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WHEN television presenters decide to mount a health campaign, it’s not hard for things to go wrong.
The team at Channel 7’s morning program, Sunrise, probably thought they were doing their good deed for the year when they encouraged viewers to undergo a range of cancer screening tests.
Morning television is all about entertainment: the audience didn’t just receive advice about mammograms, they got to watch 41-year-old presenter Samantha Armytage actually having one.
Another episode featured co-presenter David Koch, age 61, undergoing screening for prostate cancer, including a PSA test and digital rectal examination.
“For blokes, it’s so important … you’ve got to get checked. You must get checked,” he told his co-hosts.
Time for a reality check, perhaps.
Australian guidelines are much less enthusiastic than “Kochie”, saying there is no evidence to support population screening with the PSA test.
Men considering the test need to be informed about the benefits and harms before making a decision, the guidelines say.
And digital rectal examinations are not recommended as a routine accompaniment to the PSA test, again due to a lack of evidence of benefit.
But, hey, this is television …
Armytage took a similarly cavalier approach. She acknowledged BreastScreen Australia guidelines recommending regular mammograms for women begin at age 50, but confidently declared: “I would say to start at 40, if you feel like it, if you want to.”
Well, of course, if you feel like it … Because who cares about evidence.
Not BreastScreen Victoria, apparently, who enthusiastically promoted the Sunrise hosts’ participation in these “important health checks”.
“With 1 in 8 women being diagnosed with breast cancer in their lifetime, it is a great way to bring awareness and take away the fear that is often associated with getting a breast screen,” says the organisation’s website, providing a link to “Watch Sam’s mammogram”.
You might expect better from BreastScreen Victoria, but the Sunrise team are hardly alone in thinking health screening must, by definition, be a good thing.
An anaesthetist I met at a dinner party a few years ago enthusiastically shared his recent colonoscopy experience with his fellow diners, advocating for the procedure to be included in routine colorectal cancer screening for the over 50s.
When I asked what the evidence to support such an approach would be, he replied: “I’m the evidence. It saved my life.”
I mumbled something about risk–benefit analyses, but he wasn’t having any of it.
For the record, Australian guidelines do not recommend colonoscopy for asymptomatic people at average risk of colorectal cancer.
The fear of undetected cancer blazes bright for many of us, and that can make the risks posed by screening seem insignificant by comparison.
Looked at on a population level, though, they are anything but, as epidemiologist Professor Alexandra Barratt spelled out in response to the Sunrise campaign.
“Unfortunately, Channel 7’s misguided advice on breast screening ignores vast amounts of independent medical research about the downsides of cancer screening tests,” she wrote in the Sydney Morning Herald.
“It may surprise most people to learn that screening tests can lead to ‘overdiagnosis’: the detection of cancers that are so slow growing, they will never cause symptoms or death and are better left alone … screening healthy women in their 40s [for breast cancer] is more likely to harm than save lives.”
Potential harms of any screening include anxiety and emotional upheaval as well as unnecessary treatment, with all the unwanted side-effects that might bring. Without clear evidence of benefit, it’s just not worth the risk.
Such nuanced messages can be hard to convey, though, when you’re up against the spectre of cancer.
And they definitely don’t offer the entertainment value of watching a popular TV presenter get a mammogram.
Jane McCredie is a health and science writer based in Sydney.
To find a doctor, or a job, to use GP Desktop and Doctors Health, book and track your CPD, and buy textbooks and guidelines, visit doctorportal.
People who don’t see the point of Jane’s article should read up about Overdiganosis at sites such as this: https://www.preventingoverdiagnosis.net/?page_id=1176. When a screening test is applied to a low prevalence population, there is an increase in false positives, which can lead to invasive testing and harm. As the commenter above points out, invasive tests like colonoscopy carry harms of their own, including bowel perforation (rare, but potentially devastating).
Screening tests are not as benign or simple as a brake check. We should apply the same evidence-based rigour to screening as we apply to treatment, and continue to update our knowledge as new evidence emerges.
Ian Hargreaves, that is entirely spurious comparison. There is no risk from having a brake check; there is no need for evidence to examine the risk vs. benefit. There is a need for such evidence in the case of colonoscopy for colorectal cancer screening, and the evidence is fairly clear.
It would be illustrative to ask an epidemiologist like Prof Barratt whether she gets her car’s brakes checked in an annual service. There is no RCT done by a car manufacturer to show the benefit of screening, rather than waiting for symptoms such as soft brake pedal feel, prolonged stopping distance etc. Objectively, to an EBM practitioner, brake checks offer no clear evidence of benefit.
There is no specific mortality figure in the ABS website for brake failure, but given that death from land transport accidents is less than 10% of deaths from colon, breast, and prostate cancer, it seems silly to waste effort and money on unproved screening for a minor risk, but to ignore the major ones.
I have had colonoscopies since my early 40’s (born 1940 at the height of the Battle for Britain) as a result of the history of my mother and 2 of her siblings having been successfully treated for colo-rectal cancer. I had no occult blood in stool or any other abnormality, My first colonoscopy revealed several adenomatous polyps which were zapped. I then went on a polyp surveillance program and have actually lost count of the number of colonoscopies I have had over the years. Adenomatous polyps have harvested on every occasion. Several years ago, colonoscopy revealed polyps as usual, including a large one near the ileo-caecal valve, not able to be snared by the very competent gastro-enterologist performing the procedure. It was decided to repeat the colonoscopy and try a different tecnique, where the surrounds of the polyp are injected with submucosal saline, shoving it out further into the bowel lumen, where it could more easily be captured by the snare. This failed and the suggestion was that it could be tethered. What to do. Some people would tattoo the site and do a local resection per abdomen. This is frought with difficulty since an endoscopist apparently has trouble correlating where he is in bowel with the in situ anatomy outside. It was decided to do a right hemi-colectomy and this was performed endoscopically by a brilliant young colo-rectal surgeon. I was walking around the ward at the end of the day of the procedure and have had no trouble since. Polyps are still being harvested! The large polyp turned out to be benign but I didn,t care. I just wanted it out of there as you can imagine. My message is that you need to have an early colonoscopy , PARTICULARLY if there is even the slightest family history. However, the majority of these cancers come from left field, often without ANY sort of warning. FOB is a pretty pathetic screening tool. For a growth to be detected by this method, it has to have pretty much outgrown its blood supply, by which time you are running a risk of it having already turned malignant AND having spread to liver/lung etc. Governments have jumped on the cheaper FOB waggon due to cost. Sorry fellas, but some day you are going to have to grasp the nettle of screening colonoscopies. If a government adopted such a costly program then they would go down in history as the first to be fair dinkum about eliminating this horrible disease. You never know readers, but there could be one of these mongrel things quietly “festering away” in your gut right now! Good luck.
Sorry, Jane, I have to disagree with you. In many ways, I’m with Kochie & Sam & some of the others above, especially an Hargreaves.
I have found, & in most cases saved, the lives of a significant number of (usually) younger patient with various cancers by screening outside the guidelines over my practicing career. In some cases it was by following instinct & the patient’s feeling that something was not quite right. I would never say to these people that they do not fit into the “cost-benefit” cycle!! I also lost a very good friend at age 50 with colon cancer – no known risks and a relatively recent negative FOB test. Presented with PR bleed and had disseminated disease. Colonoscopy at 40 & 45 would most likely have saved her. It is high time we stopped wasting money on “political bandaids” like the universal & untargetted FOB screening – I have received 2 kits, years after my first dysplastic polyp was discovered & removed. Colonoscopy is the gold standard, and if targeted sensibly by GPs who know their patients best, is the best solution.
When the Government stops wasting billions on defence & other departmental waste & stuff-ups and throwing dollars at poliically motivated programmes without analysis of outcomes, I may listen to the “cost/benefit” argument.
Besides, Kochie’s statement has resulted in some increased GP consultations, in which I have discovered several previously undiagnosed (because the male patients are notorious irregular attenders) hypertensives, and a diabetic.
After all, at one stage of our history, most of the then accepted science said the world was flat!
While breast cancer in the 40-50 year old population is less common it exists and breastscreen allow mammograms from age forty every 2 years, they just don’t invite screening until 50. Also younger breast cancers behave worse so the ‘saving’ statistically by not screening til forty does not take into account the traumas of a breast cancer diagnosis under the age of 50 (=25% of all breast cancer diagnoses). Cost should not determine care.
I was the intern on the endocrine unit in 1982, when debate raged about whether it was best to have tight glycaemic control, and thereby risk more hypoglycaemic episodes, or to run the blood sugars much higher and avoid hypoglycaemic risk. It took about 60 years from the discovery of insulin, in an incredibly common disease, for the evidence to be established that on balance, better control prevented complications.
When AIDS was uniformly fatal, many new drugs were released with what would have normally been considered inadequate evidence for risk-benefit profile, in the hope that something would work. This approach saved many lives.
As a middle-aged non-smoker, the epidemiology is that I have about a 2/3 chance of dying from cardiovascular disease and about 1/5 from cancer. The highest death risk is from bowel cancer, the second from prostate, then being very fair skinned, melanoma. The rest are all the haematological malignancies and the difficult to diagnose/treat deep tumours like pancreas or glioma.
The problem with bowel cancer and prostate cancer is that the symptoms are very vague and generally attributable to benign disease, such as vague abdominal discomfort or diminished urine flow. Many people present with metastatic disease such as bone secondaries, or an emergency procedure for bowel obstruction. But by the simple screening measures of a PSA, colonoscopy, and skin check of the parts I can’t see, I can detect 80% of my cancer risk at the asymptomatic stage. And, like Janet’s anaesthetist acquaintance, my asymptomatic pre-malignant polyps were diagnosed and cured after I attended a lecture on screening for colorectal cancer, which pointed out that there is usually a long window between the development of adenomatous polyps and progression to cancer (similar to cervix, unlike pancreas).
I can understand that governments may prefer to have colorectal cancer evolving in about 5% of the population, rather than the expense of screening 100% of the population – but personally, the risk-benefit analysis favours screening. And while “potential harms of any screening include anxiety”, I have no anxiety when I get a vague guts ache that it may be colon cancer. Although it could still be appendicitis!
Logging into the American Cancer Society’s website today brings up the banner headline: “Colorectal cancer can be prevented. Get screened.”
Celebrities endorsing cancer screening ( usually after a personal experience ) is a modern phenomenon . Unfortunately they rarely provide a balanced view and the downsides of false positives and negatives are never mentioned.