- Email: [email protected]
PSYCHOTHERAPY IN THE NHS
988 BREAST SELF-EXAMINATION
SIR,-In the debate on the prevention and control of breast cancer, breast self-examination (BSE) has its proponents and its critics. However, valid assessments of the effects on mortality of BSE among large sections of the female population are difficult and will take many years. In the meantime circumstantial evidence, both in favour of and against a beneficial influence of BSE practice on mortality, continues to be reported.2-4 Dr Turner and colleagues (Aug 11, p 337) have presented further evidence linking health education related to BSE with staging information on tumours. On the face of it this report supports the idea that BSE does lead to earlier reporting of breast abnormalities, especially malignant lesions. Although not specifically investigating the link between BSE and breast cancer presentation, our research suggests caution in interpreting relations between provision of BSE educational material and earlier presentation of breast disease.5-7 It cannot be assumed that women who receive BSE leaflets will practise BSE or that those who do will examine their breasts competently enough to detect lesions at an early stage. Whilst much evidence accords with the view that BSE alerts women to their lesions earlier, so that their disease is diagnosed earlier, equally plausible alternative explanations remain. For example, receiving a BSE leaflet may stimulate action ina woman who is already uneasy about changes she has noticed in her breasts. Turner et al do not present data on the distribution of time from receipt of BSE leaflet to consultation with a general practitioner (GP). Such information might easily distinguish between these two explanations-. A second alternative interpretation arises from the fact that it is the GP who sends the leaflet. This act may serve as a cue to the woman that her GP will view her concerns about breast problems as legitimate reasons for consultation and may therefore stimulate the woman to go earlier than she might otherwise have done. Yet another interpretation would be that the content of a BSE leaflet communicates and reinforces the message of reporting abnormalities promptly to the doctor. However, the data on delay presented by Turner et al suggest that the leaflets had, if any, only a very small influence on reducing delay in GP consultation. This is worrying since most advocates of BSE view the message about prompt referral as an integral part of BSE teaching. On the other hand the publicity that BSE has received over the last decade and the much freer discussion of breast cancer in the community may have played a significant role in the general reduction of patient delay in reporting breast symptoms. These comments may seem pessimistic when set alongside the conclusions of Turner and colleagues: we do not mean them to be. Indeed the findings of Foster and Costanzatare beginning to provide a firm basis for the belief that BSE practice is beneficial to women destined to have breast cancer. Our concern is mainly to distinguish between the promotion of BSE as a good thing and the teaching of BSE. Our findings indicate that only about one-fifth of a generally representative group of women (ie, a group not selected for prior motivation towards BSE) will be doing BSE competently 12 months after their attendance at a structured and systematic teaching session. Evaluations of the influence of BSE on mortality will inevitably show little effect if attention is not paid to the quality of BSE practice and to what proportion of the intervention group are doing BSE monthly and systematically. The evidence on anxiety produced by BSE suggests that this is a much less troublesome aspect of BSE teaching than once feared;8 in our view more attention should be directed to those women currently practising a habit under the name of BSE that is worthless because it is done ineffectively. One attraction of BSE is that it is cheap. However, though the practice of BSE is inexpensive to the health service the teaching of BSE demands more time, effort, and money than is currently devoted to it. ’
Department of Epidemiology and Social Research, University Hospital of South Manchester, Manchester M20 9QL 1. UK Trial
DAVE HARAN LAURA L. PENDLETON PATRICIA HOBBS
of Early Detection of Breast Cancer Group. Trial of early detection of breast J 1981; 44: 618-27. Description of method. Br Cancer
cancer:
2. Greenwald P, Nasca PC, Lawrence CE, et al. Estimated effect of breast selfexamination and routine physican examinations on breast mortality N Engl J Med 1978; 299: 271-73. 3. Hugely CM, Brown RL. The value of breast self-examination. Cancer 1981, 47: 989-95 4 Foster RS, Costanza MC. Breast self-examination practices and breast cancer survival Cancer 1984; 53: 999-1005. 5. Haran D, Hobbs P, Pendleton LL. An evaluation of the teaching of breast selfexamination for the early detection of breast cancer factors that affect current awareness and anxiety In: Oborne DJ, Gruneberg MM, Eiser JR, eds. Research in psychology and medicine II- Social aspects, attitudes, communication, care and training London. Academic Press, 1979. 6. Pendleton LL, Hobbs P, Haran D. Worry related to the awareness and practice of breast self-examination Concern or anxiety. In Hobbs P, ed Public education about cancer Recent research and current programmes (UICC Tech Rep Ser vol LV) Geneva: International Union Against Cancer, 1980. 7. Hobbs P, Haran D, Pendleton LL, Jones BE, Posner TR. Public and professional aspects of the use of education in the control and prevention of cancer. Cancer Detection Prevention 1983; 6: 459-71. 8. Pendleton LL Women’s response to breast self-examination: a comparison of experiences amongst taught and untaught women PhD thesis, University of Manchester, 1984.
PSYCHOTHERAPY IN THE NHS
SIR,-Dr Aveline’scridecoeur (Oct 13, p 856) does not disguise the no evidence which confirms the specificity of psychotherapeutic practices in medicine. Moreover, it is ironic that
fact that there is
Frank, whom Aveline cites with such influential in
equating
the action of
approval,l
has been so psychotherapy with the
placebo-effect.2,3 Aveline’s comments on psychotherapy in the NHS seem to reveal substantial ignorance about the social and epidemiological context of the subject.This important theme has been taken up by Cooper,5who concludes that "all questions appertaining to the need for psychotherapeutic services must be examined [in relation to] the most pressing problems of ill-health in the general population". And it is likely to be against this background that health service planners, the community, and most doctors will consider the economic appraisal of psychotherapy. In contrast, Aveline’s account of the economic "reality of NHS psychotherapy" is not convincing. Both cost-benefit analysis and cost-effectiveness analysis depend upon the availability of information, which, in this case, is lacking.His personal assessment that "The cost of psychotherapy is not great" and that "A modest investment would secure essential training [in psychotherapeutic methods] for psychiatrists, nurses, and others" is not accompanied by evidence. Consider these statements alongside the results of a preliminary American survey,which found that psychiatrists, psychologists, and social workers reported spending 30% of their time on psychotherapy, and primary care physicians reported spending 10% of their time in this way. No figures were produced for the probably enormous amount of time spent on psychotherapeutic endeavours by psychiatric and mental health nurses and counsellors or ministers of religion, not to mention volunteers. Aveline states that
"Arguments in favour of the cost-benefit of psychotherapy must not obscure the fact that there is no alternative treatment for major problems of relationship". This remark is so illdefined clinically as to be practically incomprehensible; and, from an economic standpoint appears to take no account either of opportunity cost, or of an alternative treatment (namely, a placebo). There is no definitive evidence regarding the clinical and economic effectiveness of psychotherapy for patients with mental disorders. Since resources are scarce, health service planners need urgently to reassess the extent and impact of psychotherapy provision in the NHS. General Practice Research Unit, Institute of Psychiatry, London SF5 8AF
GREG WILKINSON
1 Aveline M. Persuasion and healing: JD Frank. Br J Psychiatry 1984; 145: 207-11 2 Frank JD. Persuasion and healing Baltimore: Johns Hopkins Press, 1961
3. Frank JD. The placebo is psychotherapy. Behav Brain Sci 1983; 6: 291-92 4. Cawley RH Evaluation of psychotherapy. Psychol Med 1971; 1: 101-03. 5. Cooper B. Psychotherapy, psychiatric epidemiology and health services. Soc Psychtatr.
1984, 19: 93-95
Tyson RL, Reder P Questions of supply and demand in dynamic psychotherapy BrJ Med Psychol 1979; 52: 301-07. 7. Beitman BD The demographics of American psychotherapists: a pilot study AmJ Psychother 1983, 37: 37-48.
6
SIR,-In the debate on the prevention and control of breast cancer, breast self-examination (BSE) has its proponents and its critics. However, valid assessments of the effects on mortality of BSE among large sections of the female population are difficult and will take many years. In the meantime circumstantial evidence, both in favour of and against a beneficial influence of BSE practice on mortality, continues to be reported.2-4 Dr Turner and colleagues (Aug 11, p 337) have presented further evidence linking health education related to BSE with staging information on tumours. On the face of it this report supports the idea that BSE does lead to earlier reporting of breast abnormalities, especially malignant lesions. Although not specifically investigating the link between BSE and breast cancer presentation, our research suggests caution in interpreting relations between provision of BSE educational material and earlier presentation of breast disease.5-7 It cannot be assumed that women who receive BSE leaflets will practise BSE or that those who do will examine their breasts competently enough to detect lesions at an early stage. Whilst much evidence accords with the view that BSE alerts women to their lesions earlier, so that their disease is diagnosed earlier, equally plausible alternative explanations remain. For example, receiving a BSE leaflet may stimulate action ina woman who is already uneasy about changes she has noticed in her breasts. Turner et al do not present data on the distribution of time from receipt of BSE leaflet to consultation with a general practitioner (GP). Such information might easily distinguish between these two explanations-. A second alternative interpretation arises from the fact that it is the GP who sends the leaflet. This act may serve as a cue to the woman that her GP will view her concerns about breast problems as legitimate reasons for consultation and may therefore stimulate the woman to go earlier than she might otherwise have done. Yet another interpretation would be that the content of a BSE leaflet communicates and reinforces the message of reporting abnormalities promptly to the doctor. However, the data on delay presented by Turner et al suggest that the leaflets had, if any, only a very small influence on reducing delay in GP consultation. This is worrying since most advocates of BSE view the message about prompt referral as an integral part of BSE teaching. On the other hand the publicity that BSE has received over the last decade and the much freer discussion of breast cancer in the community may have played a significant role in the general reduction of patient delay in reporting breast symptoms. These comments may seem pessimistic when set alongside the conclusions of Turner and colleagues: we do not mean them to be. Indeed the findings of Foster and Costanzatare beginning to provide a firm basis for the belief that BSE practice is beneficial to women destined to have breast cancer. Our concern is mainly to distinguish between the promotion of BSE as a good thing and the teaching of BSE. Our findings indicate that only about one-fifth of a generally representative group of women (ie, a group not selected for prior motivation towards BSE) will be doing BSE competently 12 months after their attendance at a structured and systematic teaching session. Evaluations of the influence of BSE on mortality will inevitably show little effect if attention is not paid to the quality of BSE practice and to what proportion of the intervention group are doing BSE monthly and systematically. The evidence on anxiety produced by BSE suggests that this is a much less troublesome aspect of BSE teaching than once feared;8 in our view more attention should be directed to those women currently practising a habit under the name of BSE that is worthless because it is done ineffectively. One attraction of BSE is that it is cheap. However, though the practice of BSE is inexpensive to the health service the teaching of BSE demands more time, effort, and money than is currently devoted to it. ’
Department of Epidemiology and Social Research, University Hospital of South Manchester, Manchester M20 9QL 1. UK Trial
DAVE HARAN LAURA L. PENDLETON PATRICIA HOBBS
of Early Detection of Breast Cancer Group. Trial of early detection of breast J 1981; 44: 618-27. Description of method. Br Cancer
cancer:
2. Greenwald P, Nasca PC, Lawrence CE, et al. Estimated effect of breast selfexamination and routine physican examinations on breast mortality N Engl J Med 1978; 299: 271-73. 3. Hugely CM, Brown RL. The value of breast self-examination. Cancer 1981, 47: 989-95 4 Foster RS, Costanza MC. Breast self-examination practices and breast cancer survival Cancer 1984; 53: 999-1005. 5. Haran D, Hobbs P, Pendleton LL. An evaluation of the teaching of breast selfexamination for the early detection of breast cancer factors that affect current awareness and anxiety In: Oborne DJ, Gruneberg MM, Eiser JR, eds. Research in psychology and medicine II- Social aspects, attitudes, communication, care and training London. Academic Press, 1979. 6. Pendleton LL, Hobbs P, Haran D. Worry related to the awareness and practice of breast self-examination Concern or anxiety. In Hobbs P, ed Public education about cancer Recent research and current programmes (UICC Tech Rep Ser vol LV) Geneva: International Union Against Cancer, 1980. 7. Hobbs P, Haran D, Pendleton LL, Jones BE, Posner TR. Public and professional aspects of the use of education in the control and prevention of cancer. Cancer Detection Prevention 1983; 6: 459-71. 8. Pendleton LL Women’s response to breast self-examination: a comparison of experiences amongst taught and untaught women PhD thesis, University of Manchester, 1984.
PSYCHOTHERAPY IN THE NHS
SIR,-Dr Aveline’scridecoeur (Oct 13, p 856) does not disguise the no evidence which confirms the specificity of psychotherapeutic practices in medicine. Moreover, it is ironic that
fact that there is
Frank, whom Aveline cites with such influential in
equating
the action of
approval,l
has been so psychotherapy with the
placebo-effect.2,3 Aveline’s comments on psychotherapy in the NHS seem to reveal substantial ignorance about the social and epidemiological context of the subject.This important theme has been taken up by Cooper,5who concludes that "all questions appertaining to the need for psychotherapeutic services must be examined [in relation to] the most pressing problems of ill-health in the general population". And it is likely to be against this background that health service planners, the community, and most doctors will consider the economic appraisal of psychotherapy. In contrast, Aveline’s account of the economic "reality of NHS psychotherapy" is not convincing. Both cost-benefit analysis and cost-effectiveness analysis depend upon the availability of information, which, in this case, is lacking.His personal assessment that "The cost of psychotherapy is not great" and that "A modest investment would secure essential training [in psychotherapeutic methods] for psychiatrists, nurses, and others" is not accompanied by evidence. Consider these statements alongside the results of a preliminary American survey,which found that psychiatrists, psychologists, and social workers reported spending 30% of their time on psychotherapy, and primary care physicians reported spending 10% of their time in this way. No figures were produced for the probably enormous amount of time spent on psychotherapeutic endeavours by psychiatric and mental health nurses and counsellors or ministers of religion, not to mention volunteers. Aveline states that
"Arguments in favour of the cost-benefit of psychotherapy must not obscure the fact that there is no alternative treatment for major problems of relationship". This remark is so illdefined clinically as to be practically incomprehensible; and, from an economic standpoint appears to take no account either of opportunity cost, or of an alternative treatment (namely, a placebo). There is no definitive evidence regarding the clinical and economic effectiveness of psychotherapy for patients with mental disorders. Since resources are scarce, health service planners need urgently to reassess the extent and impact of psychotherapy provision in the NHS. General Practice Research Unit, Institute of Psychiatry, London SF5 8AF
GREG WILKINSON
1 Aveline M. Persuasion and healing: JD Frank. Br J Psychiatry 1984; 145: 207-11 2 Frank JD. Persuasion and healing Baltimore: Johns Hopkins Press, 1961
3. Frank JD. The placebo is psychotherapy. Behav Brain Sci 1983; 6: 291-92 4. Cawley RH Evaluation of psychotherapy. Psychol Med 1971; 1: 101-03. 5. Cooper B. Psychotherapy, psychiatric epidemiology and health services. Soc Psychtatr.
1984, 19: 93-95
Tyson RL, Reder P Questions of supply and demand in dynamic psychotherapy BrJ Med Psychol 1979; 52: 301-07. 7. Beitman BD The demographics of American psychotherapists: a pilot study AmJ Psychother 1983, 37: 37-48.
6