The issue of evidence on the Breastlight breast monitoring product for women has got me thinking about how much evidence one should have before an intervention is declared to work. In an ideal world, there would be continuous monitoring of all interventions so that very late or very rare complications would show up. In the real world that doesn’t often happen and we have to make do with initial studies and then voluntary reporting of problems thereafter.
So the quality of the evidence at the start would seem important. Here’s another Boots product: advanced electronic cold sore treatment which says it ”reduces the duration of the attack and speeds up the healing time”. It’s a good concept, and certaintly cold sores are common and often unpleasant. So does it work?
Following the Christmas day bomb attempt on a US aircraft, the British and American governments have vowed to tighten airport security, including plans for CT body scanners. This has raised concerns – not least that the images generated by the scanner would infringe on personal privacy. The more pressing issue for me is radiation exposure. How big a dose will these scanners deliver, and can we be reassured that they are not going to do us harm? Attitudes towards radiation have changed over the years. While nowadays doctors are told to justify every single exposure, this has not always been the case. In the US, in the 1920s, children’s shoe shops often used x-ray machines to assess whether shoes and feet were a good match. (The trend reached the UK later.)
There were no warnings about overuse or risks to pregnant women, and it wasn’t until 1949 that a paper appeared in the New England Journal of Medicine questioning the practice. In 1956 a paper appeared in the British Medical Journal investigating the radiation dose from machines made in the UK. Attention was also drawn to case reports of children with abnormalities of the leg, thought to be due to radiation. The authors didn’t propose a ban, but they did suggest regulation.
Continue reading “Long-haul radiation”
So last week I had several emails, and then saw several adverts/advertorial, for a device which is being sold in Boots, called ‘Breast Light’. It is almost 90 UK pounds, and it is being given a prominent position in my local store. The website for it claims it is ‘for earlier detection’.
I asked the pharmacist why Boots was selling it. She said it was for patient choice, and it was a useful thing for women to have. I asked her what the evidence was that it worked. She told me to look at the website. Hmm.
I do think that Karsten Jorgensen and Peter Gotzsche deserve a medal. Over the years they have worked in the Nordic Cochrane Centre they have published, unwaveringly, what their research has shown. This is, namely, that breast screening is not very efficient and causes harm.
It shouldn’t be such a big deal – research papers come out all the time arguing against what is commonly being done. But the problem with breast screening is that it seems to contain an enormous amount of emotional investment, and the only parallel I can think of is alternative medicine.
Boris Johnson isn’t just endlessly entertaining, intelligent and amusing, but he is actually, as Mayor of London, in a position of power.
So it was amusing to read his newspaper column about how his private medical examination (“my feeling from the female doctors and nurses was that I was doing better than I ever thought possible … the general ego-boost was what I imagine it must be like to be in a South-East Asian massage parlour and receive a series of extravagant and wholly warranted compliments on one’s physique.”)
However Mr Johnson’s check-up did not go to plan, because he received the results not of his own blood and other tests, but of some other unfortunate person with leukaemia. Boris laughs this off and gets his real results couriered round.
Apparently the Mayor of London’s annual exam has to be done for “insurance purposes”. But what a waste of time and money!
News from the US, I can scarcely believe it: The New York Times reports that the American Cancer Society now accepts that screening for breast and prostate cancer is not only inefficient, but frequently inaccurate and alarmist. It has realised that such programmes – designed to detect cancer early – can do damage too, because they often detect cancers or pseudocancers that were never going to maim or kill.
That is the bit I can believe. After all, these are evidence-based observations, and none is particularly new. A recent paper in the Journal of the American Medical Association (Jama) also highlighted the weaknesses of screening. What I have difficulty with is that paper’s conclusion: “To reduce morbidity and mortality from prostate cancer and breast cancer, new approaches for screening, early detection, and prevention for both diseases should be considered.” The problem with screening and even early detection is that because these two elements sound useful, we have great difficulty in believing it when the evidence tells us they are not.
The Jama paper states that, after 25 years of screening, “conclusions are troubling: Overall cancer rates are higher, many more patients are being treated, and the absolute incidence of aggressive or later-stage disease has not been significantly decreased”. The authors also say that screening comes at significant cost, including overdiagnosis and overtreatment. The complications of therapy are likely to get worse as the population ages. Not only that, but treatments for relatively indolent disease may in themselves do harm.
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The Scottish Exhibition and Conference Centre is currently alive with the sound of thousands of GPs discussing ‘Excellence in Practice.’
But just what is a working definition of excellence? The Right Hon Mike O’Brien, Minister of State for Health, made a rather brave speech. He seemed likeable and pleasant, and able to tell mildly risque jokes about bishops, which made his frequently contradictory references to “evidence” slightly disappointing.
A valiant effort this week from the British goverment’s advisory body, the Human Genetics Commission, which has issued a draft statement of principles designed to clamp down on “direct to consumer” genetic testing kits that are sold at significant cost via the internet, without any referral from or interpretation by a doctor: Move to regulate genetic tests sold to public
It calls for pre- and post-counselling for tests designed to identify hereditary diseases, extreme caution before using tests of any sort on children or adults unable to provide informed consent, clear explanations of the limitations of any such tests, and tough measures to ensure DNA is not released to third parties.
Do read a post on the Health Care Blog - How to Rein in Medical Costs, RIGHT NOW - a fantastic down-to-earth summary of what the US is wasting healthcare resources on appears on this US blog. In this area the NHS can feel rather proud – America on the case of the NHS – in having realised already that evidence based medicine is good medicine, as well as being more cost effective. For example, here’s a quote from a US website reporting in the past few days on the two New England Journal of Medicine trials on PSA [prostate specific antigen] screening
“We must put this controversy into perspective together with our patients before embarking on a screening protocol. In practice, many men with a history of borderline or high PSA levels do not recall having had a conversation with their physician about the pros and cons of prostate cancer screening. This includes men without health insurance who then face either further testing that can cost thousands of dollars or continued confusion and concern about their cancer status.These situations are unfair to the individual. A frank discussion about the relevance of screening results, including the potential benefits and harms associated with testing, should precede any screening test for prostate cancer. To attempt this conversation after a PSA test or DRE biases an honest assessment of each individual’s beliefs and preferences”.
This has been standard practice in the UK for some time. Sometimes the NHS is actually pretty good.
The test was going okay, until I got to this: name four creatures whose names start with the letter “S”. It took me several seconds to get spider and seal. It took me three more hours to remember slug, even though one had appeared on the kitchen floor that morning. Scorpion and sea anemone came much later. Overall, I didn’t do terribly well.
This could have been worrying. The seemingly innocuous question was part of the simple test that, if you believe the tabloid press, “can detect Alzheimer’s in five minutes”. It is not difficult – who is the prime minister, when did the first world war start – but, having completed it, I found my memory wanting. And here’s the thing: I’m not very bothered about it.
The test, recently published in the British Medical Journal, was billed by its authors as a fast and easy way to screen for Alzheimer’s disease, enabling treatment to start early. It sounds good, but there are a number of problems.
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