MSC Public Health and Health Promotion, Public Health Ethics - Assignment Example

MSC Public Health and Health Promotion Public Health Ethics SHHM05 Alison Hann and Gill Olumide Is Prevention always better than Cure? The case of Breast Cancer screening Student No: 628587 Word Count: 3345 Submission Date: 14-1-2011 Introduction: In the current advent of innovation and globalization, with shrinking distances and integrated economies, the health care system is also undergoing a paradigm shift. The focus of health care has shifted from being exclusively curative and palliative in nature to an integrated approach which focuses on both prevention of diseases and providing appropriate curative and palliative strategies when those diseases do occur. The introduction of the new health care policy in the 1970’s which emphasized on health promotion as the proposed strategy for the prevention of diseases, in particular diseases in which lifestyle factors had a definitive causative role, marked the beginning of this new era of preventive medicine (Larsen, 2010). Over the centuries, there has been a widespread belief amongst both the health care providers and the general population that prevention is better than cure. However, the effectiveness of such an approach towards health care is oft debated and more recently, the term ‘Preventionitis,’ which challenges this belief, has evolved and has gained popularity. Preventionitis’ is a political term that seeks to question the commonly held belief that prevention is a better and a more cost effective method, than curing a range of the nation’s health problems. In the view of many, some preventative medicine works whilst much does not. In addition, the costs of failure are high and this challenges the dogma that prevention is cheaper than cure (Le Fanu & Social Affairs Unit, 1994). The provision of preventive health services falls under the domain of public health. Public health is an umbrella term which encompasses a wide range of health services offered to the public and has been defined as ‘The science and art of preventing disease, prolonging life and promoting health through organised efforts of the society (Ewles & Simnett, 2003).’ Preventive Medicine offers a wide range of services for the public, including and not limited to, personal health checks, family planning and immunization (Ewles & Simnett, 2003). In addition, other services offered include health education, screening for various diseases, counselling regarding health care and adaptation of healthy behaviours, and provision of preventive medications in cases where it is available (USPSTF, 2010). It is important to remember, however, that public health is a multidisciplinary and multifaceted phenomenon and its scope is not just limited to the aforementioned services. The opponents of the preventive approach to health care present several arguments against the effectiveness of preventive strategies in health promotion. It is believed that prevention of illness is limited by the fact that most of us live out our natural lifespan and die of disease that is determined by the ageing process; since this is a predetermined phenomenon, any improvement in an individual’s lifespan or quality of life is small (Le Fanu & Social Affairs Unit, 1994). Studies have revealed that the increase in life expectancy by preventing or curing all cancers for those between the ages of 15 and 65, even if this were possible, would be only seven months. Moreover, the limitation of prevention policies by epidemiology, which raises association between disease and life style factors, is unhelpful in providing proof (Le Fanu & Social Affairs Unit, 1994). Thus, all these factors have contributed towards the questionable nature of the efficacy of preventive health services being offered to the public. An important aspect of preventive health is health awareness which can be achieved by health education. An effective strategy in promoting screening modalities for cancers amongst the general public is by means of mass awareness campaigns. Awareness campaigns relating to cancer are common at the present time. Campaigns such as Colon Cancer Concern’s ‘Don’t blush, look before you flush’, and the Orchid Cancer Appeal’s ‘Know your balls - check them out’ videos, as well thousands of women running in the ‘Race for Life’ event in order to raise funds for breast cancer charities. Several types of cancers now have their own dedicated charities, concerned with helping people to be aware of cancer and its symptoms, however rare. Screening tests for cervical and breast cancer are undertaken by millions of women each year (Frayn, 2005). It has been argued by some authors that prevention policies are too heavily influenced by the political considerations of government and rest uneasily with governments’ views on individual freedom and choice (Le Fanu & Social Affairs Unit, 1994). Other writers maintain that existing policies are too weak and that more coercion, together with economic direction are needed to encourage people to adopt healthier lifestyles. Intrusiveness and ineffectiveness are criticisms that are often made of present policy (Le Fanu & Social Affairs Unit, 1994). Moreover, with the adaptation and implementation of preventative strategies there are also concerns regarding ethics because, unlike curative medicine, a code of ethics does not apply to health promotion. Screening programmes and claims about hazards to health are often not proven and create concerns for the general public (Le Fanu & Social Affairs Unit, 1994). Epidemiological studies have revealed changing trends in the patterns of health and disease over the last several decades. More recently, there has been an observed rise in the prevalence of chronic diseases such as hypertension, diabetes, obesity and cancers. A survey revealed that cancer is a major contributor towards both morbidity and mortality and accounted for around 25% of deaths in 1991(Naidoo & Wills, 1998). However, it has been elucidated that self-examination and screening procedures can prevent the occurrence of some cancers (Naidoo & Wills, 1998). Amongst all cancers, breast cancer ranks as the most common cancer amongst women and is the second most common cause of cancer related deaths amongst women (Nattinger, 2010). Breast cancer under the age of 20 is very uncommon and is rarely іdеntіfіеd іn womеn younger than the age of twеnty-fіvе. After this аgе, thе rate іncrеаsеs gradually to a peak around the time of the menopause. This іs lеssеnеd аftеr the mеnopаusе, but older womеn continue to be at a growing risk over time. In the USA and Canada, about one іn еіght women will develop brеаst cаncеr, and this is a similar statistic in many Europеаn countrіеs (Skinner, 2004). Each year in England nearly 22,000 women are diagnosed with breast cancer (1:4 women) and 13,000 women die from the disease. Radical, mutilating surgery can often be avoided because of advances in non invasive treatment options; the sooner that breast cancer is diagnosed and treated, the likelihood of surgery is reduced, together with improved chances of success (Naidoo & Wills, 1998). The еаrly dеtеctіon of brеаst cаncеr is crucial as it has been postulated that it can be most effectively treated before it has had time to spread. If brеаst cаncеr іs dіscovеrеd early аnd trеаtеd, then the chances of making a full recovery are much higher and there may be various treatment аltеrnаtіvеs (Köstеrs, 2003). It is important that all women should carry out self examination of their breasts on a monthly basis (BSE), attend for mammogram screening at regular intervals after the age of forty, and have an annual brеаst assessment by profеssіonаls (Köstеrs, 2003). However, the efficacy of this screening modality, in particular the role of breast self examination in the early detection of breast cancer is debatable. Breast cancer under the age of 20 is very uncommon аnd іs rarely іdеntіfіеd іn womеn younger than the age of twеnty-fіvе. After this аgе, thе rate іncrеаsеs gradually to a peak around thе time of the mеnopаusе. This іs lеssеnеd аftеr the mеnopаusе, but older womеn continue to be at a growing risk over time. In the USA and Canada, about one іn еіght women will develop brеаst cаncеr, and this is a similar statistic in many Europеаn countrіеs (Skinner, 2004). Risk factors for breast cancer such as age, sex, race and genetic inheritance are not controllable. A reduction in risk may possibly be achieved by adopting a healthy lifestyle or starting a family before the age of 30; scientists are still searching for the most effective chemoprevention of breast cancer. In 1985, Jack Cuzick and Baum described how women with breast cancer were treated with adjuvant tamoxifen and this demonstrated a significant reduction in the risk of cancer in the other breast (Baum, 2008). Other studies and the launch of the IBIS 1 trial for the prevention of breast cancer with tamoxifen amongst women at high risk followed this observation. Similar trials concluded that tamoxifen was likely to lead to a relative risk reduction (RRR) in the incidence of breast cancer by more than 30 per cent; however there would also be significant side effects. This research proved to be a very good example of calculating the balance between harm and benefit to inform public policy and allow patients to make their own conclusions and decisions (Baum, 2008). Discussion: Prevention of diseases can be carried out at two levels, viz. primary prevention and secondary prevention. The term primary prevention refers to measures and strategies undertaken in order to prevent a disease from occurring (Kaplan, 2000). These strategies include, and are not limited to risk factor modification achieved by means of behaviour and lifestyle changes. In the case of breast cancer, there is limited role for primary prevention since there are only a handful of modifiable risk factors identified in the causation of this disease. For women who have a positive family history of breast and/or ovarian cancers and are identified as high risk for breast cancer, it has been postulated that the administration of chemoprotective agents such as Tamoxifen or Raloxifene has a potential preventive role (Nattinger, 2010). However, since there are significant risks associated with this form of prevention, the choice of whether to undertake this preventive strategy or not have to be made after weighing the potential risks and benefits of this modality (Nattinger, 2010). The important aspects of such decisions are issues regarding the respect for a patient’s autonomy and informed consent, both of which are discussed in further detail in the discussion that ensues. On the other hand, secondary prevention refers to the early detection of disease once it has occurred, in order to intervene in a timely fashion before the disease progresses and becomes incurable (Kaplan, 2000). A major branch of public health in the form of secondary prevention is screening in order to identify people who potentially will benefit from the early detection of the beginning of a disease. There are now a diverse range of feasible current screening programmes that differ in terms of what to screen for, how to screen and who to screen (Holland, 2007). The term ‘screening’ refers to the early detection of asymptomatic disease, and not a treatment in itself. Detection of the earliest stages of a disease before it creates symptoms, followed by prompt treatment that might postpone death is the aim of screening. Avoiding the specific disease by prevention makes the assumption that we understand the cause of the disease itself (Baum, 2008). The main debate against the widespread implementation of screening strategies is their cost effectiveness and the magnitude of the benefits that such strategies have to offer. Since only a certain proportion of the population is inflicted by the disease, it is often argued whether it is justifiable and economical to screen the entire population in order to identify only a subset of the population. Early diagnosis and prevention can create a difficulty for the entire population if it is exposed to intervention and side effects for the benefit of the minority. This can be contrasted to when targeting the individual with the disease; it is the individual who reaps the benefits, as well as ‘paying the price’ for the cure (Baum, 2008). The early detection of cancer, in theory, permits early treatment that reduces the effect of the disease, as well as raising the possibilities of a cure. Same is the case with breast cancer, and thus, this breast cancer fighting strategy has led to considerable investment in research. However, as in all parts of medicine, there is always a possibility of resistance arising to unbiased research, in particular if there are personal gains of some stakeholders associated with it. For example, it has been observed that in pursuit of material gains, people enhance their professional reputations and make and make money by ignoring evidence to the contrary and giving the public and professionals an illusion of success when there is none (Thompson, 2001). In the case of breast cancer, although several novel treatment modalities have been discovered, survival rates have made only a slight improvement and therefore in addition to secondary preventive strategies such as screening, which promote the early detection of disease once it has occurred, the search for a means of primary prevention of the disease remains the focus of debate and research (Knight and Taylor, 1989). Ethical Issues involved in Breast Cancer Screening: Autonomy and informed consent are at the heart of ethical medicine. It is the responsibility of all health care professionals involved in the care of a patient, including the surgeon and the oncologist, to clearly inform the patient of the risks as well as the benefits of the proposed potential intervention, whether it is through surgery or the prescription of drugs. The patient should then be given a choice to either choose or refuse the proposed intervention/screening modality, i.e. given the right to make the decision for oneself autonomously after being informed about all the risks and benefits. Evidence-based medicine (EBM) in oncology enables physicians to do this with increasing individualisation and precision. In contrast, the public health interventions of screening and prevention have an evidence base that is less robust and the ethical model of respect for autonomy is also very poorly developed (Baum, 2008). With regard to breast cancer screening, there are several ethical issues which arise. For example, when mammography is carried out as a screening procedure for breast cancer, there is a significant risk of false positive results which varies with the age of the individual. Studies have revealed that with increasing age, the risk for false-positive results and their consequences decreases. Thus, although mammography at any age poses a tradeoff between the potential benefits and harms, the balance between increasing absolute risk reduction and decreasing harms grows more favorable over time (Humphrey, Helfand, Chan, & Woolf, 2002). Other important issues include the possibility of over-diagnosis, whereby benign lesions are picked up by mammography and further investigations have to be carried out inorder to determine whether the lesion is malignant or benign. Overdiagnosis can result in unnecessary costs due to follow-up tests and biopsies which are required in order to either confirm or rule out the possibility of the disease and arrive at a definitive diagnosis (Nattinger, 2010). Studies have revealed that for women undergoing mammography for screening for breast cancer, there is a 1% to 10% chance of being overdiagnosis (Nattinger, 2010). This has several implications since overdiagnosis is associated with significant costs which are unnecessary and thus render the cost-effectiveness of screening programs questionable. Studies evaluating the cost effectiveness of screening programs have found that the cost per year of life saved lies between $18,800 to $20,200 approximately (Nattinger, 2010). Moreover, both over-diagnosis and false positive can cause significant anxiety and psychological distress on the part of the patients (Nattinger, 2010). Thus, informed consent should not be just limited to informing the patient regarding the risks and benefits of screening but should be more comprehensive and the patients should also be informed about the possibility of overdiagnosis, missed diagnosis and false positive results. Early detection of potential problems is the benefit of screening, but it also provides some risk of harm; these include the inconvenience of participating in a screening programme, the unpleasantness of the relevant test, and an anxious wait for the results (Sox, 1998). The truth about screening: The general public believes that the core fight against cancer is ‘early detection’, and it is a common belief throughout Europe that screening for cancer saves lives. The UK government’s aim is to improve cancer survival rates in Britain to match the highest levels achieved in other European Union countries (Baum, 2009). The NHS screening programme for breast cancer (NHSBSP) through mammography has been claimed as effective and claims that it is the reason for the dramatic decline in death from breast cancer since the programme started more than 20 years ago (Baum, 2009). The success of the (NHSBSP) in reducing death from breast cancer for women over 50 is dependent upon at least 70% take-up by eligible women (Taylor and Cudby, 1992). The bias of screening: As discussed above, there are several potential risks associated with using mammography as a screening modality for breast cancer. The efficacy and cost-effectiveness of mammography is oft debated. Several authors have contested the validity and reliability of previous studies and trials conducted to evaluate the efficacy of mammography in the screening for breast cancer as there are several methodological biases which can potentially confound the results of these trials. As discussed earlier, the bias within screening can lead to a false impression of benefit, as well as the over-detection of cancer ‘look-alikes’ that if left unseen, might never threaten a patient’s life (Baum, 2009). The period from the time of detection until recurrence and death is the method by which the survival rate from cancer is measured; yet there is bias in this process. The timing of the disease in relation to the time of screening can lead to the survival rate being automatically extended even if the outcome is the same; this is called ‘lead-time bias’. If a woman’s life was never threatened by the ‘cancer’ detected, then that lead time might be as long as 30 years (Baum, M, 2009). This leads to the dilemma of whom to screen, when to initiate screening and the optimal interval between successive screenings. The time between screenings is usually between one and three years. Fast-growing tumours with a poor prognosis will appear during the intervals, whilst the slow-growing tumours with a good prognosis could be found by mammography and this is called ‘length bias’ (Baum, 2009). Another bias is the ‘self-selection’ bias by women who attend screenings who may be demographically different to those who refuse the opportunity (Baum, 2009). Thus, all these biases which occur during the screening for breast cancer have contributed to the results of the various trials and epidemiological studies conducted regarding breast cancer and the validity of the findings of such studies is currently being debated. A recent publication in the British Medical Journal of ‘Breast screening: the facts - or maybe not’ by Peter C Gøtzsche and his colleagues, from the influential and independent Nordic Cochrane Centre, (Baum, 2009) indicates that there is only a modest advantage to screening when examined in terms of mortality. The authors describe a summary of all the research that explains both the harms and benefits of the screening process, using absolute rather than relative numbers. Their research concludes that if 2,000 women are screened regularly for 10 years, one will benefit from the screening, as she will avoid dying from breast cancer (Baum, 2009). Conclusions: Prevention may be better than cure, if the benefits exceed the harm. From an ethical point of view, there are several ways in which the subjects undergoing screening can potentially be ‘harmed’. These include, the potential for the loss of autonomy, which can occur when mass screening campaigns are launched under which the general population has to undergo screening without being offered a choice; the significant anxiety and mental distress arising from the occurrences of false positive results and overdiagnosis; and also shortcomings in the process of informed consent which is not very comprehensive most of the time and some important information might be withheld from the patient. It can also result from the poor distribution of medical resources, when too high a cost is paid without any significant gains due to low rates of relative risk reduction and mortality benefits (Le Fanu & Social Affairs Unit, 1994; Nattinger, 2010). Prevention has become popular with politicians because of the mistaken belief that it would reduce the health budget (Le Fanu & Social Affairs Unit, 1994). As Baum states, the uncritical promotion of screening is unethical by modern ethical standards and reflects a paternalistic attitude that would be unacceptable for treatment aimed at curing an established disease. Government should reconsider screening and prevention as effective elements of a public health policy. With established disease, focusing on prevention can be dangerous, and very often cure is better than prevention (Baum, 2008). Thus, it can be concluded that the current prevention programs, in particular those designed for breast cancer screening such as mass screening using mammography, with all their shortcomings are of limited benefit to the patients. Hence, the notion that prevention is always better than cure is not necessarily true. Therefore, it is the responsibility of the health care professionals and policy makers to re-evaluate the effectiveness of these programs, identify its shortcomings and then devise and implement appropriate strategies to improve the pre-existing programs. References Baum, M (2008) ‘Prevention is better than cure? Not necessarily’ Spiked. Available at http://www.spiked-online.com/index.php/site/printable/4272/ Baum, M (2009) ‘Why I am still a screening Sceptic’ Spiked. Available at http://www.spiked-online.com/index.php/site/printable/6563/ Baum, M (2004) ‘What mammography misses’ Spiked. Available at http://www.spiked-online.com/Articles/0000000CA382.htm Ewles, L., and Simnett, I. (2003). Promoting health: A practical guide. 5th edn. Edinburgh: Bailliere Tindall. Fitzpatrick, M (2005) ‘Patient power can harm your health’ Spiked. Available at http://www.spiked-online.com/index.php/site/article/657/ Frayn. L (2005) ‘Checking up on ourselves’ Spiked. Available at http://www.spiked-online.com/index.php/site/article/1262/ Holland, S. 1. (2007). Public health ethics. Cambridge, UK; Malden, MA: Polity. Humphrey, L. L., Helfand, M., Chan, B. K., & Woolf, S. H. (2002). Breast Cancer Screening: A Summary of the Evidence for the U.S. Preventive Services Task Force. Annals of Internal Medicine , 347-360. Kaplan, R. M. (2000). Two Pathways to Prevention. American Psychologist , 382-397. Kaur, S.D. (2003). The Complete Natural Medicine Guide to Breast Cancer; A Practical Manual for Understanding, Prevention & Care. Canada, Toronto: Robert Rose. Knight, D. and Taylor, V.J. (1989) Health Education Breast Screening Training Resource. Oxford: NHSBSP Publications. Kösters, J.P. and Gøtzsche, P.C. (2003). "Regular self-examination or clinical examination for early detection of breast cancer". 12-54. Larsen, L. T. (2010). Is Prevention Better than Cure? Public Health Policy and the Circular Structure of Learning. APSA 2010 Annual Meeting Paper . Le Fanu, J. and Social Affairs Unit. (1994). Preventionitis: The exaggerated claims of health promotion. London: Social Affairs Unit. Mullagh, S. (1996). NOT at my age: why the present breast screening system failing women aged 65 or over. London, Age Concern. Naidoo, J. and Wills, J. (1998). Practising health promotion: Dilemmas and challenges. London: Bailliere Tindall in association with RCN. Nattinger, A. B. (2010). Breast CancerScreening and Prevention. Annals of Internal Medicine . Priestman, T. (2006). Coping with Breast Cancer. Great Britain: Ashford Colour Press. Saslow D, Hannan J, Osuch J, et al. (2004). "Clinical breast examination: practical recommendations for optimizing performance and reporting". CA Cancer J Clin 54 (6): 327–44. Skinner, C.S., Strecher, V.J. and Hospers, H. (2004). Physicians recommendations for mammography: Do tailored messages make a difference? American Journal of Public Health, 84(1), 12-13. Sox, H.C. (1998). Benefit and harm associated with screening for breast cancer. The New England Journal of Medicine, 338 (16), 1145-6. Taylor, V.J. & Cudby, H. (1992). “Why Screen for breast cancer?” , Practice Nursing, June. 5-6. Thompson, A. )2001). Ethics, Medical Research and Medicine. Netherlands: Kluwer Academic Publishers. USPSTF. (2010). U.S. Preventive Services Task Force (USPSTF). Retrieved January 10, 2011, from U.s Department of Health and Human Services: http://www.ahrq.gov/clinic/uspstfix.htm Read More