Wednesday, 19 December 2007

More good news

My cup brimmeth over.

When I wrote my article last week I meant to mention one other development which had cheered me up but I forgot at the time and, when I remembered, the moment had passed. What I was going to add was that the CT screening companies, the prostitutes of modern healthcare, were coming under critical examination.
Many people in the profession, and in particular Radiologists, have been alarmed by the lack of regulation of these companies and their direct marketing of CT scans to the worried well for purely profit motives.
The screening business had flourished for a time in the USA but, as the public became better educated and began to realise the lack of evidence for the claims the companies were making, there has been a tail off in demand. In the UK we are still on the upward slope of the curve with the worried well believing the claims that the scans can find your cancer and thereby allow you to be cured by timely surgery.
Considering the close regulation of industries which expose people to ionising radiation I have always been puzzled by the way these companies are allowed to irradiate the public with no proven evidence of benefit. The irradiation of someone without informed consent is technically assault. In hospitals we generally assume consent for irradiation but each investigation has to be justified such that we are satisfied that the benefits outweigh the risks. The benefits of screening CT are largely anecdotal so, by definition, the benefit/risk ratio is unknown and I cannot see how someone can give informed consent. I presume they ask the punters to sign a disclaimer rather than a consent form.
Anyway, last week there was a Jeremy Laurance article in The Independent that raised the issue of the dubious claims made for these "medical MOTs" and the risks to the unsuspecting public. This week calls for regulation have been made by COMARE, a government advisory panel on radiation. Even Liam Donaldson stuck the boot in.
Now, like many other bloggers - most notably DK, the news that an unelected, pressure group want to inflict more regulation and restrict the individuals choice does not generally cheer me up but in this case the public really does need to be protected. The very same public who worry about living close to a power line or having a mobile phone mast near their childrens' school are quite happy to part with anything up to £1300 to be subjected to radiation doses similar to those which caused excess cancers following the use of nuclear weapons in Japan.
Dr John Giles, a radiologist who runs Lifescan, one of the more aggressive and successful "radiation-for-reward" companies put a brave face on it today, claiming that he welcomes the report and, bizzarely, that Lifescan don't do screening scans but target individual organs. This might wash with the gullible public Lifescan usually deals with but as a radiologist he knows that CT scanning doesn't target individual organs; everything in the region scanned is irradiated. If he "targets" just the lungs and bowel that is a screening scan of the whole torso. Notwithstanding Dr Giles' welcoming of the report, COMARE states "...we have strongly recommended that services offering whole body CT scanning of asymptomatic individuals should discontinue to do so."
In fact its probably a distraction to focus too much on the radiation risk, which is unquantified for small doses. The main problem with the "scans-for-spondulis" companies is that they make unsupported claims of benefit, expose patients to the anxiety and physical risk of further investigations, and cost the taxpayer a large amount of money.
The scientific evidence in favour of screening is notoriously difficult to prove. There are still eminent scientists arguing whether breast screening is effective. CT screening for cancers is much less studied. Some cancers will not be reliably detected, others will be detected too late to alter outcome and others will be detected that would not have shortened the patient's life anyway. The best example of a cancer that is worth finding and is often picked up by chance is a renal tumour. You will find this mentioned in all the testimonials ( an indication of quackery) on the scanning company websites. The other abnormality worth finding is an aortic aneurysm. Both are easily picked up on a £50 ultrasound.
The anxiety, physical risk and cost to the taxpayer stem from the large number of false positive scans. These are scans that either show something which looks abnormal but isn't present or something that looks serious but is harmless. The scanning companies don't reveal how many "patients" have false positive scans but, in my experience, the majority of patients will have either a cyst or haemangioma in the liver, a cyst in the kidney or a solitary lung nodule. These patients would need a further investigation such as ultrasound, a repeat CT with contrast, a repeat CT after an interval or even a biopsy. Many of these would look to the NHS for these further investigations and some patients will suffer as a result of unnecessary biopsies.
Patients often contact me for screening scans and I find it difficult to explain why we don't offer them at UK-Radiology. The first time I was asked I wrote a long thesis on the scientific arguments; there just isn't a quick way to explain it. Now I say we don't consider it ethical and send a copy of my reasoning. I have been thanked a few times. If I were a quack I could use the comments on my testimonials page!

The other bit of good news this week is UK-radiology's return to first page of Google for the search term "private MRI scan". My colleagues simply don't appreciate how difficult and labour intensive it is to do this. Some have even criticised my methods (i.e. this blog - they haven't found out about my other methods yet). The easy way would have been to copy our competitors, charge the patients an extra £50 each and buy a pay-per-click campaign. That would have left me my last month's evenings and weekends free for me to enjoy away from my PC. Then again, we run an ethical company.

25 comments:

The Witch Doctor said...

Thanks for publishing this information.

Recently I received a glossy leaflet in the Christmas mail from a company advertising this very thing. A Christmas present for aging relatives perhaps? The wording was such that the reader was left with a feeling that it was a bit irresponsible not to "buy" one of these scans for anyone in the family over a certain age - not said in as many words of course. No mention of the pitfalls. No mention of any doctor taking a history or examining the patient first.

I felt this was preview of a demand led, client driven health service insidiously cultivating the worried well.

I looked up the Website and noticed a local radiologist's name which gave credibility to the whole exercise, of course.

Dr Ray said...

Thank you for your comments "witch doctor".
There is no doubt we pick up the very occasional renal tumour that saves a life but screening programs need to be based on evidence rather than anecdote. If we rely on anecdote we will be offering homeopathy on the NHS next!
Personally I think renal tumours are worth finding using ultrasound but I don't think we can offer a screening program yet. I always look when doing an aortic aneurysm screen. I did find one once during an aorta scan and the tumour was removed and turned out to be benign but there was no way to predict this and the chap was happy I had found it.
I honestly don't know whether the radiologists who support these companies have any moral qualms. Perhaps they really do believe in what they are doing or perhaps they just enjoy the income. I suspect they justify their actions by thinking if they don't do it someone else will. They are in the minority but a dozen or so radiologists is all it takes.
Plenty of interest in MRI for screening at present so I predict Lifescan will move into this rather than pack it in.

Peng Hui LEE said...

This has been dragging on for years. I posted somthing about this a while ago, and when I checked, it was 2 years back.
http://pengrad.blogspot.com/2005/04/whole-body-ct-screening.html

Peng

Peng Hui Lee said...

Some people in Germany have been doing whole body MRI screening on a trial basis: no problem with radiation there ....The protocol includes MR colonography which involves the patient lying prone in the scanner with a rectal tube and up to 2.5 litres of warm tap water in the colon.
http://www.ihf-fih.org/pdf/debatin.pdf

Peng
www.midessexray.com
PS I didn't realise recently that there was another UK radiology blog . And in case you're wondering why I'm posting this comment today, I'm on call waiting for a patient to be delivered. Happy Christmas :-)

Dr Ray said...

Thanks for your comments and the URL to your website, Peng Hui Lee. Looks like it might be a regular read now.
MRI will be the way forward and the gastro boys where I work seem to think we should be providing the service already.

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