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The misrepresentation of palliative care in the UK
Editorial
Science Photo Library
The breast cancer screening debate: closing a chapter?
Published Online October 30, 2012 http://dx.doi.org/10.1016/ S0140-6736(12)61775-9 See Review page 1778
Fierce debates about the benefits and harms of breast cancer screening have been played out in pages of The Lancet, many other journals, and the mainstream media for a decade or more. Many researchers believe that the benefits of screening, in terms of reduced breast cancer mortality, outweigh the harms (eg, overdiagnosis). Others think the opposite. These polarised discussions are likely to have caused confusion among women about attending for breast screening. In response to this debate, in October, 2011, England’s National Cancer Director, Mike Richards, initiated an independent review into breast cancer screening. This assessment is now complete and is summarised in a Review published in The Lancet. It should begin to lay the benefits versus harm controversy to rest. The Independent UK Panel on Breast Cancer Screening led by Professor Sir Michael Marmot reviewed published work (mainly randomised trials) and oral and written evidence presented by experts in the field. They focused on the UK, where women aged 50–70 years have been invited to screening every 3 years through the NHS Breast Cancer Screening Programme since 1988. The Panel found that routine breast screening leads to a 20% relative risk reduction compared with no
screening. This means for every 235 women invited for screening, one breast cancer death will be prevented, representing 43 breast cancer deaths prevented per 10 000 women aged 50 years invited to screening for the next 20 years. Additionally, the Panel found that some overdiagnosis occurs. 19% of breast cancers diagnosed in women invited for screening would not have caused any problem if left undiagnosed and untreated (a rate of 129 per 10 000 women). However, owing to the scarcity of reliable data in this area, more research is needed to accurately assess the magnitude of overdiagnosis. The Panel also considered how women feel about the available evidence: many women believe the balance of benefits to risks is worthwhile. The Panel’s report, the latest and best available systematic review, shows that the UK breast-screening programme extends lives and that, overall, the benefits outweigh the harms. Dissemination of these findings is now imperative in the media, the NHS screening programme, and between doctors and their patients. Women need to have full and complete access to this latest evidence in order to make an informed choice about breast cancer screening. ■ The Lancet
Corbis
The misrepresentation of palliative care in the UK
For more on the Liverpool care pathway for the dying patient see http://www.liv.ac.uk/media/ livacuk/mcpcil/migrated-files/ liverpool-care-pathway/ updatedlcppdfs/What_is_the_ LCP_-_Healthcare_ Professionals_-_April_2010.pdf
1714
The Liverpool Care Pathway for the Dying Patient (LCP) was developed during the late 1990s at the Royal Liverpool University Hospital in conjunction with the Marie Curie Hospice to provide the best quality palliative care to patients in all care settings. The pathway ensures patients do not receive unnecessary medical procedures and medications that do not confer benefit, as well as consideration of their physical, social, spiritual, and psychological needs. The LCP is widely recognised in the UK and abroad as a model of best practice to ensure access to a dignified, painless, and comfortable death. But in the past 2 weeks the UK media has brandished the LCP as the “death pathway”, and a minority of health professionals have stated it is a way to hasten deaths in patients. The reports claim that patients were not given consent from their families to be put on the LCP, and that they were denied appropriate care. But the LCP
recommendations make it very clear that all decisions are made in consultation with relatives and carers, and if possible the patients themselves. Furthermore, hospitals have been perversely accused of receiving payments to meet targets associated with its use. But these payments are designed to recognise best practice and support implementation. The Association of Palliative Medicine will now begin their review of the pathway. The reporting of the story has been appalling. Doctors and nurses in health-care teams for the past decade have been dedicated to ensuring dignified end-of-life care for patients throughout the country, and that is largely thanks to the Liverpool Care Pathway. The one welcome aspect of this controversy is that it draws attention to the importance of end-of-life care, and that patients, approaching the end of their lives, should be a priority, whether they are in hospital or at home. ■ The Lancet www.thelancet.com Vol 380 November 17, 2012
Science Photo Library
The breast cancer screening debate: closing a chapter?
Published Online October 30, 2012 http://dx.doi.org/10.1016/ S0140-6736(12)61775-9 See Review page 1778
Fierce debates about the benefits and harms of breast cancer screening have been played out in pages of The Lancet, many other journals, and the mainstream media for a decade or more. Many researchers believe that the benefits of screening, in terms of reduced breast cancer mortality, outweigh the harms (eg, overdiagnosis). Others think the opposite. These polarised discussions are likely to have caused confusion among women about attending for breast screening. In response to this debate, in October, 2011, England’s National Cancer Director, Mike Richards, initiated an independent review into breast cancer screening. This assessment is now complete and is summarised in a Review published in The Lancet. It should begin to lay the benefits versus harm controversy to rest. The Independent UK Panel on Breast Cancer Screening led by Professor Sir Michael Marmot reviewed published work (mainly randomised trials) and oral and written evidence presented by experts in the field. They focused on the UK, where women aged 50–70 years have been invited to screening every 3 years through the NHS Breast Cancer Screening Programme since 1988. The Panel found that routine breast screening leads to a 20% relative risk reduction compared with no
screening. This means for every 235 women invited for screening, one breast cancer death will be prevented, representing 43 breast cancer deaths prevented per 10 000 women aged 50 years invited to screening for the next 20 years. Additionally, the Panel found that some overdiagnosis occurs. 19% of breast cancers diagnosed in women invited for screening would not have caused any problem if left undiagnosed and untreated (a rate of 129 per 10 000 women). However, owing to the scarcity of reliable data in this area, more research is needed to accurately assess the magnitude of overdiagnosis. The Panel also considered how women feel about the available evidence: many women believe the balance of benefits to risks is worthwhile. The Panel’s report, the latest and best available systematic review, shows that the UK breast-screening programme extends lives and that, overall, the benefits outweigh the harms. Dissemination of these findings is now imperative in the media, the NHS screening programme, and between doctors and their patients. Women need to have full and complete access to this latest evidence in order to make an informed choice about breast cancer screening. ■ The Lancet
Corbis
The misrepresentation of palliative care in the UK
For more on the Liverpool care pathway for the dying patient see http://www.liv.ac.uk/media/ livacuk/mcpcil/migrated-files/ liverpool-care-pathway/ updatedlcppdfs/What_is_the_ LCP_-_Healthcare_ Professionals_-_April_2010.pdf
1714
The Liverpool Care Pathway for the Dying Patient (LCP) was developed during the late 1990s at the Royal Liverpool University Hospital in conjunction with the Marie Curie Hospice to provide the best quality palliative care to patients in all care settings. The pathway ensures patients do not receive unnecessary medical procedures and medications that do not confer benefit, as well as consideration of their physical, social, spiritual, and psychological needs. The LCP is widely recognised in the UK and abroad as a model of best practice to ensure access to a dignified, painless, and comfortable death. But in the past 2 weeks the UK media has brandished the LCP as the “death pathway”, and a minority of health professionals have stated it is a way to hasten deaths in patients. The reports claim that patients were not given consent from their families to be put on the LCP, and that they were denied appropriate care. But the LCP
recommendations make it very clear that all decisions are made in consultation with relatives and carers, and if possible the patients themselves. Furthermore, hospitals have been perversely accused of receiving payments to meet targets associated with its use. But these payments are designed to recognise best practice and support implementation. The Association of Palliative Medicine will now begin their review of the pathway. The reporting of the story has been appalling. Doctors and nurses in health-care teams for the past decade have been dedicated to ensuring dignified end-of-life care for patients throughout the country, and that is largely thanks to the Liverpool Care Pathway. The one welcome aspect of this controversy is that it draws attention to the importance of end-of-life care, and that patients, approaching the end of their lives, should be a priority, whether they are in hospital or at home. ■ The Lancet www.thelancet.com Vol 380 November 17, 2012