I vividly remember the Obs and Gynae OSCE style assessment we had during the fourth year of medical school. Mainly because I would rather pull my own teeth out than endure any type of observed clinical exam (the CSA looms large on the horizon already) but also because some of the stations were genuinely interesting. I remember having to discuss a positive Chlamydia test with a married woman, talk to a teenager about her contraceptive options and counsel a couple prior to amniocentesis following high risk Downs screening. I remember feeling uncomfortable even then with the uncertainty of the Downs screening process, the risk of causing miscarriage with the diagnostic tests and the difficulty in explaining all of this to people who may not have much of a grounding in statistics. It’s amazing how a 1% chance can sound and feel different to each individual couple depending on their relationship with risk and their interpretation of the statistic.
When I was pregnant with my son my husband and I had a good chat about antenatal screening and decided against having the tests for Downs as we felt that receiving a ‘1 in x chance’ result would not change our management of the pregnancy and could cause a lot of unwanted anxiety. We have decided to follow the same course during this pregnancy too. This is a very, very personal decision and although it wasn’t the right path for us does not mean it wouldn’t be right for others. I suppose I’m just hoping that each person who undergoes antenatal screening, as with any medical investigation, understands the true implications of their decision.
When I ask people about antenatal screening I sometimes get answers that amount to ‘well it’s free, why wouldn’t you?’ and I can’t help but wonder whether they have even considered the possibility of the screening test coming back high risk. It’s at this point that I have to face the fact that most people probably aren’t like me. I’m not saying my glass is always half empty but I admit to having the odd Eeyore tendency. A colleague said to me recently as I quizzed them on this topic: ‘the majority of people never consider that their result will be abnormal, they have the screening for reassurance’.
I think with any screening test we offer we should counsel the patient through the entire process so that, should their result come back as high risk, they know what the next step is and they will have had some time to consider the best path for them. This seems particularly important in antenatal screening when time is often of the essence, but equally what about those men who have PSAs ‘because the wife wants me to get it checked;, do they understand just how invasive the next step might be if it happens to come back raised?
I attended an excellent Women’s Health Study Day recently and one of the consultant Obstetricians spent some time talking about antenatal screening and the availability of the new ‘Harmony’ test. My understanding of the test is that it samples foetal cells within the maternal circulation and is able to pick up 99% of cases of Downs Syndrome with a false positive rate of <0.1%. It’s currently available privately for around £395 but the hope is that as this price falls it will become financially and ethically viable within the NHS, particularly given the fact it will largely remove the need for amniocentesis and CVS sampling.
Screening programmes undoubtedly have a vital role within modern medicine, for example cervical and breast screening have the potential to reduce mortality by 60% and 30% respectively1, but I wonder whether we need to think harder about how we present these tests to our patients. Should the worst happen and the test comes back positive or high risk, are they prepared for the next steps? Have they been adequately primed for the possibility of bad news? Have they had the opportunity to consider the impact on themselves and their family and have they made a proper informed decision to proceed with the screening in the first place? Maybe a touch of the Eeyores is what we all need from time to time.
1. Elovainio, L, Nieminen, P, Miller, A, 1997. Impact of cancer screening on women’s health. International Journal of Gynecology & Obstetrics, 58, p. 137–147
Dr Laura O’Loghlen is an ST1 who lives in Cheltenham and works in Gloucestershire