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Awareness campaigns lead to overtreatment and divert resources from where they are needed
Programmes such as Public Health England’s lung cancer awareness campaign, urging people to see their GP if a cough lasts three weeks or longer, form a major part of the Government’s drive to improve cancer survival. Raising awareness of signs and symptoms will help us diagnose and treat cancers earlier, so the argument goes.
But in my view such campaigns exemplify the aphorism ‘the road to hell is paved with good intentions’.
It is only natural for those who have experienced cancer themselves or in loved ones to want to do something about it. ‘Something must be done’, however, is no reason for doing just anything.
While there is much hand-wringing over diagnosis rates being lower than in the rest of Europe, cancer mortality here has been improving at least as fast as in other European countries – implying we are just as good at treating potentially life-shortening cases.1
Only when set against all-cause mortality data can a population intervention be shown to have done more good than harm, yet many of these campaigns are not properly evaluated to assess any harms – including the consequences of diverting resources.
These campaigns are essentially self-screening tests, so they should fulfil the Wilson-Jungner screening criteria, notably that benefits must outweigh costs, and there must be adequate diagnosis and treatment facilities.2 Yet these points are rarely considered.
Indeed, an earlier breast self-examination campaign turned out not to cut mortality, but instead increased the number of benign lesions biopsied, patient anxiety and costs to the health system.3
The ‘three-week cough’ campaign also risks doing more harm than good. GPs know that, contrary to NICE guidance, self-limiting coughs can last at least four weeks.4 The pilot did show positive signs, but one initially supportive chest physician now tells me her clinics are overrun with incidental chest X-ray findings.
GPs are also well aware of the pitfalls of PSA screening5, yet there is still pressure from charities and pressure groups for men to be screened.
If we think something might do good, we must prove it before risking harm. Let’s not pave the road to hell with any more unevidenced, unresourced good intentions.
Dr John Cosgrove is a GP in Cheshire and RCGP Council member
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These campaigns help us detect cancers at a more treatable stage
We know that one in two people in the UK born after 1960 will be diagnosed with some form of cancer during their lifetime. Patients in the UK tend to present with more advanced disease and have poorer survival rates than those in Europe, and the UK has among the lowest five-year survival of comparable nations for breast, colorectal, lung and ovarian cancers.6
The most likely explanations are either late presentation, late onward referral or suboptimal access to treatment.
A Cancer Research UK survey found public awareness of cancer signs and risk factors varies widely. Less than 25% could recall less ‘typical’ symptoms such as loss of appetite, weight loss and nausea, while knowledge that difficulty swallowing could be a sign of cancer was worryingly low at less than 1%.7
Various campaigns and schemes have been run in recent decades to improve prevention, symptom awareness and early diagnosis. The Be Clear on Cancer campaigns run by Cancer Research UK and Public Health England are designed to tackle late presentation of possible cancer and promote earlier diagnosis.
Results from these campaigns since 2010 have been shown increases in cancer and symptom awareness. For example, 62% of people surveyed knew ‘blood in pee’ was a symptom after this campaign ran, up from 31% before the launch.8 Furthermore, 9% more lung cancers were diagnosed in patients first investigated for this cancer during the campaign, when compared with the previous year.9 There was also an increase of 2.3 percentage points in the proportion of these patients undergoing potentially curative treatment.
I believe this shows such campaigns should be pursued to improve population health-seeking behaviours. We should ensure they are adequately funded so the public receives frequent and widespread exposure to campaign messages over time, and health professionals receive extra capacity and diagnostics.
That said, we need to evaluate and refine the campaigns continuously to make sure the messages are based on sound evidence. We also need to make sure there is rigorous, independent assessment of outcomes.
I maintain this is all making a difference, doing much more good than harm.
Dr Anant Sachdev is a GP in Bracknell, and GP cancer lead at NHS East Berkshire CCGs
1. Beral V and Peto R. UK cancer survival statistics are misleading and make survival worse than it is. BMJ 2010; 341:c4112
2. Wilson JMG, Jungner G. Principles and practice of screening for disease. Geneva: WHO; 1968
3. Thomas D, Gao, D, Ray R et al. Randomized trial of breast self-examination in Shanghai: final results. J Natl Cancer Inst 2002; 94(19): 1445–57
4. Praities, N. ‘Three-week cough’ campaign under fire from GP cancer leads. PulseToday, June 2012
5. Andriole G, Crawford D, Grubb R et al. Mortality results from a randomized prostate-cancer screening trial. N Engl J Med 2009; 360: 1310–1319
6. De Angelis R, Sant M, Coleman MP et al. Cancer survival in Europe 1999–2007 by country and age: results of EUROCARE-5 – a population-based study. Lancet 2014; 15: 23–24
7. Cancer Research UK. Cancer Awareness Measure Key Findings Report; 2014 and Trends Analysis (2008-2014)
8. Public Health England. Evaluation – Blood in Pee
9. Department of Health. Tripartite Letter: Be Clear on Cancer symptom awareness campaigns. December 2013.