Personal View: Screening must remain a free choice
Authors: Margaret McCartney
Journal: BMJ (2004)

Charity letters asking for donations are a fact of life. This morning, however, there was a charity letter asking not for my money, but merely my support. The “Ignorance Isn't Bliss” campaign—launched this week and run by the Prostate Research Campaign UK with support from AstraZeneca—wants me, as a general practitioner, to display posters, and disperse leaflets encouraging women to use the “carrot and stick” approach to “persuade your man to talk to his doctor about his prostate health.” This campaign is different: it is for prostates, but for women. Sisters, we are being encouraged to “leave medical information leaflets lying around where he is likely to find them—ie, the bathroom, near the remote control or the car seat.” Women are wanted for our nagging abilities—and if you can't do it face to face (by “tugging at his heart-strings—do it for me/us/the family, as it means such a lot”), we are to do it by stealth. We are encouraged to lie, deceive, pressurise, and whine till we get our own way (“Book a double appointment with the doctor for a check up for the both of you, and tell him he's going with you.”)


I would not enjoy being shepherded by my husband for a cervical smear


I have no doubt that the people behind this campaign are sincere people who want to reduce deaths from prostate cancer. On that I fully support them. However, I can't support this campaign.

Why? If I were the general practitioner responsible for “checking up” a competent adult pressurised into coming to see me, I would feel rather troubled. Firstly, what check up? We offer few screening tests that are clearly effective and none that are entirely harmless. The Prostate Research Campaign's leaflet tells us that as men get older “regular check-ups... are even more necessary.” To be fair, the accompanying letter from professors of oncology and urology makes clear the controversy surrounding prostatic specific antigen (PSA) testing, but the leaflet, intended for women to arm themselves with information before tackling the household male, does not. It merely states that one in three men with a high PSA will have cancer, and that “his chances are greatly improved by early diagnosis and early intervention.”

This I object to. If one thing is clear, it is that PSA testing is highly contentious and unproven as an effective screening tool; and there is a good argument that the test should not be done at all unless as part of a trial—for example, the ProspecT trial. Until this study reports, PSA screening cannot be advocated for the population—and certainly not for an individual without circumspect consideration. While GPs are obliged to offer a PSA test, after counselling, the unfortunate conclusion I fear from reading the leaflet is that good men get PSA tests done, and good women make sure of it.

The idea that the only good citizen is one who has screening tests is, to me, abhorrent. I wonder what would happen if the situation was reversed. I would not enjoy being shepherded in to my local health centre by my husband for a cervical smear. No competent adult should be cajoled or manipulated into doing what someone else thinks is best for them. Adults are capable of making their own decisions about risk, but they need good, honest information to do that.

There is a danger to the culture of “awareness.” While knowledge is power, it is only functional if harnessed to disperse and aid decision making properly. Otherwise, well meaning campaigns are in danger of worrying the well and failing to reach the very people who may be most likely to benefit. While superficially the idea of increased awareness of prostate disease seems intuitively correct, the idea that women should seize responsibility for men's health implies that men are incapable of making their own decisions or getting their own information. This could be seen as patronising and even emasculating.

Are there not other ways that could better improve male health? For example, there is surely a need for further research into how best to get clear information on health directly to boys and men. Or how access to health services should work for symptomatic men—do we need to provide more of a “barber shop” walk in service rather than the current “salon” style, pre-booking arrangement that currently dominates in general practice?

Whatever other work needs to be done, meanwhile it should be made clear that engaging in screening is a free choice, which may or may not have benefits, and significant side effects. Over the last few years many unproven screening tests have become widely available. Besides the cost to the NHS the potential detrimental cost to the individual is lost somewhere in the feel-good, check-up, on-the-safe-side, do-the-right-thing vibe. It should not be. I agree with the Prostate Research Campaign that ignorance is not bliss. But ignorance of the implications of false positives, false negatives, potentially unnecessary invasive interventions, and the current lack of evidence to support PSA screening—that is not bliss either.