Most couples are aware of the potential hazards of putting off “trying for a baby” – and rightly so. As less than 2.2 per cent of women over 43 who undergo IVF are successful, it’s not as if there is an easy solution on hand for couples who fail to conceive naturally.
But now a host of fertility tests is piggybacking on to this fear that women (and, yes, men) may be leaving it too late. The most established test measures a woman’s follicle stimulating hormone, or FSH. This fluctuates slightly through the menstrual cycle, but rises in the menopause. However, this test is not useful for everyone, as it may not give much more meaningful information beyond what a woman already knows about her body.
Continue reading “The stork knows best”
Over the past couple of decades, chlamydia screening has been discussed, started, changed, discussed, evaluated, disagreed with, and discussed again.
One thing I think has been missing is large scale Randomised Controlled Trials performed early on, and used to make cost-effective decisions.
Instead decisions have been made on trials that have now been decided as flawed, and last year the National Audit Office - Chlamydia testing ‘wasting money’ – concluded that millions have been wasted.
And this week the BMJ reports that screening for chlamydia with a single test doesn’t prevent pelvic inflammatory disease. – Randomised controlled trial of screening for Chlamydia trachomatis to prevent pelvic inflammatory disease: the POPI (prevention of pelvic infection) trial
Obtaining more information will be nearly impossible – now that screening kits in GP surgeries are endemic, any more “pure” trials – where people are either screened as part of a study, or aren’t screened as part of a study, are going to be much harder to do.
A collection of papers published today in the Journal of Medical Screening affirm that breast screening is a good thing. The first, from the Wolfson Institute of Preventive Medicine, takes two sets of data – one from a randomised trial in Sweden, and the other from England’s Breast Screening Programme (and not, therefore, a randomised controlled trial.) The paper concludes that “between 2 and 2.5 lives are saved for every over-diagnosed case.”
The second paper is regarding the ‘Age’ trial. The women were randomised to either screening from age 40/41 or age 48. They concluded that uptake was “comparable with that in the UK screening programme”. The conclusion I expect to be put out in a small media gale is that breast screening is good, desirable, and that woman want to have it.
I fear that this will not take us to the real argument about breast screening which we do need to have. Given what we know about breast screening (and we could pick holes in this trial, not just about the fact that breast cancer deaths are declining independent of screening) – which is best seen in Cochrane reviews (when all the evidence, not just the bits that fit your argument, are assessed) about breast screening. We know that overdiagnosis, with all the attendant surgery, chemo or radiotherapy, exists. But most women attending for breast screening do not. The real debate needs to be with each woman as she is given properly informed consent so that she can choose to have, or not to have, screening. An independent review of the cost effectiveness of breast screening is sorely needed.
Maybe I’m not imagining it: maybe we are all getting a bit more attuned to the problems with screening, even in the US.
But when the doctor who discovered prostate specific antigen (PSA) - which is commonly used to try to detect prostate cancer – writes in an article in the New York Times The Great Prostate Mistake, that “ I never dreamed that my discovery four decades ago would lead to such a profit-driven public health disaster. The medical community must confront reality and stop the inappropriate use of PSA screening. Doing so would save billions of dollars and rescue millions of men from unnecessary, debilitating treatments” hope is definitely in the air.
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?
Is it an unsightly freckle – or a deadly melanoma? To find out, many people now visit private or high-street clinics offering mole checks. Some people say they just want a quick consultation; others seem reluctant to “bother” their doctor. These services have proliferated recently, but how reliable are they?
Dermatology is one of the few medical specialities that still rely, to a great extent, on pattern recognition. Indeed, being able to make a diagnosis from a glance – the role of the consultant during a traditional dermatological assessment – is, I am told, what makes it so satisfying.
Continue reading “Of moles and men”
Very nice judgement from the UK Advertising Standards Authority on television adverts from Lifescan, the screening company, who have been told that they can’t use their ads in this form again.
So that’s their leaflets gone and now their TV advert. Well done to the complainants – I don’t have a TV so was spared these ads.
Although I am mystified as to why the ASA haven’t held up point three: “ The possibility of results leading to unpleasant and distressing tests and examinations, which might prove to be needless. We considered it unlikely.” Consideration doesn’t really cut it with me: I’d prefer evidence.
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.
An early contender for the most annoying research publication of the year has been delivered courtesy of the Journal of Medical Screening. Entitled Barriers to cervical screening attendance in England: a population-based surveythe researchers interviewed 580 women face to face and then corrolated their voting behaviour with their attendance at cervical screening and “barriers to attendance”.
The press release clangs the alarmist bell – and aren’t all medical press releases involving cancer liable to heavy handed treatment – ”Women who don’t vote are less likely to attend cervical screening. In the first study to test the theory that low cervical screening uptake is associated with broader social disillusionment, a paper in the JMS has shown that women who said they rarely or never voted in elections were more likely to be overdue for screening. ”
The paper goes on to say: “The association between voting behaviour and screening uptake lends support to the hypothesis that falling screening coverage may be indicative of a broader phenomenon of disillusionment, and further research in this area is warranted”.