Thankfully, the debate has matured quite a bit since those days.  We are now hearing a somewhat more balanced discussion which pays greater attention to some of the complexities involved. One such complexity, as illustrated by a new study, is the potential for screening to lead to over-diagnosis and unnecessary treatment.

Alex Barratt, Associate Professor in the School of Public Health at the University of Sydney, and a co-author of the new study, reports on its findings:

“The idea of over-diagnosis of invasive breast cancer in a mammography screening programme is disturbing, counter-intuitive and confusing.  But there is accumulating evidence that over-diagnosis of breast cancer is substantial and is the biggest downside of mammography screening.

We have just published a study which estimates over-diagnosis of breast cancer in NSW since the introduction of BreastScreenNSW.  We estimated over-diagnosis at 30-42%.

This means that through earlier detection of breast cancer, about 25% (23-29%) of all NSW women diagnosed with breast cancer are undergoing cancer treatments (such as lumpectomy, mastectomy, radiation therapy and endocrine therapy) for cancers that would not have manifested in their lives.

The benefit of mammography screening is a reduction in the risk of dying from breast cancer. The price though is an increased risk of having breast cancer detected, because screening finds more cancers, including cancers which are so slow growing they would never be found without screening.

We did this study because we noticed that the incidence of invasive breast cancer among women 50-69 years (the target age group) almost doubled with the introduction of screening (from 150/100,000 per year to just under 300/100,000). This steep increase in incidence was not observed in women outside the screening range (ie less than 40 years and over 80 years). It was apparent, but less steep in the partially screened age groups (40-49 and 70-79).

The increase in incidence in women 50-69 years could be caused by changes in risk factors such as Hormone Replacement Therapy, obesity, and nulliparity. All of these increased over the same years as BreastScreen was rolled out, in women of the same age. However, we adjusted our results for these increases; if anything we over adjusted for them.  Our study is the first to formally adjust for these risk factors.

Incidence also goes up when screening is introduced because of lead time – the earlier detection achieved by screening.  We also adjusted for lead time; if anything we over-adjusted for lead time.

Even after these adjustments, we found 30-42% excess incidence over that expected with screening. This finding is very compelling evidence that over-diagnosis due to screening is behind the increasing breast cancer incidence in women 50-69 years of age.

This is in addition to the detection of DCIS (Ductal Carcinoma In Situ) by screening mammography. DCIS comprises about 18% of all “cancers” found by BreastScreen NSW and a very substantial proportion of that is likely to be over-diagnosis too.

DCIS very rarely presents clinically, and detection and treatment of screen detected DCIS has not caused a decline in breast cancer incidence (as occurs with cervical cancer screening and the detection of precancerous cervical lesions).

Over-diagnosis is a very significant downside of mammography screening.  In addition to the treatment risks and side effects, there is the psychological trauma of a cancer diagnosis, and its implications for insurance and cancer risk assessment in other family members.

What does it all mean? Firstly policy makers need to be aware that over-diagnosis in breast cancer screening is substantial.

It needs to be considered  when assessing any expansion of the screening program, or the introduction of another cancer screening program (which may also be affected by over-diagnosis), such as a breast cancer MRI screening program or a lung cancer screening program.

Secondly, breast screening programs need to review whether their informed c onsent information is adequate, or needs to be upgraded to provide information on overdiagnosis as well as on mortality reduction. (see here for estimates of outcomes of screening mammography for Australian women).

Thirdly, we need better tests – either a better screening test that doesn’t cause over-diagnosis or a better triage test to sort the aggressive from the indolent screen detected breast cancers.”

I came across this event while doing some research recently on new media and health, which also led me to some blogs that might be of interest. I found many of these at this link to “50 excellent health blogs”.

• The Effect Measure is a public health blog in the US authored by senior public health scientists and practitioners whose identity is kept anonymous, so they can speak frankly. Here’s what they say about themselves: “In epidemiology an effect is the endpoint of a causal mechanism. An effect measure is an estimate of the influence of a particular factor on a population’s health. The Editors of Effect Measure are senior public health scientists and practitioners. Their names would be immediately recognizable to many in the public health community. They prefer to keep their online and public lives separate to allow maximum freedom of expression. Paul Revere was a member of the first local Board of Health in the United States (Boston, 1799). The Editors sign their posts “Revere” to recognize the public service of a professional forerunner better known for other things.”

• The Pump Handle is another public health blog, mainly written by US epidemiologists.  It’s “a place for people interested in public health and the environment to discuss the issues that interest us, particularly when they’re not getting the treatment we think they deserve in the mainstream media.

The story of the pump handle is familiar to any first-semester public health student: During the London cholera epidemic of 1854, John Snow examined maps of cholera cases and traced the disease to water from a local pump. At the time, the prevailing theory held that cholera spread through the air, rather than water, so Snow faced criticism from others in the science community – not to mention resistance from the water companies. He finally convinced community leaders to remove the pump’s handle to prevent further exposure.

More than a century later, thousands of people still die from cholera each year, and providing clean drinking water to the world’s entire population is a far-off goal. The Pump Handle symbolizes both a public health victory and the challenges facing the public health and environmental fields today.”

• Health Wonk Review is a biweekly compendium of the best of the health policy blogs. More than two dozen health policy, infrastructure, insurance, technology, and managed care bloggers participate by contributing their best recent blog postings to a roving digest, with each issue hosted at a different participant’s blog. “For participants, it’s a way to network and share ideas, and for those readers who don’t live in this space every day, it’s a way to sample some of the latest thinking and the ‘best of the best’.”

• Wall Street Journal’s blog on health and the business of health

• CDC’s Public Health Matters blog

• Covering Health is a blog maintained by the Association of Health Care Journalists. It is intended to help keep journalists who report on health and health care issues informed about the latest news in the field, aware of noteworthy stories and reports, and able to connect with colleagues.

•  World Health News, from the Harvard School of Public Health

• Global Health Ideas from some social entrepreneurs

• Gary Schwitzer, University of Minnesota School of Journalism & Mass Communication, Publisher, HealthNewsReview.org

• Hooked: Ethics, Medicine and Pharma from Professor Howard Brody, Director of Institute for Medical Humanities, at University of Texas

• Dr Keven Pho is a primary care doctor in New Hampsire and a prolific blogger who seems worth reading. I’m giving him a trial anyway. He says he was voted the best medical blog of 2008 (I presume that’s in the US), and has over 20,000 RSS subscribers and 15,000 Twitter followers.

Let me know if there are any others worth a mention.

And thanks to Becky Freeman at USyd for putting me on the trail of the Journal of Medical Internet Research. How quickly the world of media and health has and is changing….

BTW, Croakey is now twittering. You can stay abreast of the latest posts here…

And thanks to Pharmacy News for giving Croakey a mention in its cover story on blogging and pharmacy (October issue). As you may have noticed, Croakey is a relative newcomer to the new media world and still finding a way. So it’s nice to get some feedback that Croakey is “out there”…

Will this further increase the inequities in access to good health and to health services? Or will it help close these gaps?

It doesn’t seem such an unreasonable ask when we have so much evidence that those who are most likely to have health problems are least likely to have access to useful health care.

A study published in the latest Australian and NZ Journal of Public Health provides yet more ammunition for this line of questioning.

Researchers from the ANU and University of Newcastle used data from a 2004 survey of 10,905 women aged 53 to 58 to examine the relationship between socioeconomic status and health service use.

Given that poorer and more disadvantaged groups are generally more likely to have chronic diseases and other health problems, you might expect them to use health services more often.

Not so. While GP use was roughly the same between the wealthier and the poorer, the better off women were more likely to report having used dental services, specialists, allied health practitioners, and alternative health providers.

The researchers say their findings support experts who have questioned the private health insurance rebate, and suggest that it is adding to inequities by enabling wealthier women to access allied health services, often important in the management of chronic diseases, that poorer women without insurance could not afford.

“The pattern of findings suggests that inequalities in care are to some extent shaped by the health care system itself, where out-of-pocket costs and private care influence access,” the researchers said.

“International findings are in line with these conclusions – inequity in ambulatory medical and dental care in universal systems is found to be greatest in countries where private health insurance and direct private payments play some role in access to services.”

The researchers note that their findings don’t prove that poorer women are being under-treated as their study could not rule out the possibility that advantaged women are being over-serviced. “Nevertheless,” they said, “this in itself could still be considered inequitable in that health expenditure is not being distributed according to need.”

The researchers conclude that their findings “suggest unfairness and inefficiency in the allocation of services as those who are sickest and hence potentially have the greatest capacity to benefit from health care, are not those most likely to receive it.”

Meanwhile, the Australian Healthcare and Hospitals Association has just issued this release, putting pressure on the AMA to join its stance opposing the private health insurance rebate.

It says: “The private health insurance rebate is a grossly inefficient means of supporting private health care and would deliver much greater gains to the community if spent directly on health services and infrastructure. AHHA calls on all health groups to unite in advocating for the re-direction of the private health insurance rebate funds into public hospitals and community-based care.”

Now wouldn’t that be something – imagine if the closing the gaps question was asked, not only by Health Ministers, but by powerbrokers like the AMA…what a difference that might make.

Dr Janette Vardy, a medical oncologist at Sydney Cancer Centre and the University of  Sydney, has sent in this report:

“We are conducting a research study evaluating a home and internet based “brain training programme” (cognitive rehabilitation programme) in cancer survivors who have noticed changes in their memory, concentration and thinking (cognition) following chemotherapy.

Purpose of the study
Research has shown that people diagnosed with cancer may report changes in their cognitive function and these changes may be made worse by some cancer treatments. Changes in cognitive function do not affect everyone but it is thought that about 15-30 percent of cancer patients experience this problem.

For some people, these changes are temporary with return to their pre-cancer functioning after completing treatment. For others, the changes are long-lasting and can interfere with everyday activities and quality of life.

Currently there is no effective treatment known to benefit cancer survivors who report cognitive impairment after chemotherapy. Cognitive rehabilitation programmes have been tested in other patient groups with encouraging results.

This study will measure the effectiveness of the “brain training” programme in improving self reported cognitive function and performance, mood, energy, quality of life and stress.

Who is conducting the study?
This study is being conducted around Australia through the Sydney Cancer Centre and the Survivorship Research Group from the Centre for Medical Psychology and Evidence-based Decision-making at the University of Sydney; Dr Janette Vardy, Medical Oncologist, Dr Victoria Bray, Medical Oncologist, and Ms Haryana Dhillon, Behavioural Scientist, are leading this study.

Who can take part in this study?
We are looking for cancer survivors aged 18 and above who are experiencing problems with their memory, concentration, reaction time and/or thinking (cognition) after receiving chemotherapy for an early stage cancer.  Chemotherapy needs to have been completed within the last 6 – 60 months.

What is involved in the study?
All study participants will take part in a telephone session where they will be given skills to help manage their cognitive difficulties. In addition, half of the participants will receive the computer programme to be practised at home for 4x forty minute sessions per week for 15 weeks (i.e. 40 hours).

Participants will be asked to complete questionnaires about their memory, mood, energy levels, quality of life and stress. They will also be asked to perform a computer cognition assessment. The questionnaires and cognition assessment will take approximately 45 minutes to complete in total and these tests will be completed on 3 occasions during the trial (i.e. at baseline, on completion of the brain training programme and 6 months following completion of the brain training programme).

The computer programme, questionnaires and cognition assessment are designed to done at home and participants will therefore require access to computer and internet facilities.”

If you are interested in receiving further information on this study, please contact:
Trial free call number:    1800 778 167
Dr Victoria Bray:              02 9767 5132
Ms Haryana Dhillon:       02 9036 5392

Dawson contributed to the fatigue risk management guidelines which recently caused Queensland Health some media grief, and today he’s taken us well beyond those headlines.  Adelaide surgeon Guy Maddern also wrote about related issues in Crikey this week.

I particularly liked Dawson’s observation that:

“Fatigue risk management is the perfect example of what Tony Blair described as a ‘wicked problem’. That is, one for which the solution is complex, multi-factorial and will require thoughtfulness, flexibility and time. Successful fatigue risk management in health care will require exactly that.”

Using that definition, it seems to me that most problems in health are absolutely wicked.

Writing from Washington, health policy analyst Dr Lesley Russell says the studies are big news there, especially with the Presidential focus on health reform. The devices industry will fight hard to retain a multi-million dollar market, she says:

“It is very interesting to look at the response to the publication of these studies in the US, where one of the arguments raging around the health care reform legislation under consideration in the Congress is government funding of comparative effectiveness research and the use to which the data generated might be put.

President Obama and health and economic policy experts have been calling for just these kinds of studies as a means of controlling health costs and ensuring better health outcomes and the House bill has $1.1 billion to establish a Center for Comparative Effectiveness Research.

Opponents see this as Big Brother, in the form of the government entering the health arena, making decisions that will deprive patients of choice, ration health care and result in ‘socialized medicine’.  The UK National Institute for Health and Clinical Excellence (NICE ) is definitely not seen as nice by these people, who are apparently happy to see decisions about what treatment they get made on the basis of bank balance or the profit motives of their health insurer.

The number of vertebroplasty procedures in the US has doubled in the past six years.  Last year 73,000 people had the treatment which costs $2,500 to $3,000 plus $1,000 – 2,000 for an MRI.  This procedure cost Medicare (the government-funded health care program for people aged 65 and over) $21 million.  The total US market in  vertebroplasty had a value of about $45 million in 2008 and is projected to grow annually at a rate of 13.5 percent.

There is even less data on the effects of kyphoplasty, which involves pumping the vertebra with a balloon to restore its shape before injecting cement, and which has a much larger market, estimated at more than $500 million a year.

But this is now where the US situation is headed, with the industry already out in the media emphasizing how kyphoplasty is different.

There is a comparative study of the two procedures underway, funded by the manufacturers, but results are apparently some way off.  There are some ten US medical device companies who are involved in this field, and the early indications are that they will not cede this profitable arena without a tough fight.

In the meantime, who should make the decisions about continued funding of this treatment and on what basis?

One of the researchers on the US paper has said that people who want vertebroplasty should still be able to get it – but only if they enter a clinical trial that collects data on every case.”

• Lesley Russell is Menzies Foundation Fellow at the Menzies Centre for Health Policy University of Sydney/Australian National University and Research Associate, US Studies Centre, University of Sydney

Sally Crossing, the chair of Cancer Voices NSW, also appeared at the Senate committee hearing this morning, and here is her report for Croakey readers:

“Cancer Voices NSW was invited to put the broad cancer patient view to the Senate Community Affairs Committee Inquiry into Gene Patents on 5 August 09.

Cancer Voices NSW provides the independent voice of people affected by cancer. It is the peak coalition for cancer support and advocacy groups in NSW, working in partnership to improve the cancer experience of the nearly 40,000 people who are diagnosed each year.

We support our member group – the Breast Cancer Action Group NSW’s (BCAG NSW) submission, noting the recent major threats regarding access to and ownership of breast cancer genes, posed by enforcement of international gene patents.  Cancer Voices NSW is concerned that such threats will arise for other cancers and asked the Inquiry to recommend that the Australian Government amend legislation to preclude them.

As an ethical principle, we do not believe that genes, as natural parts of the human body, should be patentable. We strongly recommend that Australian patent law be amended so that no part of the human body can be patented.

We note that international case studies show that enforcement of gene patents reduces access and drives up testing costs dramatically for patients.  Enforcement also hinders scientific research and the sharing of important medical knowledge (Luigi Palombi:  Gene Cartels Biotech Patents in the Age of Free Trade, Scribe Publications 2009) And we have seen no evidence that offering patents is necessary to encourage the identification or isolation of human genes.

Cancer patients want attention drawn to:

High risk cancer families: Currently some people from high risk cancer families can access genetic tests for gene mutations associated with their cancer through public familial cancer centres and testing facilities.  Commercial monopolies over cancer genes, achievable through patenting, are likely to lead to increased costs, as evidenced by the projected charges by Genetic Technologies P/L which has an international patent for the BrCa 1 and Br Ca 2 genes.  A longer term outcome would be increased health care costs for cancer treatment that may well have been avoided.

Medical research & pharmacogenomics: Cancer Voices is very aware of the need for access to genetic material by medical researchers.  We see the development of pharmacogenomics, or personalised treatment though the use of genetic testing of our tumour tissue, to be the light on the hill for we cancer patients.  Personalised cancer treatment, using the recent surge in knowledge about human genes, will improve patient outcomes and reduce wastage of ineffective drugs and the overall costs of health care.

We are all hoping that reserachers will make progress quickly so that we, as well as those who follow us, can benefit.  I firmly include myself among those hopers!

To this end we have successfully encouraged the Cancer Council NSW to fund a collaborative study, and have warmly welcomed the International Cancer Genome Consortium, supported by the Australian Government to the tune of $20m. That project aims to speed up delivery of personalised treatment.  We are concerned that if if genes and genetic material can be patented, and if those patents are enforced, this vital area of medical research will be more costly, slower and less translatable to the end beneficiaries.

Cancer Voices NSW, in its role of representing the interests of people affected by cancer strongly supports an amendment of the Patents Act, to prohibit the granting of patents over such natural materials as human genes.  Apart from the ethical aspects, the understanding of the role of genes in cancer is an exciting new field with enormous potential for us all.  We do not want to see it compromised by patent monopolies over human genes, limiting badly needed opportunities in diagnosis, prognosis and treatment of cancer (and many other diseases).

In parallel, we also commend the establishment of a National Genetic Framework as proposed by the Royal College of Pathologists of Australasia, to ensure that Australia has appropriate regulations of genetic testing in place.

The NHMRC is seeking comment on its strategic plan,  and has also released a review conducted in October 2007 and chaired by Professor Alan Bernstein, the then President of the Canadian Institutes of Health Research, as well as a review conducted in January 2008 and chaired by Dr Elias Zerhouni, Director of the United States National Institutes of Health (both available here).

In the article below, Professor Glenn Salkeld, head of the School of Public Health at the University of Sydney, gives an overview of the Nutbeam review and urges colleagues to “get active”:

“We should all get behind the recommendations of Nutbeam Report of the Review of Public Health Research Funding in Australia. If I had to pick one sentence that captures the spirit of the report it is this:

“High quality public health research that leads to improved health outcomes is most likely to emerge from a thriving public health research community conducting a combination of investigator driven and strategic research.”

This report is all about what it will take to truly deliver the promise that public health research will improve population health. Yes, it will take additional investment by NHMRC in public health research but the message here is not simply to ‘splash the cash’. Rather, a far more strategic and crafted approach to how the investment is made and how it links to policy and practice is required.

The Report contains 14 recommendations that call on NHMRC to take a greater role in leadership in public health research and in improving the processes and coordination of research, policy and practice in Australia.

The report delivers the recommendations in 3 sections: strategic leadership and co-ordination (aligning to the Government’s preventative health strategy), changes to funding strategies and mechanisms and improvement’s to NHMRC application and assessment processes.

The sentiments behind the recommendations are forward thinking and collaborative. Strategic thinking, priority driven research, innovation, flexibility and responsiveness, transparency, infrastructure and workforce capacity building are needed.

The Report calls for NHMRC to move beyond descriptive research and fund more intervention research.

There is a separate and comprehensive set of recommendations relating to Indigenous Public Health Research. Again the call is to move beyond further descriptive studies and focus on intervention research and on rigorous evaluation of interventions in priority research areas.

The deployment of these ideas and improvements will take strong leadership and political commitment by NHMRC. We are not off to a good start.

Recommendation 3 calls on DoHA to further develop the Public Health Education and Research Program (PHERP) to support national Centres of Excellence in key public health priority areas. So what does DoHA do? Abolish PHERP.

PHERP has delivered generalist public health education to the masses but we need to move on and develop specialist training and workforce capacity building.

As the Nutbeam Report observes, we have spread our public health research talent too thin in the application of PHERP funds. What we need is a smaller number of world-class groupings in Australia.

The recent call for NHMRC Centres of Research Excellence in Public Health and Health Services Research are an important step towards that objective.

Imagine what could be achieved if that was matched with a DoHA initiative to fund a national Public Health Office Training Program that took our best and brightest MPH graduates and delivered specialty training ‘in the field’.

While we’re at it, what are we doing to support the next generation of health policy makers?

Then there is the all important track record in public health research funding. In the last decade the NHMRC research funding pie has grown substantially yet the success rate for Public Health for project grants, research fellowship and program grants has been poor. There is a dearth of NHMRC Senior Research Fellows in Public Health.

Many countries have faced the same problems, how to build public health workforce capacity, focus on strategic research (whilst maintaining important investigator driven research) and how best to transfer results into policy and practice. Canada leads the way with the establishment of a Public Health Research Canada Strategic Plan which includes start-up funding grants, rapid response intervention program, infrastructure grants and support for 14 Chairs at mid-career (Associate Professor) level. All great ideas – good enough to borrow for ourselves.

For a relatively modest investment in money, infrastructure and improved processes NHMRC has an opportunity reap great rewards from their investment in Public Health.

We have a unique opportunity with the Government’s commitment to preventative health to do just that. Write to Warwick Anderson, the CEO of NHRMC, and tell him you back the Nutbeam Report recommendations. The sooner the better.”

(Ironically enough, one of the review’s recommendations was the establishment of a national public health research register to improve transparency around research funded by governments.)

Professor Don Nutbeam, who chaired the group that produced the review, said he assumed the delay was due to delays in final sign-off from Health Minister Nicola Roxon’s office. He thought this was more likely to be “cock-up than conspiracy”, reflecting the “inefficiencies and the bureaucratic nightmare that’s been created around the NHMRC and its relationship with the Government.”

I tried to find out more from Roxon’s office but my phone calls weren’t returned (perhaps not surprising, given this was in the midst of the swine flu frenzy). I also was unsuccessful in obtaining comment from the NHMRC ceo Professor Warwick Anderson.

But yesterday, we were both attending an NHMRC workshop in Canberra, and he finally was ready to talk. He put up his hand, saying the delay could not be blamed on the Minister’s office. It was the result of an administrative decision within the NHMRC to release the review, together with two other reviews, as part of a document outlining the Council’s strategy for the future.

He said the review, which was forwarded to the Minister’s office last week, would be released “shortly”.

Nutbeam has been hearing similar promises for some months now. We will keep you posted…

Erstwhile Croakey correspondent Jennifer Doggett has written a piece for ABC-Online challenging the wisdom of  increasing tobacco tax, arguing that it would be regressive and harm the poor (it will “mean they cut back on other essentials, such as food, heating and housing costs.)

I suppose the corollary of this argument is that all caring people should support the lowering of tobacco tax to make it easier for those who smoke most (the poor) to keep on smoking and thus widen even further the smoking caused disease gap between rich and poor. What a perverse way of “helping” the poor while feeling good about social justice.

The poor, along with the young, are the most responsive to tobacco price rises. The heavy smoking Kerry Packer wouldn’t have cared less if he paid $13 a pack or $30, but budget conscious people do.

The responsiveness takes the form of quitting (the poor are quitting at broadly the same rate as the more well off, but from a much higher “ever smoking” prevalence) but also from reducing the amount smoked each day. Between 1980 and  2004, average daily consumption in Australia reduced from 20 (males) and 18 (females) cigarettes a  day to 14 – a 30% decline.

Along the way Jennifer trots out the myth that will not die that “seventy to 80 per cent of people with serious mental illnesses smoke and for people with schizophrenia the smoking rate is 90 per cent”.

A recent metanalysis of all studies of smoking & schizophrenia showed the average smoking prevalence was 62% (range 14-80%) with none topping 90%. (see Chapman S, Ragg M, McGeechan K. Citation bias in the reporting of the prevalence of smoking in people with schizophrenia. Aust NZ J Psychiatry 2009;43:277-82.)

While those with mental illness are under-studied, some evidence suggests that their cessation rates mirror those of the wider community. Yes, they smoke more, but their rate of decline (from a higher starting point) is not dissimilar to everyone else’s.

The only thing one needs to know about why tobacco tax is a the most effective way of bringing smoking down is to look at the tobacco industry’s reaction. Each year, you can set your watch by the predictability of their lobbying.

As Philip Morris put it with such candour as far back as 1983 in an internal memo “the most certain way to reduce consumption is through price”.