Who benefits if screening is sued to oblivion? Not women
Dr Ciara Kelly
‘Human error misses a high number of abnormalities in all screening systems’
THE long-awaited review of cervical screening by the Royal College of Obstetricians and Gynaecologists (RCOG) is about to be published — they are just waiting for all the women involved to be informed of the results.
However, much of it has been leaked in the media and it has been widely reported that there may be hundreds more false negatives — tests reported as normal but which were subsequently found to have abnormalities — uncovered in it.
On one radio show last week I heard these women, whose tests are being examined, described as “further claimants” — this is before these women have even received their results, let alone made a claim. And this, sadly, is how many view the ongoing situation with CervicalCheck — simply as cause for litigation.
But it is far more complicated. If the leaks are true, it means the original screening performed on the women, the Scally Inquiry and the RCOG review have now potentially come up with three different sets of results when looking at the same tests. Which I hope may go some way towards illustrating how subjective cervical screening really is — the cytologist is literally trying to differentiate between shades of purple on a slide.
It should also be pointed out that in this latest review, those looking at the tests knew the slides came from women with cancer. They were scouring them, looking for evidence of what they knew to be there. They were also likely to have had more time with each slide than is normal in cervical screening.
These two factors — the knowledge the slides were from patients with cancer and the extra time — means this review can’t be fairly compared with what occurred in the original screening. The benefit of hindsight creates a bias. It’s like comparing apples with oranges.
The RCOG reviewers knew 100pc of their slides were from patients with cancer. Those examining slides in general cervical screening know that 980 out of every 1,000 slides are completely normal. Only 20 out of every 1,000 have precancerous changes. These create very different sets of expectations.
Screening at its very best is a leaky sieve. It catches between 12 and 15 of those 20 abnormal slides. But five to eight will be missed. What we’re actually trying to do now in our courts is to decide if those five to eight missed slides, those false negatives, were missed reasonably, because they were hard to see, or unreasonably, because they were obvious. And, to be perfectly honest, it’s like dancing on the head of a pin.
The truth is that human error, for whatever reason, misses a high number of abnormalities in all screening systems, here and everywhere else. Trying to somehow work out which errors are acceptable and which errors aren’t is not an exact science.
We are currently ascribing negligence to many false negatives despite our rate of false negatives being no higher than elsewhere. Which begs the question about our courts’ ability to put these issues in context.
And I know this is technical and I know it’s confusing, but it’s important. Cervical screening saves Irish women’s lives. It is a public health success story, despite its limitations. If it is sued into oblivion, despite delivering results comparable to all international norms, who will benefit? Certainly not women. No one will benefit except those in receipt of legal fees.
So where do we go from here? To be honest, I don’t know. If hundreds more women with cervical cancer take cases against our national screening programme — the programme that catches and prevents as many cervical cancers as any screening system in the world — with subsequent millions paid out to every plaintiff, then it is possible we are looking at a compensation bill in the hundreds of millions.
Fear of that potential litigation is why, as I pointed out previously in this newspaper, they have stopped auditing CervicalCheck. So now we’re no longer assessing standards within it, which means falling standards could go unnoticed, leaving all women at risk. We are still getting governance wrong.
I suspect the real Government plan here is to hope the claims aren’t too manifold and the pay-outs aren’t too high and to just hang on until HPV testing improves the accuracy of cervical screening and the HPV vaccine reduces the incidence of cervical cancer. In other words, this is a problem that won’t continue into the future so they are just hoping to ride out the storm until it goes away.
And that may save CervicalCheck in the long run, because without the two saving graces of HPV testing and the HPV vaccine, it’s entirely possible cervical screening would cease here altogether.
But what about our other screening programmes?
They too are at risk.
Our adversarial, highly litigious legal system is simply not compatible with the high level of false negatives in even the best public health screening. My understanding is that the lawyers are now circling BreastCheck too, to the extent that its legal costs are mounting.
BreastCheck does not have the advantage of innovations coming down the line to improve its accuracy. What will happen if it is sued into oblivion over its own false negatives? How would we feel if BreastCheck stopped? It is another screening programme which saves women’s lives despite the fact that, sadly, it doesn’t catch every breast cancer. If we were to lose BreastCheck or other screening programmes because our courts can’t grasp the limitations of screening programmes, who will that actually serve?
Lawyers, currently being lauded as women’s advocates, will have done women no favours. No favours at all.