{"id":45944,"date":"2019-10-25T13:42:26","date_gmt":"2019-10-25T12:42:26","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=45944"},"modified":"2019-11-07T20:11:17","modified_gmt":"2019-11-07T19:11:17","slug":"margaret-mccartney-cancer-screening-review-diminishes-informed-choice","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2019\/10\/25\/margaret-mccartney-cancer-screening-review-diminishes-informed-choice\/","title":{"rendered":"Margaret McCartney: Cancer screening review diminishes informed choice\u00a0"},"content":{"rendered":"<p class=\"standfirst\"><span style=\"font-weight: 400\">We should resist the push for financial incentives, increased screening uptake, reorganisation, and restructuring, says Margaret McCartney<br \/>\n<\/span><\/p>\n<p><!--more--><span style=\"font-weight: 400\">Mike Richards\u2019<a href=\"https:\/\/bit.ly\/2OTjM1a\"> independent review of adult screening programmes<\/a> in England is out and <\/span><a href=\"https:\/\/www.bmj.com\/content\/367\/bmj.l6059\"><span style=\"font-weight: 400\">can be summarised<\/span><\/a><span style=\"font-weight: 400\"> as: \u201cnothing is too much.\u201d [1] Calling for financial incentives, increased uptake, reorganisation, and restructuring, Richards writes: \u201cEvery day of delay is a missed opportunity to catch a person\u2019s cancer or disease at an earlier point, and potentially save their life.\u201d<\/span><\/p>\n<p><span style=\"font-weight: 400\">Healthcare in the UK is a shifting entanglement of policies and politics, frequently at odds with each other. Initiatives launched with aplomb are reversed later in quiet. We get soundbites, not substance, and crucially, little chance to permanently embed learning and improve the way evidence and policy meet. The last decade saw acknowledgement of overdiagnosis and the ethical need for choice in screening. This report waves that off<\/span><span style=\"font-weight: 400\">. <\/span><span style=\"font-weight: 400\">It misunderstands what screening is, and what it can and cannot do.<\/span><\/p>\n<p><span style=\"font-weight: 400\">First: there\u2019s the idea that a days\u2019 delay can kill someone in the screening process. Let\u2019s recap: screening is designed to find disease at an early stage (or as <a href=\"https:\/\/apps.who.int\/iris\/bitstream\/handle\/10665\/37650\/WHO_PHP_34.pdf?sequence=17\">Wilson and Jungner put it, at \u201clatent\u201d stage<\/a>). Taken to its logical conclusion, people would need to be screened daily to prevent \u201cdelay\u201d<\/span><span style=\"font-weight: 400\">\u2014<\/span><span style=\"font-weight: 400\">an absurd proposition that would do untold harm.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">We should, however, be concerned about delays<\/span><span style=\"font-weight: 400\">\u2014<\/span><span style=\"font-weight: 400\">but which one? <a href=\"https:\/\/www.england.nhs.uk\/statistics\/wp-content\/uploads\/sites\/2\/2019\/07\/Cancer-Waiting-Times-Annual-Report-201819-Final-1.pdf\">What about the 62-day wait<\/a> for first treatment for cancer following an urgent GP referral<\/span><span style=\"font-weight: 400\">\u2014<\/span><span style=\"font-weight: 400\">below target, worse than last year, and falling. Or the incompetence of Capita, <a href=\"https:\/\/doi.org\/10.1136\/bmj.l1347\">who didn\u2019t invite many thousands of women<\/a> to cervical screening, or inform several thousand of their results. That\u2019s where to sling your arrows.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">As for \u201cLung Health Checks\u201d<\/span><span style=\"font-weight: 400\">\u2014<\/span><span style=\"font-weight: 400\">CT scans for heavy smokers in some areas<\/span><span style=\"font-weight: 400\">\u2014<\/span><span style=\"font-weight: 400\">which the report describes as being \u201cpiloted\u201d and \u201crolled out nationally\u201d if they succeed. <\/span><span style=\"font-size: 1rem\">This despite the fact that lung cancer screening has not been approved by the UK National Screening Committee\u2014\u00a0\u00a0a cause for concern\u2014and where are the pre-specified standards, planned to be independently assessed, that would tell us whether or not this \u201cpilot\u201d has succeeded? <\/span><span style=\"font-weight: 400\">The standards of screening to be adopted should be those of Wilson and Jungner.\u00a0 It is because it is rare for screening programmes to offer more good than harm that we need specialist consideration that understands the science which underpins it<\/span><span style=\"font-weight: 400\">\u2014<\/span><span style=\"font-weight: 400\">and this includes rigorous cost effectiveness analysis. Resources spent on screening healthy people cannot be given to people who are dealing with the reality of deprivation, early multimorbidity, and under resourced mental health services.<\/span><\/p>\n<p><span style=\"font-weight: 400\">We must, I am afraid, go on<\/span><span style=\"font-weight: 400\">\u2014t<\/span><span style=\"font-weight: 400\">o the bald statement that \u201ca decreasing proportion of women are being screened. This is a major concern and must be reversed.\u201d Now, this might be of note if, for example, some women want screening, but can&#8217;t access it, or find the means unacceptable<\/span><span style=\"font-weight: 400\">\u2014<\/span><span style=\"font-weight: 400\">for example, a self taken HPV test may be more acceptable to some. But if a woman has made an informed choice that she does not want to have screening, it is bewildering, and unethical, that the system seeks to reverse her choice. Rather than the recommendation seeking \u201cimplementation of evidence-based initiatives to increase uptake,\u201d we should want to improve the quality of the informed decisions people make<\/span><span style=\"font-weight: 400\">\u2014<\/span><span style=\"font-weight: 400\">no matter what they are. Have we forgotten autonomy? It seems so, for the recommendation is to offer financial incentives to GPs to increase uptake, rather than improve the quality of decision making. This is a return to the worst of the Quality and Outcomes Framework, and creates an inherent conflict of interest. We should reject this absolutely.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">The UK National Screening Committee is one of the few bits of the NHS which works very well.\u00a0 It stands for evidence, for cool assessment of cost effectiveness and potential harms, and calm consideration. As I have written before, it is deeply boring, and we should be grateful for that. It is light not heat, and science before soundbites. Anything that threatens, rather than strengthens that function is to be resisted. Richards wants a reorganisation, placing this function in NHS England. Not only does this threaten the independence of the UK National Screening Committee, it drives wedges between the four nations. For despite the cover claims that this report is \u201cindependent,\u201d secretariat was provided by NHS England. A repeated problem for the NHS is not realising what is good until it is gone.<\/span><\/p>\n<p><em><strong><span class=\"il\">Margaret<\/span>\u00a0<span class=\"il\">McCartney<\/span><\/strong> is a GP partner, Glasgow.<\/em><\/p>\n<p><em><strong>Competing interests<\/strong>: MMC is a senior fellow for evidence and values at the RCGP, and a freelance writer and broadcaster who also receives royalties for three books. She has written frequently about screening and complained to regulators about advertising for non evidence based screening and around informed choice. She gives a small amount regularly to Keep our NHS public and is honorary fellow at the CEBM Oxford.<\/em><\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>We should resist the push for financial incentives, increased screening uptake, reorganisation, and restructuring, says Margaret McCartney [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/bmj\/2019\/10\/25\/margaret-mccartney-cancer-screening-review-diminishes-informed-choice\/\">More&#8230;<\/a><\/p>\n","protected":false},"author":1,"featured_media":45945,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[236,5756],"tags":[],"class_list":["post-45944","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-nhs","category-too-much-medicine"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.6 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Margaret McCartney: Cancer screening review diminishes informed choice\u00a0 - 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