'challenges for a GP and medical columnist’

margaret.mccartney@ft.com

My shared challenges

Helping people access fair information

• Accurate information

• Challenging poor evidence/assumption,

• useful ‘choice’

• Being independent

• ….Avoiding libel

Making our minds up

In an information market, who do we trust to give us fair information about health?

• Doctors/health professionals• Charities/lay people• Media outlets, journalists, the internet/bloggers• PR industry• Pharmaceutical companies• Researchers and journals

Who is truly independent?

“The benefits of breast screening far outweigh the risks and I would strongly encourage all women to make an informed choice to attend for screening when invited”

Julietta Patnick, director of NHS Cancer Screening Programmes

‘over diagnosis is fact’

What would be more useful information?

• Number needed to screen• Rate of false positives and negatives• Implications of these

• Standard NHS information• ‘1 in 9’ women will get breast cancer at some

point in their life’• 1 in 20 recalled • No NNS/absolute risks used

Systematic review, Nordic Cochrane Centre, 2006

• 1,000 women over 10 years

• one would have her life prolonged

• 10 would endure potentially unnecessary treatment for breast cancer

• Another 200 of those women would have "false positive" results

Herceptin

• ‘don’t let my mum die’ - Telegraph• Instant cure-all” Once in a decade, a drug comes along that represents a

real medical advance, and when it does we must grasp the chance to use it.

The Observer, Leader, May 22nd 05• “remember there is still another key step that Herceptin

has to go through, which is the NICE and the SMC approval processes for use of Herceptin by the NHS…hopes that NICE and the SMC will approve the use of Herceptin quickly” Breast Cancer Campaign

Breast Cancer Action Group of Australia

• “we deplore the situation in which it appears that women are being provided with information which is not adequately balanced via the media and some clinicians as well as the lack of generally balanced information.”

• No industry funding, entirely independent

What would be more useful?

• 20-30 per cent of women have HER-2 positive breast cancer

• The HER-2 test is only 80 per cent accurate

• two years worth of data in 2005; HERA trial

• 77.4 %of patients were disease-free and alive.

If Herceptin was used in addition, then 85.8% alive and disease-free cardiac side effects.

The full analysis HERA due in 2007

Dr Jane Keidan BMJ Jan 2007

“ More careful analysis of the "50% benefit" which had been widely quoted in the medical and non-medical press….and fixed in my mind, actually translated into a 4-5% benefit to me, which equally balanced the cardiac risk. So I elected not to receive the drug and will be happy with this decision even if my tumour returns.

“This story illustrates how even a medically trained and usually rational woman becomes vulnerable when diagnosed as having a potentially life threatening illness.

The eGFR test

• requirement of current GP contract

• Patients with groups of CKD as defined by eGFR to be on ACE inhibitor

• No evidence base for this

• Inappropriate, unnecessary treatment

• Political, not clinical, target

A reader’s reaction• This whole process has pissed me off totally, and raises a number of issues:

• I seem to have had blood samples taken which have been used for tests I had not been asked to consent to, nor was I given any advance information that they would be carried out, nor any proper initial explanation of what the results implied. I was then subjected to further medical investigations without a proper explanation of why they were necessary, apart from there apparently being a need to establish a base line for measuring future progress of any `problem' found in these investigations.

I am now taking medication (at some cost to taxpayers generally as I don't pay for prescriptions) to try to prevent the remote possibility of my needing an intervention, which should I survive for long enough to need it, will probably not be available in any case.

treatment ‘choice’

• Statins

• Hypertension

- all standardised and contract treatments

Who are we treating?

Individuals or population?

GPs or public health doctors?

The Flora Lady

• Man aged 42 – TC:HDL ratio 6

• Never smoked, no family history CVS disease

• Exercises regularly, BP 138/80

• ‘at least I know’

• ‘I thought I’d need those statin tablets.. as well as changing my margarine.’

Guidelines

What do I do?

• WOSCOPS matches population• From the trial • “PRAVASTATIN RAPIDLY REDUCES RISK OF

HEART ATTACKS AND SAVES LIVES OF PEOPLE WITH HIGH CHOLESTEROL AND NO PREVIOUS HEART ATTACK

• West of Scotland Coronary Prevention Study Appears in 16th November NEJM”

WOSCOPS

“ People with high cholesterol can rapidly reduce their risk of having a first-time heart attack by 31 per cent and their risk of death by 22 per cent, by taking a widely prescribed drug called pravastatin sodium. This is the conclusion of a landmark study presented today at the annual meeting of the American Heart Association. The results appear in the 16th November edition of the New England Journal of Medicine…”

John-Arne Skolbekken BMJ1998;

• Yet another way of stating the facts would be to say that patients with angina or after a myocardial infarction may improve their probability of avoiding coronary death from 91.5% to 95% by taking simvastatin, while people without prior coronary disease may improve their probability from 98.3% to 98.8% by taking pravastatin ….

…

• Medicine is not an exact science. Therefore, 200 men without any prior heart disease have to swallow 357 700 tablets over five years to save one of them from dying from coronary heart disease. This is due to the fact that no exact knowledge exists as to whom of these 200 will benefit from the treatment.

• Side effects underestimated(20% thought to have some) - Impact on quality of life- “I don’t go salsa dancing any more’Drop out rates from some statin studies 30%How far should a doctor ‘recommend’ Rx?Do we advocate for guidelines or the

patient?

What I try to do

• Share helpful information• Discuss priorities, side effects and aims• Veer off protocols• Share uncertainties• ….Lose control • Offer advice/advocacy/lateral

‘housekeeping’ perspective• Holistic Care

who can be relied on to give independent, fair, and evidence

based advice?• Medics? Politicised/deprofessionalised/self

interest

• Media? PR/sales/lack of science graduates

• Press releases? Panic or pertinant

• Researchers/experts? How to interpret papers/meaningfulness

A plea…

• NNT, absolute vs relative risks and ‘community abstracts’ published as standard

• what will the press will make of it? and patients without the knowledge to understand it – and patients and doctors without access to full details

• Lots of adverse effects go unstudied