-menopausal woman with a family history of osteoporosis) then you may well want to consider having treatment with medication to reduce your risk – but if this is the case then your GP can arrange the proper test, which is a Dexascan.

Worst of all is the aftercare once you have had your scans. No doubt to cut costs the test results are simply forwarded to your GP, who is left to deal with the interpretation and emotional fallout from abnormal test results. All too often private companies are able to pick up the financial benefit from screening and leave the real cost to the NHS, and Lifeline Screening UK Ltd are far from alone in this practice – Spire Healthcare do the same with their Lifescans, and company medicals have been doing it for years. It is high time that we started seeing screening tests in the same light as any other medical intervention – capable of both benefits and harms – and regulated them accordingly. The onus should be on the company to prove benefits outweigh harms before they are licensed to offer screening tests to the public – but maybe then they would just be left with the tests the NHS already offers, and where would be the profit in that?

Will Exercise Help Your Depression? Only You Can tell

The long-held belief that exercise can be beneficial in treating depression was brought into question last week by a study, published in the BMJ and widely reported in the news, which reported that exercise did not improve recovery in patients suffering from depression.

Exercise
Exercise can take many forms, but will it help depression?
Image courtesy of freedigitalphotos.net

As you can imagine, the study has prompted much debate. Can such a definite statement be made about so complex and varied a condition as depression? (probably not); how do you define exercise? (your guess is as good as mine); is that really what the study showed? (not really, it just showed that patients encouraged to undertake a programme of exercise got better at the same rate as those who did not). Interesting and erudite as these discussions might be, they are not really relevant if you have depression and want to know whether or not to get your trainers on – because you don’t want to know if exercise will treat depression, you want to know if it will help withyour depression. Thankfully there is another clinical trial you can refer to – the ultimate clinical trial where n=1 – that means there is only one patient (you) trying one treatment and seeing if it works.

We do a lot of n=1 trials in medicine. Every time we try a cream for a rash, a medicine for indigestion or an antibiotic for tonsillitis we are essentially conducting an experiment: Here’s a symptom, there’s a treatment, see if it helps. If it doesn’t, try something else. It’s not great science, but it is good medicine.

Of course, an n=1 trial won’t work for everything in medicine. Firstly, you need to be sure that the treatment you are about to try doesn’t carry a significant risk (which is why frontal lobotomy as a cure for depression has somewhat gone out of fashion), and then you need to be able to know if it has worked, and in a reasonable timescale. For this second reason, a trial of treatment is not much help when it comes to deciding many of the big questions in medicine – like whether or not to take a statin for cholesterol, or to have your PSA measured to try to detect prostate cancer – for these dilemmas there is no escaping the need for large-scale clinical trials to help guide us. A statin is not going to make you feel better, so how would you know it was working? Even if it lowers your cholesterol, how do you know that this will do something that actually matters to you – like stopping you having a heart attack? There’s no value in a ‘try it and see’ approach here.

Exercise in depression, however, is ideal for an n=1 trial. Exercise is clearly a safe treatment to try – more than that, we know it has many health benefits beyond any help it might be for depression. What is more, there is good reason to think it might help lift mood – whether it is just the benefit of feeling fit, effects on serotonin levels or the magic of endorphins it seems worth looking into. What is more, those who testify to its benefits report that they actually feelbetter soon after exercise – no need for a 2-6 week trial like there is for antidepressants. Of course, you may have to try it a few times to get a feel for it. You might overdo it one day and feel worse, or find one form of exercise works better for you than another, but the message is clear – if you are going to benefit, you will feel the benefit of your experiment sooner rather than later.

So what should you do if you have a negative trial – if you give exercise a go and feel as flat as ever, or maybe even worse? Well there is still a more general principle that will work for everyone, and it is this: When you are depressed there will be some things that, when you do them, help you to feel a little bit better. Whether it is exercise, gardening, music, art stroking the cat or just getting up on time in the morning doesn’t matter – whatever it is, you’ll feel better if you do it, so try to do it more!

Who’s Afraid of the Big Bad C?

There is a numbers game called 21, where two players count up in steps of 1, 2 or 3 with each trying to force the other to call the number 21 – I hear that sometimes drinking is involved. Doctors and their patients often play a similar game, only with words rather than numbers, and without the usual inebriation.

A typical opening gambit from the patient might be: “I’m sure it’s nothing to worry about, doctor,” which is a gentle thrust easily countered by: “Is there anything you are concerned it could be?” This usually finds its mark and the doctor is home and dry, but a determined patient might stubbornly pass the baton once more like this: “Do you think it’s serious, doctor?”, and the physician is undone – the C word must now be used. Not the vulgar C word that might excite a Censorship Board, but the genuinely offensive version that we are truly afraid of. The C word that has the power to turn our world upside-down: Cancer – because it’s always cancer that lurks in the background of these conversations.

I am sure there are individuals who can take it in their stride, but there is no doubt that as a society we are terrified of cancer, and will go to remarkable lengths to try to avoid it. And rightly so, it kills people – we should indeed see it as our enemy and combat it wherever we can – but what is it that gives cancer such a unique status in our society? After all, it is not the only condition associated with significant mortality.

The extraordinary potential for cancer to impact a person’s life was powerfully described by Emma Gilbey Keller in her article for The Guardian on 27th April, as she eloquently detailed her own 40 day journey with the disease – from first detection of abnormal cells by mammography, through bilateral mastectomy, ITU, infection and eventual recovery. Harrowing. Her own word, and the only one that is suitable. Anyone involved in health care should read her article and then have some time alone to think. It certainly got me thinking.

If the only thing that is bad about cancer is that it kills people, then I should be delighted for her – she certainly won’t die from breast cancer now. Her oncologist was clearly pleased – pronouncing the all clear 5 days after the operation, another triumph, another life saved. So why did the article leave me feeling sickened and angry at the doctors who did this to her? Maybe there is much more to cancer than death – and is death inevitable anyway? Emma Gilbey Keller’s cancer was detected by screening and was the earliest type of breast cancer, known as Ductal Carcinoma In Situ, or DCIS. Under the microscope DCIS looks like cancer, and so doctors have given it this exalted title, but in real life it is disingenuous to brand it that way. When I hear the word cancer I think of something that will inevitably spread and kill if left untreated. DCIS is more likely to go away on its own as our immune system sorts it out. Estimates are difficult, but between 14% and 53% are thought to develop into an invasive cancer over a period of 10 years. The problem is that the treatment for DCIS is largely the same as for a true cancer – surgery and radiotherapy.

The day you are told you have cancer is likely to burn its way into your memory with the clarity usually reserved for your wedding, the birth of your child or a national disaster like 9/11. So what would I fear if I were to be diagnosed? Death, yes, but far more than that. Loss of control would be top of my list. Knowing that life was suddenly put on hold – whatever I had planned for the next however many weeks will have to be shelved. And the expectation for this is high – doctors get very annoyed if you suggest delaying treatment until after your holiday, or some important deadline at work. Cancel everything, they will demand, your life is at stake.

Then there is telling everyone – and the inevitable talk that will follow. Well meant, I’m sure, but can I bear the idea of people saying: “Have you heard?” and “He’s being so brave.” How do you tell people? Will they know what to say to me? Do I want this label? Do I have a choice?

Finally there is the treatment. Surgery – that’s going to hurt! And not surgery that will give you something in return, a new lease of life like a cataract operation or a new hip. Surgery for a breast cancer, or a prostate cancer picked up on screening will not make you feel any better – you weren’t feeling ill in the first place. And radiotherapy, chemotherapy, whatever they suggest – side effects, nausea, tiredness, depression, the list goes on. Risks carried with every part of it, but eclipsed by the drive to get rid of this thing that I can’t even see. Emma Gilbey Keller said risk was the reason she had to do it – she couldn’t take the risk of doing nothing. I don’t blame her for one moment, but when you think about the risks she did take in order to eliminate that one risk; the definite, palpable pain she went through in order to prevent something that might, or might not, happen sometime in the future; the permanent changes to her body (remodelling, her plastic surgeon arrogantly called it)…well it certainly gets you thinking.

The biggest harm associated with cancer screening is the fact that there will inevitably be some people who are treated needlessly, as their ‘cancer’ will never actually make them ill. When the only treatment doctors can offer them is as aggressive as it is for cancers like breast or prostate cancer, the medical profession needs to acknowledge that in trying to cure someone of this disease, it will inflict on them much of the pain and misery associated with the very condition it is trying to prevent. And when doctors dare to use a word as powerful and emotive as the Big C, they must be very careful that they are not coercing people to look for cancers that no-one knows how to treat – and very cautious if radical treatment is the only option they have to offer if they find something.