Time to abandon early detection cancer screening?

8 January, 2019

Courtesy of Anoop Balachandran on EVIDENCE-BASED-HEALTH@JISCMAIL.AC.UK, we share this interesting article below co-authored by John Ioannidis titled: ‘Time to abandon early detection cancer screening’. We are intrigued about the coincidence that it appeared on the same Day that UK Prime Minister, Theresa May launched the NHS UK’s 10-year plan, in which one major objective seems to be expanding/ enhancing prevention of cancer focusing on early detection / screening to save hundreds of thousands of life. An interesting coincidence.

Click and READ ON - [*see note below]

https://onlinelibrary.wiley.com/doi/full/10.1111/eci.13062

[ABSTRACT: Time to abandon early detection cancer screening

Hans Olov Adami Mette Kalager Unnur Valdimarsdottir Michael Bretthauer John P. A. Ioannidis

European Journal of Clinical Investigation

First published: 19 December 2018 https://doi.org/10.1111/eci.13062 ]

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We read the article and thought of how it may be used in some LMICs. We make the following observations and comments:

We debated the content of the article and felt that the generalisation of focus may actually dissuade some LMIC countries that are about to embark on screening for cancer from doing so. Already many are reluctant to fund their health systems adequately. The focus of the article on only whether ‘screening prevents mortality’ ignores other desirable outcomes like positive patient-centred care and quality of life lived by cancer patients (psychological, mental, physical, economic, etc). The cost of treating established cancer is more than screen detected cancer. Before screening for breast cancer became routing in HICs, patients were diagnosed late ( as is still common in LMICs today) and they underwent radical and super radical surgeries including in some cases opening the chest to chase lymph nodes. The post operative life of those victims should not return for what ever reason.

Surely, ‘Overdiagnosis defined as the detection of a disease or condition that would not cause symptoms or death during an individuals lifetime’ by the authors needs to be tackled, but how do we know that screening-diagnosed cancer would not have progressed to the more complicated cancer during lifetime of the patient. Today in HICs at least, confirmatory tests following a positive screening test helps to determine the next steps to management e.g. for Prostate cancer (where Gleason score staging on biopsy samples taken after the screening by minimal access techniques).

The authors say that ‘The number of patients affected is larger than for cancer, but the treatment is often less invasive and harmful’, to which we say that that is exactly the point – treatment is less invasive, less painful, often shorter and therefore cheaper for screening detected cancer, for which doctor and patient decide to proceed to treatment. Increasingly, and rightly, so it is not left to only doctor and patient, it is now a multidisciplinary team decision (MDTs).

The authors propose that ‘The currently prevailing nudging of the population towards cancer screening tests with little effect and a doubtful benefit‐harm balance should be stopped’, to which we comment that this is not a helpful message/proposition for LMIC countries that do not have any screening at all, whether population-wide or selective, on a national level. Not even the preventive screening ( cervix, colon), talk less of early detection type of screening ( breast, prostate). We foresee some LMICs quoting/using the authors proposition not to advance on modern cancer control approaches for their citizens.

The authors say that ‘People should be informed unpassionately and objectively, and informed nonparticipation should be an accepted choice. Consequently, high attendance for such screening needs to be abandoned as a quality indicator for healthcare’, which we totally agree with because in our experience at least in HICs and some LMICs that is the position even now with screening. Patient consent is mandatory, and non participation attracts no sanctions!.

We also read the authors statement that ‘After almost three decades of opportunistic PSA‐testing on an industrial scale, and extensive assessment of mortality trends, the evidence of benefit is still so unconvincing that the US Preventive Services Task Force is now leaving it entirely to patients and doctors to decide what to do’, But we comment that that is / or should be the classic ethical medical practice ethos: patient and doctor ( or MDT these days) weigh the evidence and come to a decision that is best for the particular patient. Serial PSA readings is still a good indicator for selected patients e.g. those with positive family history, etc.

We do not agree with the authors when they said that ’Therefore, population‐based early detection approaches should be abandoned’ because that’s like throwing the baby out with the bath water. Even if population-wide screening is to be ‘banned’, we would rather advocate and promote selective early detection approaches e.g. serial PSA for at-risk persons should be encouraged.

In this world where the Global North health systems are strong, this article may be better understood and interpreted both by policy makers and care providers, but the authors proposal poses a risk for the LMICs where policy makers may use it as an alibi not to even start any screening services in their health system. We did not see the necessary differentiation in the article.

Joseph Ana.

AFRICA CENTRE FOR CLINICAL GOVERNANCE RESEARCH & PATIENT SAFETY

@Health Resources International (HRI) WA.

National Implementing Organisation: 12-Pillar Clinical Governance

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HIFA profile: Joseph Ana is the Lead Consultant and Trainer at the Africa Centre for Clinical Governance Research and Patient Safety in Calabar, Nigeria. In 2015 he won the NMA Award of Excellence for establishing 12-Pillar Clinical Governance, Quality and Safety initiative in Nigeria. He has been the pioneer Chairman of the Nigerian Medical Association (NMA) National Committee on Clinical Governance and Research since 2012. He is also Chairman of the Quality & Performance subcommittee of the Technical Working Group for the implementation of the Nigeria Health Act. He is a pioneer Trustee-Director of the NMF (Nigerian Medical Forum) which took the BMJ to West Africa in 1995. He is particularly interested in strengthening health systems for quality and safety in LMICs. He has written Five books on the 12-Pillar Clinical Governance for LMICs, including a TOOLS for Implementation. He established the Department of Clinical Governance, Servicom & e-health in the Cross River State Ministry of Health, Nigeria in 2007. Website: www.hriwestafrica.com Joseph is a member of the HIFA Steering Group: http://www.hifa.org/people/steering-group

http://www.hifa.org/support/members/joseph-0

jneana AT yahoo.co.uk