Political woo

October 30th, 2009 by Ben Goldacre in bad science, numerical context, politics, screening | 93 Comments »

Ben Goldacre, Saturday 31 October 2009, The Guardian.

Every now and then it’s fun to dip into the world of politics and find out what our lords and masters are saying about science. First we find Brooks Newmark, Conservative MP for Braintree, introducing a bill to reduce the age for cervical cancer screening to 20. The Sun has been running a campaign to lower the screening age, on the back of Jade Goody’s death at 28 from cervical cancer, and gathered 108,000 signatures on a petition. The Metro newspaper have commissioned a poll showing that 82% of 16 to 24-year olds in England agree with lowering the screening age.

“Cervical cancer may be rare in women under 25,” says Mr Newmark: “but it is inexcusable to dismiss the cases that occur as negligible statistics.” Oh, statistics. “We have a vaccination programme that ends at the age of 18 and a screening programme that begins at the age of 25. That leaves young women between the ages of 18 and 25 caught in a medical limbo, eligible for neither vaccination nor screening.”

Somebody should do something: an intuition which you will find at the bottom of many calls to extend screening programmes beyond the population in which they can provide useful information, and into low risk populations where they simply waste resources, or do more harm than good.

If screening worked, you would expect to see a reduced incidence of cervical cancer diagnoses in people who have been screened, compared with people who have not been screened, in the 5 years after screening: because precancerous lesions will have been detected and dealt with before they got to a more advanced stage.

In August 2009 the British Medical Journal published a large study examining this very question. It found that screening was associated with an 80% reduction at age 64, 60% at age 40, and so on. But cervical screening in women aged 20-24 has little or no impact on rates of invasive cervical cancer in the following 5 years. Only the Liberal Democrat MP Evan Harris introduced these findings to the debate (with the rather excellent line: “The honourable Member for Braintree cited evidence from The Sun, so I want to refer to a recent edition of the British Medical Journal”).

Meanwhile on the very same day David Tredinnick, Conservative MP for Bosworth, stood up to speak on medicine. Scientists and doctors who doubt the efficacy of alternative therapies are superstitious, ignorant, and racially prejudiced, he explained. “It is no good people saying that just because we cannot prove something, it does not work… I believe that the Department needs to be very open to the idea of energy transfers and the people who work in that sphere.”

He went on. “In 2001 I raised in the House the influence of the moon, on the basis of the evidence then that at certain phases of the moon there are more accidents. Surgeons will not operate because blood clotting is not effective and the police have to put more people on the street.”

Where does this moon stuff come from? “I am talking about a long-standing discipline—an art and a science—that has been with us since ancient Egyptian, Roman, Babylonian and Assyrian times. It is part of the Chinese, Muslim and Hindu cultures… Criticism is deeply offensive to those cultures,” says Tredinnnick: “and I have a Muslim college in my constituency.”

Any attempts to challenge Tredinnick’s ideas are based, he explains, on “superstition, ignorance and prejudice” by scientists who are “deeply prejudiced, and racially prejudiced too, which is troubling.” So I hardly dare to mention that Tredinnick tried and failed to claim £125 in parliamentary expenses for attending an intimate relationships course teaching how to “honour the female and also the male essence and the importance of celebrating each”, run by a homeopath.

Meanwhile the flag-bearers for conservatism at the Spectator are now promoting climate change denialism, as George Monbiot has pointed out, and Aids denialism, under the tedious flag of “only starting a debate”, even in their print edition. And finally, the NextLeft blog recently pointed out that of all the top ten conservative blogs, every single one is sceptical about man-made climate change. It could be an interesting five years ahead.


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93 Responses



  1. scarynige said,

    October 30, 2009 at 11:27 pm

    Ben, I’m a great fan of your work but don’t you do yourself a disservice by resorting to an ad hominem attack on Tredinnick? I was expecting you to quote a paper that examined the evidence for cyclical physiological effects with the same periodicity as the moon’s cycle round the earth.

    Trying and failing to claim expenses for a barely related activity doesn’t cast much doubt on it. I’m sure he’d have been refused expenses for the same course run by a qualified sex therapist too (if that’s a meaningful job title), as in both cases it has nothing to do with being an MP.

  2. DevonDozer said,

    October 31, 2009 at 12:37 am

    It won’t be interesting at all. Just more of the same old twaddle, but different coloured rosettes. Blair had his babes and the heir to Blair has his ‘cuties’. Plus ca change . . .

    I see that the EU constitution is about to be nodded through, so they’re all redundant anyway. Why not just get rid of them? They don’t do anything – apart from making life difficult for the rest of us – and cost us remaining taxpayers a fortune.

  3. TriathNanEilean said,

    October 31, 2009 at 1:31 am

    I’m sympathetic to what you are saying DevonDozer, for many MPs are a waste of space. But while some of them are pathetically greedy, they don’t really cost us that much, since there are only 648 of them. Compared to the bankers who we’ve just had to put hundreds of billions at risk to save, and who then return to paying themselves obscene bonuses, MPs are small fry.

  4. Pro-reason said,

    October 31, 2009 at 3:07 am

    I actually think it’s *his* position that is racist. He is saying that science is a white thing. Quite a few dark doctors might be rather annoyed by that.

  5. danielearwicker said,

    October 31, 2009 at 10:11 am

    “Energy transfers”?

  6. mockingbird said,

    October 31, 2009 at 10:40 am

    Is this the study you’re talking about Ben? www.bmj.com/cgi/content/full/339/jul28_2/b2968?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=1&author1=Sasieni&andorexacttitle=and&titleabstract=cervical&andorexacttitleabs=and&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=date&fdate=7/1/2009&tdate=9/30/2009&resourcetype=HWCIT

  7. kristinam85 said,

    October 31, 2009 at 10:57 am

    The PAP-test is so quick, so easy, so cheap. Why should a relatively rich country like the UK restrict people’s access to this test!? It is almost like restricting who can use a band aid and when. Why is the NHS throwing something like 200 pounds per girl for the half-baked HPV vaccination, but cannot spare the 10 pounds for just one extra PAP test at age 20?

  8. aggressivePerfector said,

    October 31, 2009 at 11:00 am

    The timing of this article is really excellent, coinciding perfectly with the government being completely frank and open about its attitude to science and evidence, with the sacking of chief drugs advisor Professor Nutt.

  9. tanveer said,

    October 31, 2009 at 11:34 am

    I don’t think it is a matter of left or right politics. At the moment there does not seem to be much difference between the parties on most issues and none of the parties have any great ideas for getting us out of the mess we are in. Politicians, in general, do not think of science as important despite all of the rhetoric that they spout and their grasp of it has always been shaky.

  10. natsils24 said,

    October 31, 2009 at 12:31 pm

    kristinam85 – It doesn’t matter what the PAP test costs or how quick and easy it is. It is a screening test and as Ben mentioned in his article the BMJ paper and other published evidence shows clearly that it is ineffective to screen women under the age of 25. Any screening test has a risk of both false positives and negatives and therefore causing needless investigations and worry for the patient. That is why there is always an age criteria for any screening process, you need to use the evidence to decide which population you are going to screen.

    I personally would love to meet a surgeon who doesn’t want to operate during certain phases of the moon! I am a final year medical student, the reason I doubt the efficacy of alternative therapies is that I have read to evidence (or lack of it) for their effectiveness. But then again I am probably horribly prejudiced too!

  11. Santiago G Moreno said,

    October 31, 2009 at 12:48 pm

    It is worrying to see how some politicians, who are the ones making decisions, have no clue about the biases that information may carry with it. Perhaps it is time to run a worldwide campaign about argumentative fallacies…

  12. matt TC said,

    October 31, 2009 at 1:17 pm

    I for one am fully open to the idea of “energy transfers” for our universe would be a significantly more boring place without them.
    Although, I suspect, out of all the possible energy transfers he is talking about the ones which don’t exist.

  13. MarkE said,

    October 31, 2009 at 1:37 pm

    It’s a bit unfair to say that ‘only’ Evan Harris introduced the BMJ findings to the debate: because Brooks Newmark was introducing a 10-minute rule Bill, under the Commons Standing Orders there can only be one speech in favour and one against (of a maximum of 10 minutes). Most 10-minute rulw Bills aren’t opposed, so Evan harris speaking against it was reasonably significant in procedural terms. More details at: www.parliament.uk/about/how/laws/private_members.cfm

  14. Jeesh42 said,

    October 31, 2009 at 1:39 pm

    Re kristinam85: Are you saying, “let’s do it ’cause it’s cheap, even though it’s useless”?

    As explained in the article, this isn’t a case of the health service denying screening because of “negligible statistics” or because of cost, but because it doesn’t help that group of people in any way. It’s not about “cost-effectiveness”, just “effectiveness” full stop. It wouldn’t save *that one extra life*, like Brooks Newmark seems to think.

  15. emen said,

    October 31, 2009 at 2:43 pm

    Natsils –
    are these data about the false negatives and false positives of the Pap test based on 3-yearly tests?
    Why don’t the NHS screen for cervical cancer every year, like the health services in most European countries? Is there no evidence of any benefit from an annual test at all?

    I think that the argument “needless worry for the patient” is pretty weak. When you are really ill and the doctors take 2 weeks to consider every single detail of your illness (including having a LOOK at an MRI or CT scan), 2 weeks after 2 weeks after 2 weeks will pass and no medical staff will worry about needlessly worrying you.

    A patient can be told about the chances of false positives and they can decide THEMSELVES what they want to worry about: the lack of testing or the chances of getting a false positive result.

  16. natsils24 said,

    October 31, 2009 at 3:11 pm

    emen – Firstly I didn’t give any data about the false positives and false negatives of the Pap test. With the introduction of liquid based cytology for the smear test the accuracy has improved. What we are screening for is for dyskaryosis (abnormal cells which can be pre-malignant) and therefore women who will need further investigation with a colposcopy or cervical biopsy, both far more invasive procedures with their own risks.

    In the UK screening is at 3yrly intervals up to 50 yrs old and 4yrly up to 50 – 64. The decision was made for this time interval based on an audit which identified this as the most appropriate screening interval (P Sasieni, J Adams and J Cuzick, Benefits of cervical screening at different ages: evidence from the UK audit of screening histories, British Journal of Cancer, July 2003). When you have had an abnormal smear test the further investigation you will referred for depends on the level of the abnormality and therefore your risk of cervical premalignant disease.

    Needless worry for the patient isn’t a pretty weak argument in my opinion. It is something we take into account whenever you do any investigation for a patient as we know that waiting for results is extremely stressful. I agree that patients should be told about the possibility of false postives and false negatives in order to give informed consent for screening, that is never called into question. My point was that the evidence for screening women under the age of 25 has not shown it to be effective and therefore carrying out such an intervention in this age population does not have any benefits, only risks.

  17. natsils24 said,

    October 31, 2009 at 3:12 pm

    Sorry, that should have said screening is 5yrly between ages 50 – 64

  18. natsils24 said,

    October 31, 2009 at 3:43 pm

    emen – Firstly I didn’t give any data about the false positives and false negatives of the Pap test. With the introduction of liquid based cytology for the smear test the accuracy has improved. What we are screening for is for dyskaryosis (abnormal cells which can be pre-malignant) and therefore women who will need further investigation with a colposcopy or cervical biopsy, both far more invasive procedures with their own risks.
    In the UK screening is at 3yrly intervals up to 50 yrs old and 5yrly up to 50 – 64. The decision was made for this time interval based on an audit which identified this as the most appropriate screening interval (P Sasieni, J Adams and J Cuzick, Benefits of cervical screening at different ages: evidence from the UK audit of screening histories, British Journal of Cancer, July 2003). When you have had an abnormal smear test the further investigation you will referred for depends on the level of the abnormality and therefore your risk of cervical premalignant disease.
    Needless worry for the patient isn’t a pretty weak argument in my opinion. It is something we take into account whenever you do any investigation for a patient as we know that waiting for results is extremely stressful. I agree that patients should be told about the possibility of false postives and false negatives in order to give informed consent for screening, that is never called into question. My point was that the evidence for screening women under the age of 25 has not shown it to be effective and therefore carrying out such an intervention in this age population does not have any benefits, only risks.

  19. CoralBloom said,

    October 31, 2009 at 3:56 pm

    Now we know what to do when they arrive canvassing for our votes. Examinations on the door step.

  20. vintermann said,

    October 31, 2009 at 4:52 pm

    “I actually think it’s *his* position that is racist. He is saying that science is a white thing. ”

    Agreed. Amartya Sen has cried in the desert about this for a long time.

  21. phunksta said,

    October 31, 2009 at 8:25 pm

    Ben I’ve enjoyed your column for a while now, but lumping ‘climate change denialism’ in with this is, if I may say so, just a little hypocritical.

    There is no doubt that the debate is highly polarised, and there is no shortage of both good and bad science at each pole.

    Monbiot has shown time after time his attititude toward good science, and this article again shows no particular improvement in attitude.

    It is a fact that climate ‘science’ is for the most part actually statistics – you yourself are fond of pointing out there is a clear difference. Monbiot has many time been seen to be selective about choices of facts, and drawing dubious conclusions from statistics (and he is certainly not alone in this when it comes to climatology), so your choice to quote him here as some sort of paragon of virtue is a puzzling one.

    Personally, I think there are enough good hard facts about man’s effects on the environment (chop down rain forest bad duh) for us as a race to change our ways. There should be no need to induce hysteria and fear. Yes we can ‘play’ with virtual laboratories (computer models) as no ‘real’ laboratory is conceivable for this scale of experiment, and they may also show us interesting possibilities – this kind of activity however should not be confused with science.

  22. emen said,

    October 31, 2009 at 8:36 pm

    Thanks natsils!, have found it.

    “Five-yearly screening offers considerable protection (83%) against cancer at ages 55-69 years and even annual screening offers only modest additional protection (87%). Three-yearly screening offers additional protection (84%) over 5-yearly screening (73%) for cancers at ages 40-54 years, but is almost as good as annual screening (88%). In women aged 20-39 years, even annual screening is not as effective (76%) as 3-yearly screening in older women, and 3 years after screening cancer rates return to those in unscreened women. This calls into question the policy of having a uniform screening interval from age 20 to 64 years and stresses the value of screening in middle-aged women.”

    So:
    – annual screening is a little bit more effective, 84 v 88% in 40-54 years
    – but in women who are 20-39, annual screening would be 76%, but they don’t say how effective the 3-yearly actually is, presumably less than 76%?

    I’m just wondering, because as far as I know, everywhere in the EU (and it seems from this research, in North America as well) they screen annually.

    So there is a difference, just not big enough to bother?

  23. kristinam85 said,

    October 31, 2009 at 9:24 pm

    To Jeesh42:
    Yes, basically I am saying lets to it anyway. Also putting a band-aid on a minor scratch does not help the healing or reduce the pain, but does that mean we should have a centralized decision-maker to hand out band-aids only to those who it deem eligible for band-aids based on clinical band-aid data?

    I am glad to live in another European country which recommends getting a PAP test as soon as you become sexually active. I am aware that a personal anecdote does not constitute proof, but this policy has already proven beneficial to me. I won’t get into too much personal detail here. But natsils24 is definitely wrong to say that testing “… in this age population does not have ANY benefits”.

  24. sainthubbins said,

    November 1, 2009 at 12:10 am

    emen

    If you download the full text pdf from
    www.hta.ac.uk/1350
    (bed time reading!) you can work your way through the full analysis the swap to the new NHS LBC cervical screening regime was based upon.

    To help answer your question…
    Page 43, table 20 shows incremental cost per invasive cancer avoided. Compares estimates of 5, 3 and 2 yearly screening. As interval decreases, less cancers but more cost.

    Money, money, money!

  25. natsils24 said,

    November 1, 2009 at 1:44 am

    kristinam85 – Reading it back the any in that sentence wasn’t my best use of the word ever, I should have put screening in this age group offers minimal benefits (just finished nights!). But the BMJ article does state that “screening at ages 20-24 has no detectable impact on cervical cancer rates at ages 25-29″. The actual paper is a very good read and does explain the situation far better than I ever could.

    Of course there will always be cases of cervical cancer in this young age group, the same as there will be cases of breast cancer in those not eligible for a mammogram yet or colorectal cancer in those too young for the faecal occult blood sampling. But a decision has to be made based on the best avaliable evidence on which age group screening will be carried out in. I fully support the screening process and think it is a fantastic thing, however there have to be limits to it. If there was new evidence showing its effectiveness in the 20-24 age group then I would support the age limit being lowered, however without this I think the current policy is the best one for the national screening program.

  26. Brady said,

    November 1, 2009 at 8:49 am

    I too was a bit shocked at Ben’s last paragraph taking a cheap dig at global warming skeptics. The black and white lumping in of Aids denialism with the skeptism of catastrophic man-made global warming is, I think, akin to mixing up evolution with creatiionism.

    Ben is marvellous at exposing health scares but seems to be less than critical with regards to the theory of man-made global warming.

    Please inform yourself as to the wealth of non-politicised peer reviewed scientific literature of the “dangerous denialists” by visiting:
    wattsupwiththat.com/
    and links therein,
    …or for the more statistically minded:
    www.climateaudit.org/

    No more “dip(s) into the world of politics” please Ben, stay with exposing health scare where you shine.

  27. frizzyjeff said,

    November 1, 2009 at 10:40 am

    Hopefully someone can explain something that has been puzzling me as long as this debate about lowering the screening age has been going on. I live in Scotland and got my first smear when I was 19 and have been getting them every 3 years since. All of my friends also started getting theirs when they were under 25, some of them even started at under 18 because their doctors knew that they were sexually active. So when the British media talk about lowering the British screening age do they really mean the English screening age or are there just a lot of rebel docotors in NHS Scotland?

  28. ossian said,

    November 1, 2009 at 11:58 am

    The policy is indeed different in Scotland. I wish people would stop talking about UK and British policy as if their is a single NHS when NHS Scotland has it’s own policies and guidelines.

    “The Scottish Cervical Screening Programme has been in place since 1989. All eligable women in Scotland between the ages of 20 and 60 are invited for a cervical smear test every 3 years.”

  29. kejr said,

    November 1, 2009 at 2:29 pm

    Oh dear, it seems some people (Brady and Phunksta)are willing to accept ben’s arguments about peer review and correct use of statistics only when it suits them. Re climate change – the peer review literature overwhelmingly supports AGW was a phenomenon we should all be concerned about.

    As for global warming being ‘statistics’, actually the models are all based on relatively basic physics, on physical relationships (ie CO2 absorption of infra red) known for over 100 years.

    It’s terribly depressing that exactly the same tactics as used by Aids denialists are the same ones used to deny AGW yet so many seem easily duped. (the same tactics used by ‘alternative’ health gurus, 9/11 conspiracy theorists and for years by the tobacco lobby). Doubly so when it’s on a website where the author has done so much to progress greater scientific understanding.

    And as for wattsupwiththat – a man who has more in common with most homeopaths & nutrionists, ie no formal qualifications, ex weatherman who doesn’t understand the subject he chooses to pontificate on.

    As for statistics, climateaudit has more in common with the type of dubious statistical analysis Ben defenestrates regularly in his columns. For a decent analysis and to educate yourself in statistics a much better bet is
    tamino.wordpress.com/

  30. irishaxeman said,

    November 1, 2009 at 5:47 pm

    The tenor of all of the stuff quoted by Ben is deeply chilling, as is the dismissal of Professor Nutt (and the possible loss of more scientists from the Committee. From Blair’s re-birthing and religiosity onwards, we seem to have the eruption of scientific denial amongst the uneducated political classes in this country (i.e. most politicians). I’m afraid I’m of the Terry Pratchett Tendency on this, that we’re stuffed since politicians only have a 5 year event horizon, and the media almost never tell the truth/facts (try finding out what’s really driving the postal dispute).

  31. phunksta said,

    November 1, 2009 at 6:51 pm

    Sorry kejr you’re lost me there. Did you read past the first 10 words of my post before deciding i’d pitched my tent in the sceptic camp?
    I think you proved my point quite well enough for me!
    If you don’t mind i’ll continue to question and observe.

  32. kejr said,

    November 1, 2009 at 7:03 pm

    Phunksta, sorry my point is that the scientific case is most certainly not based on statistics.

    Also, you claim the debate is polarised, but that’s not framing the problem correctly as there is no debate as such (at least not in the scientific literature) In the same way. that ‘House of Numbers’ is just wanting to debate HIV & Aids so there is an attempt to frame AGW as a debate. However the question is really to determine how sensitive the climate is to CO2, what are the wider impacts and how do you address the problem.

    Out of interest, would you care to reference some of those errors / sloppy attitude to science which Monbiot is guilty of?

  33. njdowrick said,

    November 1, 2009 at 8:16 pm

    Re: 21 (Phunksta). You say:

    “Yes we can ‘play’ with virtual laboratories (computer models) as no ‘real’ laboratory is conceivable for this scale of experiment, and they may also show us interesting possibilities – this kind of activity however should not be confused with science.”

    I’ve read comments like this before in other places, and I’m confused. I used to be a theoretical particle physicist, and I used computer models to study QCD (the theory of the strong interactions). No analytical solution appears to exist to problems such as “What is the mass of the proton?”, yet computer models that implement the equations of QCD provide answers. Are you saying that there’s a problem with this?

    A more familiar example: predicting the paths of asteroids. Surely computer models are used to integrate the equations of motion in order to find out where an asteroid is likely to end up? Again, what’s the problem with this?

    You may have objections to the actual models that climate scientists use (mesh too coarse, important physics omitted, etc.) but if so it would be better to state these objections, rather than to attack computer models per se. Making predictions from basic laws in any non-trivial system almost always requires vast amounts of computation: climate science is not unique in this regard.

  34. skyesteve said,

    November 1, 2009 at 8:45 pm

    @ kristinam85, natsils24 and frizzyjeff – as ossian points out the starting age for cervical screening in Scotland is 20 – www.isdscotland.org/isd/1673.html – so I guess up here we must feel the pros outweigh the cons. Again as ossian says there is NO UK NHS. Health is a devolved matter and the NHS in Scotland is entirely separate to that in England, Wales and Northern Ireland. The majority of us who work in it think it’s much better for that separation too as we’ve avoided all the worst of New Labour (and previously Tory) health “reforms”.

  35. emen said,

    November 1, 2009 at 9:48 pm

    natsils24, I understand what you are saying when you say

    “Of course there will always be cases of cervical cancer in this young age group, the same as there will be cases of breast cancer in those not eligible for a mammogram yet or colorectal cancer in those too young for the faecal occult blood sampling. But a decision has to be made based on the best avaliable evidence on which age group screening will be carried out in. I fully support the screening process and think it is a fantastic thing, however there have to be limits to it.”

    – and I agree that there has to be a limit. If you are a rich hypochondriac, I’m sure you would think there is benefit in a 3 monthly screening. :-)
    I just think it is spectacular that most countries in the EU draw the line at once a year and start the screening earlier (even in Scotland as it seems) – while the English NHS claim there is no benefit in screening more often.

    I understand the reason – in groups where cervical cancer is less common, you get more false positive results that you will have to investigate and waste resources. However, I often wish the NHS were more honest and stopped saying there is no benefit. It is misleading because it gives patients a false sense of security when it is basically a cost-effectiveness issue.

    Similarly, the NHS call ovarian cancer the “silent killer” because it has no specific symptoms and they claim “it is not possible to screen for ovarian cancer”. Of course it is possible – it is not available on the NHS because it is not cost-effective, but in some EU countries they annually screen for ovarian cancer.

    Mind you: I am NOT saying that it SHOULD be annual and let’s have a riot and demand it. If it is not available because there is no money for it, fine, then it is not available.
    All I am saying, the NHS should stop lying like that.

    (And please don’t say that it is about “needless worrying for the patient”. I’m sure if the high false positive rate of screening is clear, some patients would rather not to have the test. But I would prefer to have the choice to decide.)

  36. pv said,

    November 1, 2009 at 11:54 pm

    @danielearwicker said,
    October 31, 2009 at 10:11 am

    “Energy transfers”?

    Water – kettle – gas/electricity – teapot – drink = energy transfers.

  37. progjohn said,

    November 2, 2009 at 8:55 am

    The difference is in the number:

    Energy is a scientific concept.

    Energies are woo nonsense.

    Tredinnick said energy but presumably meant energies, unless he was thinking of electroconvulsive therapy or giving sick people a warm bath.

  38. Caledonian1976 said,

    November 2, 2009 at 10:27 am

    @ Brady .26

    No more “dip(s) into the world of politics” please Ben, stay with exposing health scare where you shine.

    ——–

    Climate change, and the issue of whether it is man-made or not, is a science issue.

    Politics=policy. Temperature changes, and their causes, relate to science.

  39. iamjohn said,

    November 2, 2009 at 1:27 pm

    Brilliant firewall from Tredinnick: I raise points in parliament, they are true and if you challenge them then it is because you are racist, and anyway, I have a Muslim college in my constituency.

  40. mikewhit said,

    November 2, 2009 at 1:37 pm

    >>
    the NHS call ovarian cancer the “silent killer”
    <<

    I appreciate that CA125 values can be raised due to other factors, but an annual (6-monthly depending on age ?) CA125 check could also establish a baseline value for the patient from which an unusually raised value could then be observed – then a quick ultrasound scan could look for ascites etc.

    I understand that survival probability is much better if you get it prior to stage 3, which an annual check would help in doing. Too late for my mum-in-law unfortunately …

  41. skyesteve said,

    November 2, 2009 at 2:52 pm

    @ mikewhit – the value of Ca125 screening continues to be looked at but as yet there is no convincing evidence for the kind of screening that you suggest. At present the guidelines of the National Academy of Clinical Biochemistry recommend screening only women deemed to be at high risk (e.g. strong family history – in which case should be done in combination with trans-vaginal ultra-sound scanning +/- genetic studies) or in post-menopausal women with a pelvic mass. They do not recommend opportunistic screening of asymptomatic women. There is currently a large trial in progress looking at screening in over 200,000 women aged 50 to 74 which is due to publish in 2015.
    In practice (and speaking as a non-gynaecologist/non-oncologist) I would screen a women at any age with a pelvic mass but then I would automatically also get a TV scan on these women and probably refer them to one of my specialist colleagues.
    In essence there is no current convincing evidence of any survival benefit for early treatment based on elevated Ca125 levels alone. The real worry for me with all these demands for screening asymptomatic people is that, aside from the very real physical and psychological morbidity which may be associated with false positives, there is the very real danger of false negatives leading to false reassurance and complacency and that, for me, is even scarier.
    There is a very good article on tumour markers in the British Medical Journal of 10th October 2009, available on line.

  42. natsils24 said,

    November 2, 2009 at 6:44 pm

    mikewhit – under the WHO screening criteria there must be “There should be a latent or early symptomatic stage” for any disease you screen for, as well as “There should be a suitable and acceptable screening test or examination”.

    CA-125 has been suggested as a screening test for ovarian cancer, but only about 50% of women with early stage ovarian cancer have a raised CA-125, as well as CA-125 being raised in other conditions bar ovarian cancer. The other route is to combine a CA-125 level with a transvaginal ultrasound which is the best modality for viewing the ovaries, however it still can’t definately distinguish between a simple cyst and a cancer.

    At the moment there is a large trial called UKCTOCS being conducted into screening, one group has CA-125 and then transvaginal US if abnormal, the other transvaginal US and CA-125 if abnormal with a third group having no screening tests. The first results were published in March this year and have concluded that both screening modalities are feasible, however the trial still has many years to run in order to provide enough evidence for such a screening programme.

    emen – Actually it was the BMJ article said that for cervical cancer “screening at ages 20-24 has no detectable impact on cervical cancer rates at ages 25-29″, from an independent paper, it was not an NHS thing. As much as we hate it, the NHS has finite resources and it does make decisions based on how best to spend the pot of money. But it is evidence based.

  43. Squander Two said,

    November 2, 2009 at 8:26 pm

    njdowrick,

    > A more familiar example: predicting the paths of asteroids. Surely computer models are used to integrate the equations of motion in order to find out where an asteroid is likely to end up?

    There is a slight difference between bodies moving in a vaccum, being affected only rarely by anything other than their own momentum and each other’s gravity, and climate, many of the significant influences on which are still understood either incompletely or not at all.

  44. phunksta said,

    November 2, 2009 at 9:08 pm

    At the danger of turning this into ‘yet another thread hijacked for climate change debate’….

    @njdowrick re: 33 – I totally agree that computer models are an extremely useful tool. I am no particle physicist, yet computer science is somewhat familiar to me.
    I understand that the raw power to harness mathemetics that require iteration is key to opening up all sorts of ‘new windows’ on research (what I loosely termed ‘possiblities’); be that in particle physics, economics, climate science or any other similar subject of analysis.

    Yet, is there a grand unification theory? Is there a model that can predict the stock exchange with enough accuracy to guarantee a win on any trade? Can human behaviours and interactions be predicted with any accuracy? Can tomorrows weather be predicted with absolute accuracy? I do believe that the methods use to predict the movement of asteroids require constant observational input to remain accurate?

    I hope and have faith that the scientists involved understand the differences, and are largely good enough to use such results responsibly. My gripe only begins when politicians pervert weak correlations and dubious conclusions into hard policy, usually involving some extra taxation; quite on topic for Ben’s latest blog I would say.

    @kejr – I’d agree that the basic physics you refer to are certainly regarded as reliable. To suggest otherwise is simply patronising. As for the ‘no debate’ argument that’s simply insulting.

    I am not going to post hundreds of URL’s into Ben’s comments system because I believe to do so would be rude (and I have probably been rude enough to him already!); they are freely available on very good websites (largely written by scientists active in the debate you claim does not exists) and I do not believe repeating them here is neccessary.
    I write that knowing that I’m wasting breath, as I doubt you’ve ever read anywhere beyond the start of any argument that runs counter to your system of beliefs.

    Again you seem to have missed the point of my orignal post; I am not a climate sceptic, ‘denier’ or any other kind of evangelist. I do not consider myself either convinced or duped by either set of arguments. All I’ve really heard in your argument is the same old dogma re-hashed.
    Shame really when njdowrick had challenged my statements so eloquently.

    I won’t comment again on this, not because I feel I have lost an argument here, but because of the ‘thread hijack’ that has transpired. I fear the orginal point has been entirely lost.

  45. emen said,

    November 2, 2009 at 10:23 pm

    natsils, sure, but was that based on 3-yearly or annual screening, do you know?

  46. emen said,

    November 2, 2009 at 10:36 pm

    skyesteve

    it might be something that everybody here except me knows, but how do you identify a pelvic mass if you don’t screen the woman?
    just interested

  47. emen said,

    November 2, 2009 at 10:42 pm

    sorry, I mean “scan”
    (not screen)

  48. skyesteve said,

    November 3, 2009 at 8:25 am

    @emen – by good old fashioned history taking and examination which any good doctor should be able to do. You’d be surprised sometimes at how small are the ovarian masses (and other pelvic masses) than can be picked up by basic abdominal and pelvic examination. Too much in modern medicine we have become blinded by technology. I’m not that old but even I was taught that history and examination will give you the likely diagnosis in the vast majority of cases. The tests then become confirmatory. So if a woman of any age presents to me with unexplained alterations of menstrual function, unexpected abdominal pain/bloatedness, etc that’s someone I would want to examine and investigate further – and Ca125 and TV scanning would likely be part of that investigation as said above. That would be “targetted” screening (as would screening high risk women). The issue is is targetted screening better than just pulling people off the street and screening them all? For ovarian cancer at least the answer is currently “yes” for targetted screening. For cervical and breast a decision has been taken that the age groups and screening intervals are based on the best balance between picking up cases and avoiding the very real morbidity associated with false positive and false negative results. Again we would be more “aggressive in our screening for “high risk” women. But I agree that it’s not an exact science and there will always be people who slip through the net as no assessment carries wiht it 100% specificity and sensitivity and that’s just life.

  49. skyesteve said,

    November 3, 2009 at 8:27 am

    “For cervical and breast a decision has been taken that the age groups and screening intervals are based on the best balance between picking up cases and avoiding the very real morbidity associated with false positive and false negative results.” – an d, yes, I accept, cost too.

  50. njdowrick said,

    November 3, 2009 at 11:59 am

    @squander two (#43): you say

    “There is a slight difference between bodies moving in a vaccum, being affected only rarely by anything other than their own momentum and each other’s gravity, and climate, many of the significant influences on which are still understood either incompletely or not at all.”

    I agree completely: and so, if climate models are to be criticised it should be on such grounds, and not because computer models are somehow not real science.

    @phunksta (#44): I have no real quarrel with what you say. In an earlier age, I can imagine you agreeing with Ernest Rutherford when he said “If you need to use statistics to analyze your results, you’ve done the wrong experiment!” (OWTTE) In reality, computer modelling is an indispensible part of much of modern science: indeed, I can’t see how else to reach any sort of conclusion on the causes of climate change, whatever they may turn out to be. If you feel that the models used aren’t reliable enough yet to be trusted, then that’s fair enough – but if so, the problem isn’t caused by the use of computer models.

    No need to respond – I don’t think we disagree, and in any case it’s hard to say anything original on this subject!

  51. skyesteve said,

    November 3, 2009 at 1:10 pm

    @emen – some more thoughts on screening for gynaecological malignancy – there are about 600 new cases of ovarian cancer each year in Scotland (rare under 30 years of age with peak incidence in 60s); the average Scottish GP would see one new case every 5 years so high index of suspicion needed. There is a scoring system (that I don’t claim to fully understand) which is supposed to help with decision making with possible ovarian cancer. It’s called the RMI score and uses a combination of ultrasound findings, Ca125 level and menopausal status to identify “high risk”.
    Targetted screening is suggested in some quarters for women with 2 first degree relatives with ovarian cancer OR 1 with ovarian and 1 with breast cancer under 50 years of age OR 1 with ovarian and 2 with breast under 60 yoa OR 2 with colon + 1 with some other gut malignancy at least one of which miust be under 50yoa. These recommendations come from the 2003 SIGN guideline on ovarian cancer –

    www.sign.ac.uk/guidelines/fulltext/75/index.html

    With cervical screening 5 yearly smears reduces the incidence by 83.6%, 3 yearly by 91.2% and annually by 93.3%. As I say decision to do 3 yearly based on these figures, pros and cons of false +ves and false -ves and cost to the NHS where rationing is an every day fact of life in one form or another.

  52. olster said,

    November 3, 2009 at 1:54 pm

    Apologies if this is already somewhere in this thread but…

    As if by magic, Physician’s First Watch (for November 3, 2009) covers the news that US physicians OVERUSE (my emphasis) the PAP.

    “Only about one fifth of U.S. clinicians consistently follow guidelines for Pap testing, with many overusing such screening, according to a federally funded survey in Annals of Internal Medicine.”

    That’s Annals of Internal Medicine, November 3, 2009 vol. 151 no. 9 602-611

    Annals link here: click.jwatch.org/cts/click?q=227%3B67304842%3BytM6Q3zlk%2Fy9s5bkO%2Bd291SDX5%2FSGYmQgAvUUEcvOXc%3D

    American Cancer Society guidelines on cervical cancer screening: click.jwatch.org/cts/click?q=227%3B67304842%3BytM6Q3zlk%2Fy9s5bkO%2Bd299mxUmz6Ccp8gAvUUEcvOXc%3D

    American College of Obstetricians and Gynecologists guidelines: click.jwatch.org/cts/click?q=227%3B67304842%3BytM6Q3zlk%2Fy9s5bkO%2Bd297NNK1oN0PxZgAvUUEcvOXc%3D

    and:
    USPSTF guidelines: click.jwatch.org/cts/click?q=227%3B67304842%3BytM6Q3zlk%2Fy9s5bkO%2Bd29%2FxSiuB8%2Fit6gAvUUEcvOXc%3D

    So when people claim the US screen more people, they may not in fact be doing so under their own guidelines.

  53. olster said,

    November 3, 2009 at 2:00 pm

    @njdowrick & @squander two

    >@squander two (#43): you say
    >“There is a slight difference between bodies moving in
    >a vaccum, being affected only rarely by anything other
    >than their own momentum and each other’s gravity, and
    >climate, many of the significant influences on which
    >are still understood either incompletely or not at all.”

    Something being affected by its own momentum????

    I thought this went out of the window with Newtonian physics!

    A body moving through a vacuum will not be ‘affected by its own momentum’, but will only be affected by new forces applied to it (gravity etc). Momentum IS NOT A FORCE!
    (disclaimer- I am not a physicist, but I do have an intercalated radiological physics degreee… Almost the real thing!)

  54. emen said,

    November 3, 2009 at 4:57 pm

    skyesteve, thank you!
    it was very interesting

    In some EU countries (including France and Germany) women are advised to have a yearly “overall” gynaecological screening, with a smear test and and ultrasound test and all that, even if they haven’t got symptoms. But of course, the financial arrangements are different, a higher percentage of the GDP is spent on healthcare, rationing is not that strict etc.

  55. mikewhit said,

    November 3, 2009 at 6:34 pm

    Thanks for the update on screening.

    I think it just needs more awareness by the GP, and willingness to refer for tests, since in the case I am familiar with, no TV ultrasound was performed initially, it was just put down to a digestive issue.

    As I may have said on here before, I believe there is an unwillingness in the UK to refer a GP patient for tests, the assumption is that whatever it is will just sort itself out, which is probably largely true.

    However I personally know of three other cases where a test would have caught an eventually fatal condition, when the person had been to the doc before with symptoms but sent away with ‘let’s just wait and see’.

    One, stroke/cerebral, the other two, cancer not counting the ovarian cancer first mentioned.

  56. skyesteve said,

    November 3, 2009 at 6:55 pm

    @mikewhit – it’s back to that thing about medicine being a mixture of science and art. “Watchful waiting” as it’s commonly referred to is a long-established part of good primary care – and long may it continue otherwise we have the over-the-top, fear-of-litigation led healthcare seen in other parts of the western world which, to be blunt, is just crap medicine.
    I would hope a good GP would always say to someone with new but non-specific, non-”red flag” symptoms “if these symptoms persist for more than a week or two you need to come back and see me as we may need to look into this problem further”. If we simply perform (or refer for) a whole battery of tests on any patient presenting with new non-specific symptoms the whole NHS would grind to a halt rapidly.
    Please don’t forget that, although it may not seem like it to you, we have the best, most evidence-based primary care in the world (at least in Scotland we do!) IMHO.

  57. natsils24 said,

    November 3, 2009 at 7:51 pm

    @ mikewhit

    Sadly medicine is not an exact science and sometimes wait and see can actually be a good strategy, I have seen it use very effectively by hospital consultants and GP as sometimes pathology is not clear cut at first. We call it watchful waiting and it should be just that, we wait to see what happens but with regular appointments in order to detect any change in clinical status. I think the whole debate surrounding screening, which as I said I fully support is the fact that it is just that, it is screening. No screening test is 100% accurate, both false positives and false negatives, and tests are fallable. Thats why they have to be used with caution and why patients should be fully informed of the symptoms of the disease that is being screened for so they can present if they are concerned.

    @ skyesteve

    The RMI score is used to decide where the patient should be managed in a cancer unit or at a specialist cancer centre due to their risk of malignancy.

  58. emen said,

    November 3, 2009 at 7:51 pm

    mikewhit, I agree with you:

    “there is an unwillingness in the UK to refer a GP patient for tests, the assumption is that whatever it is will just sort itself out”

    with the addition that I wouldn’t want to see a doctor if I wanted to wait for it to sort itself out, would I.

    If the GP refers somebody for a scan and the result is normal, I wouldn’t call it “wasting resources” but a more accurate diagnosis. More accurate than one which is based on mere guessing.

    The question is: what can you do (in order to save your life)? I think there is a rule on this blog that we shouldn’t discuss personal medical history or conditions here, so all I would say that the lesson I learnt is that sometimes you simply have to go private.

  59. Squander Two said,

    November 3, 2009 at 8:05 pm

    olster,

    > Something being affected by its own momentum????

    Yes, I obviously know this. However, we were talking about computer modelling. In a model, the movement of an object is affected by the code simulating its momentum. The fact that that code doesn’t represent a real-world force makes it a different type of effect, not a non-effect.

    I’m a pedant myself, but I at least try to be pedantic in context.

  60. natsils24 said,

    November 3, 2009 at 8:16 pm

    @ emen

    I think sometimes GPs get a bit of a hard time. They have an exceedingly difficult job, every day they have to distinguish between patients with symptoms that could be caused by something innocent, or something extremely sinister. It is like the needle in the haystack at times. In hospital we have the luxury of tests, and scans but sometimes we forget to use our clinical judgement. We are taught to look for horses, not zebras, i.e. if the symptoms fit it probably is something common, but always keep the rare things in mind. Scans and other tests help but 80% of diagnoses can be made on the basis of history alone, with examination findings helping to support it. And scans are never perfect.

    This doesn’t apply to screening which is a centralised process that GPs actively encourage people to go for.

  61. skyesteve said,

    November 3, 2009 at 8:21 pm

    @emen – of course there will be people who individually are not happy with the service they receive from the NHS and I sympathise with them. If something doesn’t go well for you that’s clearly bad for you as an individual. But no system is perfect (there aren’t enough robots to go round as someone once said).
    The fact remains that, for primary care at least, we have levels of satisfaction (and I am only qualified to talk about Scotland) that are the envy of any other service or industry at levels nearing 99%.
    I don’t know any GP that relies on “mere guessing” as you put it. We do try an practice evidence-based medicine and the new contract encourages that. Good medicine is, as I say, about good history taking and examination which will help define the tests that will help to confirm the diagnosis and guide the treatment.
    But the majority of people presenting to GPs do have mild self-limiting problems or chronic non-life-threatening problems the management of which is not helped by a whole load of unnecessary tests.
    The problem with doing lots of tests on lots of people is that you run the real risk of unnecessary anxiety or inappropriate reassurance.
    You say that a normal scan isn’t wasting resources. But if we refer people for tests that they don’t need that does cost money which has to be found from finite resources. It also means that someone else who does need the test might have to wait longer for it and thus have their diagnosis and treatment unnecessarily delayed.
    It’s a difficult circle to square but by and large I think we get it right most of the time.

  62. olster said,

    November 4, 2009 at 5:18 am

    @Squander Two

    re: > Something being affected by its own momentum????

    Ah- yes, sorry about that- you are obviously a victim of me being a latecomer to the party… I really should read the other posts next time!

  63. outeast said,

    November 4, 2009 at 11:36 am

    Is it just me who saw Tredinnick’s comment on having a Muslim college in his constituency as a dog-whistle to his fellow Members? I heard it as, like, ‘OK chaps, you know why I’m saying this, we all know it’s balls but I get to please my constituents by saying it and you get to ignore me, so everyone’s happy and no harm done.’ But then, I’m a big one for the principle of charity…

  64. lizD said,

    November 4, 2009 at 3:32 pm

    To add to the EU/US/UK information on screening, in Australia, the screening age is 17, regardless of whether you are sexually active, with tests done every two years. If you have an abnormal result, you are screened every six months after treatment until you have a clear test again.

    As someone whose sister was diagnosed with ‘abnormal’ cells at 23, treated and given a clear bill of health, I’d have to agree with lowering the screening age and getting more information out there in a form that doesn’t cause public hysteria.

  65. natsils24 said,

    November 4, 2009 at 9:48 pm

    @ lizD

    Firstly I don’t see the point in ever doing a smear test on someone that young who has never been sexually active. The vast majority of cases of cervical cancer are due to HPV infection which is sexually transmitted, plus I would not like to be the person doing a speculum examination on someone who has not been sexually active.

    There will always be cases of someone who has had abnormal cells at a young age, however, the evidence for screening this young age group is just not there at the moment and this is why we don’t screen them, unless they have worrying signs or symptoms. And in the UK we practice evidence based medicine, we have to use the avaliable research to guide policy. Which is the case with the current UK cervical screening programme.

  66. Chi Square said,

    November 5, 2009 at 5:16 pm

    Hi Ben,
    This is unrelated to this week’s column, but I was just watching and interview with Suzanne Somers about her new book “Knock Out”, a book about treatment options for cancer patients; a subject on which Ms. Somers claims to be an authority on as she has “survived” cancer (by “survive” she means she was misdiagnosed). A lot of outrageous claims were made in this 3 minute interview and I would appreciate it if you would look into this and perhaps write a column on it in the near future. By the way, I just finished your book and in Canada we don’t refer to Aboriginal peoples as “native Canadian Indians”.

  67. longyan said,

    November 6, 2009 at 2:25 am

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  68. csrster said,

    November 6, 2009 at 11:12 am

    Chi Square: Ben’s already clued up on Suzanne Somers. See
    the link “Can you let me know the moment this person lands in the UK please” in the miniblog.

  69. Dirg said,

    November 6, 2009 at 7:07 pm

    Thank goodness in Canada any female can ask for and receive a pap test. Here it is recommended that a female get a pap test every year starting in your late teens (or as soon as you become sexually active). Two of my girlfriends had pre-cancerous cells when they were teenagers, another girlfriend had outright cancer in her teens and another friend had cancer in her twenties. Without a regular pap test all of these women would have died, and apparently had they lived in Britain they would all be dead.

  70. adamk said,

    November 6, 2009 at 8:05 pm

    @emen and mikewhit
    when a GP says ‘come back if its not better in 2 weeks’ you can think of that as a test – a ‘if its not better in 2 weeks we may need to investigate further’ test. This is a very useful and valid tool.
    I think people often have an almost magical belief in ‘tests’ , a belief that there is an investigation out there which will tell them exactly what the problem is. This is often not the case.
    Also tests and scans are not without there inherent dangers – every CT thorax/abdomen performed exposes the patient to a large dose of (possibly cancer inducing) radiation , for example.
    Then there is the money question – it seems to be taken as bad taste to mention health care and money in the same breath , but is the reality of the NHS. For every unnecessary test , money is spent that might have been better spent elsewhere.
    On the subject of screening , mammography , the other great screening programme in the UK for women , may be an example of the dangers of too much screening. there is some debate as to whether mammography is picking up large numbers of very early breast cancers, which would have never developed into anything serious. The women involved then have to go through traumatic surgery , and emotional turmoil , which may have been completely unnecessary.

  71. skyesteve said,

    November 6, 2009 at 10:17 pm

    @ dirg – there is no evidence that annual screening, especially in young women under 20, significantly reduces the mortality from cervical cancer. An abnormal smear does NOT mean cervical cancer – it doesn’t even mean you will go onto develop cervical cancer. There are three grades of abnormal smear before you get anywhere near cancer – CIN 1, CIN 2 and CIN 3 (CIN = cervical intra-epitheleal neoplasia). We know that if left alone one third of CIN 1 will revert to normal, one third will stay at CIN 1 and one third will progress to CIN 2; for CIN 2 one third will regress to CIN 1, one third will stay at CIN 2 and one third will progress to CIN 3; even at CIN 3 one third will regress, one third will stay static and one third will progress to cervical cancer.
    What happens in Scotland is you get you first smear at 20 then every 3 years after that. If at any stage you are found to have CIN you will almost certainly be referred to a gynaecologist for colposcopy – direct visualisation of the cervix using a microscope at which point the extent of any lesion can be identified, biopsies taken if necessary and treatment initiated (which may include excision of the transition or transformation zone – effectively the junction between the external and internal surfaces of the cervix – this is the usual area at which malignancy arises; alternatively a large biopsy – so-called cone biopsy – may be taken to assess the extent of any abnormality if this is not obvious at colposcopy). Subsequent follow-up depends to some extent on the severity of the initial abnormality but for lower grades at least it would typically consist of another smear after 6 months and, if that was okay, another after 12 months and, if that was okay, back to routine 3 yearly screening thereafter. You might find the following link useful.

    www.screeningservices.org.uk/csw/prof/quality/colp_sopps09/c150_follow_up.pdf

    Your statement that “all of these women would have died” is simply not evidence-based and cannot be substantiated. It is the kind of “shock, horror” headline of the tabloid press which is just not helpful. Sorry.

  72. quasilobachevski said,

    November 8, 2009 at 2:08 am

    Dirg,

    I don’t have much to add to skyesteve’s very informative reply, but as a Brit living in the US I want to comment on one sentence.

    Thank goodness in Canada any female can ask for and receive a pap test.

    The clear implication here, commonly repeated on the likes of Fox News, is that there are treatments which are simply not available in the UK (because the NHS is a crypto-Stalinist government-run organization etc etc).

    This is not the case. Certain treatments are not covered by the NHS, and if you want one of these you have to “go private” and pay for yourself, just as you would in many other countries. You can take out health insurance, if you choose to.

    I realise that this wasn’t exactly what you were getting at, but I’m so fed up with the coverage of these issues here that I feel the need to combat this insinuation whenever I encounter it.

  73. emen said,

    November 8, 2009 at 4:55 pm

    skyesteve #56

    I agree with you, of course, on the principle of watchful waiting. Let me tell you an (imaginary) example to clarify what I mean.

    A female patient turns up at the GP, with severe abdominal and low back pain. The GP listens to her story, takes her temperature, examines her abdomen, exludes appenticitis and some other things. At that point he is left with 1. PID 2. vaginal infection 3. severe cystitis 4. ectopic pregnancy (and I can’t know what else). He knows that he needs to have some tests and scans done to decide what is wrong.
    What happens then? Is he going to ask her to come back next Tuesday, when the practice nurse is there?, and she will take some swabs and samples, then he will wait for an extra week for the results to come back. Meanwhile, he prescribes the patient two different types of antibiotics, in the hope that one of them should work on whatever it is that she has.
    Or should the GP ask her to go to A&E?
    Or is there any way for that patient to see a urogynaecologist within 2 days, who can do the scans and tests? Without being admitted to hospital?

    I’m not criticising the GP service here, at all: I am really trying to understand how the service works.
    Because I wouldn’t think it would be safe for this patient to wait for two weeks and see, or would you?

    What I’m sometimes concerned about is problems like these: that are not long-term managable conditions, like asthma, and not life-threateningly dangerous to go to A&E, but the GP surgery is not equipped enough to do the necessary tests and scans. What happens then?
    That is (also) what I meant by the GPs being reluctant to refer patients for tests and scans.

  74. emen said,

    November 8, 2009 at 5:09 pm

    quasilobachevski #72

    “Certain treatments are not covered by the NHS, and if you want one of these you have to “go private” and pay for yourself, just as you would in many other countries. You can take out health insurance, if you choose to.”

    That’s exactly what I often think.

    But the NHS should also be honest and not feel embarrassed to “mention health care and money in the same breath, when it is the reality of the NHS.”

    Cervical smear testing only once in 3 years, and only if you are over 25, because we can’t afford to waste resources on investigating false positive results. A small number of cancer cases will be missed, but only a small number. You can have it done as often as you want, privately.

    But really, they should stop mumbling things like “we have evidence-based medicine here” = everybody else in the world is a bunch of idiots if they screen more often and we are cleverer than anybody else.

  75. skyesteve said,

    November 8, 2009 at 8:52 pm

    Hi Emen. Thanks for you reply – I can only speak for myself but in the scenario you describe let me work my way through your own differential diagnosis if I may:-

    1. appendicitis – yes I know that you exclude that but the key here may be the history and examination(sorry to keep harking back to that) – fever, nausea/vomiting, tachycardia (sorry, fast heart rate), perhaps some looseness of stool; pain that starts initially in central abdomen and is “colicky” in nature (i.e. gripping quality that comes and goes) but then becomes more severe, constant and shifts to the right lower abdomen (right liliac fossa – RIF) would be strongly suggestive of appendicitis; examination may reveal tenderness in the RIF associated with guarding (where the muscles tense up in repsonse to peritoneal irritation) and rebound (an extra spasm of pain when the hand is removed from the abdomen suddenly). This person has appendicitis till proved otherwise (although if their period was also late then you would have to consdier ectopic) and I would admit her as an emergency.

    2. PID – again fever would possibly be present and there may be some abdominal tenderness and guarding/rebound; pelvic examination might reveal tenderness to either side of the cervix in the upper vaginal vault together with discomfort when the cervix itself is moved (so-called cervical excitation); if her period was late then again an ectopic would need to be considered in which case I would do a pregnancy test there and then (modern pregnancy tests are very sensitive); I would also check her urine for white cells, red cells, protein and nitrites (which are produced in the presence of bacteria); I would also do chlamydia and high vaginal swabs and take blood for a full blood count (to look for high white cells which would suggest infection) and an ESR (erythrocyte sedimentation rate which increases in presence of infection or inflammation) – I can also do the ESR in my consulting room with result in an hour.
    Thereafter how I proceed would depend on how well or otherwise the patient was (and you have to take into consideration my 20 years of experience here) – if she was not too unwell and PID seemed likely I would commence antibiotics (whilst awaiting test results) and probably review her in 24 to 48 hrs depending on my level of concern; if she was unwell I would have no hesitation in admitting her as an emergency to Gynaecology.

    3. vaginal infection – these tend to be superficial (although vaginal abscesses can occur) and there would possibly be vaginal discharge (in which case I would take swabs and possibly commence treatment based on likely diagnosis). Straightforward vaginal infections tend not to make someone unwell per se. If they were unwell I would proceed as per PID above.

    4. ectopic pregnancy – you are right to mention this; it must always be considered in women of fertile age who are sexually active and, as said, may present like PID or appendicitis, although there is often some vaginal bleeding too together with a history of late period and positive home pregnancy test ( or symptoms of early pregnancy). If I had even the smallest suspicion of ectopic pregnancy this lady would be admitted as an emergency to gynaecology.

    5. Don’t forget the possibility of sexually transmitted infection, though again with this I would proceed as per PID.

    In the end of the day it comes down to how unwell the person is (and possible diagnoses) as to whether I admit them or arrange to review them. It’s not unusual if I am concerned sufficiently about someone (but I’m not sure whether they need admitting) for me to review and reassess someone that same day.
    You right, most GP surgeries don’t have in-house ultrasound scanning (though some do). This is because to be good at anything like that you need to do it regularly. Most GPs would not be able to keep up their skills and this would then risk things being missed. There are sound reasons why specialist services are centralised as they are.
    Hope this is helpful and, perhaps, reassuring. Please remember most GPs (and, indeed, most doctors in general)have the interests and needs of their patients at the forefront of their decision making process.
    In the UK we get a fantastic deal – nobody pays “up front” and GPs don’t have to worry about the costs when making clinical decisions.
    Contrast this with the USA where I did some primary care research. Here’s one anecdote that I saw (and couldn’t believe) with my own eyes – lady has a definite pathology requiring a specific drug which her doctor wants to prescribe but before he can he has to phone her insurance company there and then in the consultation to ask (a) can he prescribe this drug type for the lady (remember clinically there is NO doubt she needs it) and (2) if so which brand should he prescribe (he tells me the insurance company keeps changing brands every few weeks in attempt to cut costs by ensuring the cheapest brand is used). Now remember this lady is one of the lucky 40% of US citizens who actually has insurance coverage. Can anyone really say that’s a better system than the NHS?
    P.S. Who are the coolest people in hospitals? The ultra-sound people…

  76. quasilobachevski said,

    November 9, 2009 at 12:59 am

    skyesteve,

    Now remember this lady is one of the lucky 40% of US citizens who actually has insurance coverage.

    Thanks for another very interesting and informative post. But I can’t let this go unmentioned – the real stats are shocking enough without this sort of exaggeration. I believe census information indicates that about 45 million Americans don’t have health insurance. The population is roughly 300 million, so about 15% of people are uninsured at any one time.

    Many people drift in and out of insured statues (depending on their employment status etc) so the number of people uninsured at some point during any one year is somewhat larger, but nowhere near 60%.

  77. quasilobachevski said,

    November 9, 2009 at 1:05 am

    “Many people drift in and out of insured statues”

    Ooops. Of course I meant “status”! Ben, any chance of a preview button for comments?

  78. skyesteve said,

    November 9, 2009 at 7:59 am

    Sorry quasilobachevski – you’re quite right and I should have been more precise. When I was working in the USA (in New Mexico) the figures I saw suggested that 40% had FULL insurance cover. So I accept I should have put in the word FULL and also that my figures may be time and locality specific and therefore not generalisable (is that a word?!).

  79. skyesteve said,

    November 9, 2009 at 9:15 am

    Oh, and figures suggest 71% of working adults in the US have difficulty paying medical bills (including 41% with insurance – in otherwords they are under-insured i.e. they don’t have FULL coverage).

    www.ncbi.nlm.nih.gov/pmc/articles/PMC516134/

    In the UK this is just not an issue.

  80. quasilobachevski said,

    November 9, 2009 at 5:28 pm

    skyesteve,

    Oh, and figures suggest 71% of working adults in the US have difficulty paying medical bills (including 41% with insurance – in otherwords they are under-insured i.e. they don’t have FULL coverage).

    This seems very plausible – indeed, I’m not quite sure what “full” insurance would mean. Most health insurance in the US requires “copayment”, so the patient pays a proportion of the cost of each procedure.

    There’s no doubt in my mind that the NHS is a massively better system than the US model, both in terms of cost and coverage. (Indeed, I don’t really understand how the Glenn Becks of this world can persist in asserting the contrary.) I merely wanted to correct that one factual point.

  81. skyesteve said,

    November 9, 2009 at 7:31 pm

    quasilobachevski – you are quite right – mea culpa – I should be more specific/accurate with the statistics I use here (that’s part of the purpose of this site afterall!).
    However, the concept of “under-insurance” is a well-recognised part of the US healthcare debate with up to 75 million Americans aged 19 – 64 are either under-insured or have no insurance at all:-

    brighamandwomens.staywellsolutionsonline.com/RelatedItems/6,616350

    The precise figures don’t really matter. I think we can both agree that the issue is that the wealthiest nation on Earth denies a substantial minority of its citizens the right to modern high-quality health care and its politicians would rather slag off the NHS (which, for all its faults, is a fab service) rather than get their own house in order. I think it’s called free market economics or something like that…

  82. quasilobachevski said,

    November 9, 2009 at 8:46 pm

    skyesteve,

    Exactly!

  83. emen said,

    November 12, 2009 at 12:25 pm

    Wow, thank you, skyesteve!

    OK, let’s see.

    “I would do a pregnancy test there and then (…), I would also check her urine for white cells, red cells, protein and nitrites (…), I would also do chlamydia and high vaginal swabs and take blood for a full blood count (to look for high white cells which would suggest infection) and an ESR (erythrocyte sedimentation rate which increases in presence of infection or inflammation) – I can also do the ESR in my consulting room with result in an hour”

    So you could (would if necessary) do a
    1. pregnancy test
    2. urine test
    3. blood test
    4. vaginal swabs
    5. ESR

    there and then, in your surgery, within the 10-minute appointment, with the results available immediately or on the same day?

    Because if yes, I will have to move to Scotland (from England), because I have never heard of anything like that happen in a GP surgery here. My GP can’t do any of these tests, the nurse (with whom you would have to make another appointment) can do the urine and can take the vag. swabs, but she needs to send them off somewhere to get analysed (takes about a week). No bloods taken by the nurse, you have to go somewhere else, make an appointment first etc.

    Wow again.

    Also, I agree with adamk that

    “When a GP says ‘come back if its not better in 2 weeks’ you can think of that as a test – a ‘if its not better in 2 weeks we may need to investigate further’ test. This is a very useful and valid tool.”

    but in practice, this often means going back again and again, the GP trying out different tablets or increasing doses without doing any test or referring you anywhere, in fact treating something he doesn’t know what it is for weeks or months.

  84. emen said,

    November 12, 2009 at 1:09 pm

    “Can anyone really say that’s a better system than the NHS?”

    No.
    But you will find that there are other countries in the developed world apart from the US and the UK.

    Why is it that everybody who critices the NHS is always immediately told about healthcare in the US?
    Why don’t you look at the French, German or Finnish system?

    In France (in general), you pay for one third of your healthcare costs. Normally you take out insurance or you can pay as you go. If you can’t afford insurance, the state will pay for the missing third.
    In Germany, you pay 11-13% of your income to a healthcare company, the state pays for the rest. If you are not employed, you get the service free.

    Both systems are a bit more complicated than that, but the basics are true: everybody gets the service and if you earn enough, you pay for a part of it. For that contribution you get a MUCH BETTER service than the NHS. Yes, it is possible to do a hernia operation one week after the diagnosis, and not have to go on a nine-month waiting list.
    Yes, a doctor CAN sit in the room while you are having your MRI scan and dictate the findings into a dictaphone as the images are being made, so afterwards the secretary types it up, gives it to you and you go away KNOWING the results (compare in the NHS, where even if you have a suspected cancerous tumour, and you have been in the specialist system for months, the doctor can allow himself – clinical guidelines will allow him – two weeks before looking at the images, and then comes the multidisciplinary team meeting, where they will all decide that they have no idea, and give themselves another week to think about what to do to find out.)

    Somebody said on this blog a few months ago, that you now have access to psychotherapy on the NHS within 2 months or sooner. I decided to investigate: I asked a friend of mine who is a psychiatrist, and the answer was: oh, no, of course not, not in the area where she works. The waiting list is 2-3 years, or it WAS, before they were told they can’t refer anybody for psychotherapy for the time being. They need to sort out this waiting list first, nobody can even GET ON IT.

    Swine flu vaccine? Free, sure. But only if you are in the risk group. If you are not in the risk group, you will not get it. In other EU countries you might contribute TOWARDS the cost if you are not in the risk group, but at least you can decide whether you want it or not.

    I don’t think I am far from the truth when I say that people who have lived in another Western European country and have ever experienced better, will NOT say that the NHS is a fantastic system. It is free (at the point of receiving the service!), but you pay a huge price for it being free: you simply don’t get the quality of the healthcare that should be possible in the 21st century.
    (The NHS generally has quite a bad reputation in Western Europe, if you are interested.)

    And what choices have you got in Britain? You can go private, take out insurance or pay from your savings when you need it. In private healthcare, the service is completely market-oriented, where your membership fee goes up as you get older, if you have had a complicated disease etc., it might not cover what you need. Just like in the US.

    And where did we start? Oh, cervical cancer screening. Ben criticising the MP who introduces a bill to lower the screening age. And people from other countries commented how younger women are included in other countries and benefit from it.

    It seems to me that it is a taboo to criticise and suggest reforming the healthcare system in Britain. Like you are immediately a bad person or something.
    But we will never have a better healthcare system here if we keep repeating that it is better to provide bad quality healthcare than no healthcare at all, and that the only alternative would be the US model.

  85. skyesteve said,

    November 12, 2009 at 9:48 pm

    Emen – 1. pregnancy test – yes I can do this in the consultation with result available in about a minute or so.

    2. urine test – again I can do a basic “dipstick” test – this will help to identify the presence of white cells (suggestive of infection), nitrites (suggestive of infection), protein (suggestive of infection but also found with kidney disease), blood/red cells (suggestive of infection but can also be caused by bleeding anywhere along the urinary tract), ketones (found with fasting or in poorly controlled diabetes) and glucose (found in diabetes of course). All these things can be tested for by a single dipstick with all results in maximum of 2 minutes. Sadly dipsticks are not conclusive and, although I may make a clinical decision on them (e.g. start antibioticsfor possible urinary tract) this decision would be made in conjunction with the history and physical examination and I would usually send the sample to the lab for full analysis – microscopy (to look for significant levels of white and red blood cells), culture for infection and, if significant dipstick protein, urine protein levels.

    3. blood tests – these do have to be sent away but basic results (e.g. full blood count, kidney function liver function, etc.) are usually available online in about 2 working days. I can access them directly from the lab’s results system from my consulting room computer if necessary and in a case of real urgency I can ask the lab to do the tests when they receive them so they may be available the same day if I time the pick up lab van right! In the near future we are hoping to have a machine in our adjoining community hospital that can do these basic blood tests which of course will speed things up considerably.

    4. vaginal swabs – again these go to the lab and do take a few days for results for the simple reason it takes that long to culture up bacteria. Some GPs will look at “wet smear” in their consulting room to look for trachoma which can be seen under a microscope but I don’t do that myself.

    5. ESR – yes I do this in my room with result in an hour.

    Oh, and in my practice, 15 minute appointments are standard which definitely helps. But there’s nothing above that couldn’t be done in any average GP surgery – I’m certainly no super-doc.

  86. emen said,

    November 13, 2009 at 10:41 pm

    An interesting point in today’s New Statesman by Mike Richards

    Mike Richards: “Undoubtedly, our cancer survival rates have been poorer than many other countries. The question is, why? The more we look into that, the more apparent it is that late diagnosis is the problem and, therefore, failure to get the patient to the curative treatment. The curative treatments for cancer are very often not that expensive. The best treatment for cancer in many cases is surgery, and well-done surgery is not that expensive, whether it is for breast cancer, lung cancer or colorectal cancer. We are simply not picking up patients early enough.

    This comes back to the previous discussion about primary care, of which I am a very strong supporter; I am from a family of general practitioners. We have tied the hands of our general practitioners to a certain extent because we have asked them to be overzealous gatekeepers, but we have not given them access to diagnostic tests. This is why I so strongly welcome the recent announcements that we will improve access to diagnostics for GPs. For cancer patients, for example, this will mean that people who have a low risk of having cancer based on their symptoms – but not no risk – will be investigated, and investigated quickly. The vast majority will then be reassured, but the small number who are found to have cancer will go into the system at a curable stage. That is a very important point. We need to put more emphasis on diagnosis and take more money out of the hospital system in terms of people being in beds when they do not need to be.”

  87. emen said,

    November 13, 2009 at 10:43 pm

    …who is the national cancer director at the Department of Health

    www.newstatesman.com/health/2009/11/health-care-system-change-nhs

  88. skyesteve said,

    November 15, 2009 at 12:45 pm

    For England? It’s Prof. Mike Richards

    www.dh.gov.uk/en/AboutUs/MinistersAndDepartmentLeaders/NationalClinicalDirectors/NationalDirectorsBiography/DH_4105307

  89. skyesteve said,

    November 15, 2009 at 9:37 pm

    …but not for Scotland, Wales or Northern Ireland. I don’t know about Wales or Northern Ireland but here in Scotland we have our own initiatives on cancer.
    Anyway, I haven’t read the article but it’s hard to disagree with that part which you quote Emen.
    But this doesn’t say “let’s screen everyone for every thing every year”. Nor does it mention the very real morbidity associated with unnecessary investigation. It’s a very difficulat balance to strike but I think on the whole, at least in my part of the world, we do the best we can.
    I have no problem getting someone seen within a week or two for necessary assessment if I have the slightest suspicion of cancer but at the same time I have a prime directive – ” do no harm” – and that means not causing unnecessary physical and psychological morbidity by over-zealous investigation.
    That’s where “art” plus over 20 years experience comes in (I hope!).
    Right, no more posts on this one – I promise!

  90. bodenca said,

    November 16, 2009 at 4:08 pm

    I think if I were an early twenty-something women, I would still be dissatisfied with the justification of NHS policy within this thread, although all its main elements have appeared.
    So, I’ll be melodramatic and see if that gets the general arguments across. Here goes!

    There is no such thing as a “screening programme”. Screening does not give true positives and false positives. It just gives positives. These have to be found true or false by a follow-up test. It is a “screening and follow up programme” or useless.

    In assessing risks of a potential programme, the follow-up is critical. It is usually (more) invasive. It may involve ionising radiation. Will this small intervention danger to a larger number of false positive patients cause more suffering than would the greater disease danger to the smaller number of true positives if left undiagnosed?

    In assessing resource usage also, the resource-demanding follow-up is usually critical. How much suffering will the diversion of medical skills, facilities and equipment away from other treatments cause? Added to the suffering of false positives if the programme goes ahead, will this exceed the suffering of true positives left unscreened until they present later? This is the case whether health treatment is a cost to a national service such as the NHS or to a health insurance fund, or some fancy mixture of the two.

    Perhaps the Scottish NHS policy was a “best guess” but more recent consideration could show the English programme to be wiser. The Scots are likely to carry on regardless because it is so difficult to withdraw an unwise service once it is established.
    Then again, as both screening and follow-up procedures are improved, the time to extend screening in England to a further age cohort may already have arrived, but not yet be statistically demonstrable.
    We know only that it is unsound to ground criticism of one nation on the past judgements of another, not which is better.

    That said, distrust any overseas system which relies even in part on private insurance companies (or medics) who may vie to show they are “better” by offering medically unjustifiable screenings and treatments. And now our papers, and some politicians, are trying to do the same.

  91. heavens said,

    November 20, 2009 at 11:07 am

    @23 says, “I am glad to live in another European country which recommends getting a PAP test as soon as you become sexually active.”

    Um, that’d be pretty much worthless.

    The point of a pap smear is to find cervical cancer caused by a sexually transmitted virus. It takes years for this virus to cause cancer, not days or weeks — “years”, as in “median latency is generally believed to be 15 to 30 years”. Pretty much nobody has ever seen any sort of clinically detectable change in less than one year, which makes “as soon as you become sexually active” kind of silly.

    Have you perhaps confused a pap smear with a pelvic exam? (That is very widely recommended “as soon as you become sexually active,” or even before then.)

    Or do you think that your country’s health service thinks all the women lie to their physicians about their sexual lives? I suppose that if the regulator thought that most women were having sex at age 15, but lying to their docs until they were married at age 25, then you might suggest “as soon as you are willing to admit that you’re sexually active, because we believe that’s several years after you really started”.

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  93. ignoranceisalearnedbehavior said,

    November 22, 2009 at 1:01 am

    Living in the US currently where things are often done differently (and sometimes not at all) it occurred to me that this might be of interest,

    www.acog.org/from_home/publications/press_releases/nr11-20-09.cfm

    particularly this excerpt, “A significant increase in premature births has recently been documented among women who have been treated with excisional procedures for dysplasia. “Adolescents have most of their childbearing years ahead of them, so it’s important to avoid unnecessary procedures that negatively affect the cervix,” says Dr. Waxman. “Screening for cervical cancer in adolescents only serves to increase their anxiety and has led to overuse of follow-up procedures for something that usually resolves on its own.” Naturally I haven’t read the original report or looked at the research data, but it’s noteworthy that the [insert unfavored press body of the minute] lobby is asking for something even the treatment-hungry Americans are finding of dubious benefit at best, harmful at worst.

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