Cancer screening saves lives — it needs protecting
Concerns about the future of cancer screening are genuine and certainly not ‘hysterical’. Public health is at stake, writes Dan O’Brien
OVER the past nine days, a wave of alarm has gone through the Irish medical profession about the future of public health in Ireland.
On an issue which has little or nothing to do with the self-interest of doctors, some have spoken out because they have profound concerns for the future of screening services of all kinds. In a worstcase scenario they fear people could die unnecessarily in the future if what happened in the High Court last Friday week is not reversed on appeal.
Before getting into the detail of that judgment, consider what some of the people who know what they are talking about have said over the past week.
“Cervical screening is now in jeopardy,” said Dr Ciara Kelly, a former GP who is a presenter on Newstalk radio.
Dr Ray Walley, a past president of the Irish Medical Organisation, widened the concern beyond that disease, saying: “General opinion among medics in discussion nationwide is that we are seeing the death knell of public health screening.”
Dr Ailin Rogers, chair of the Irish Surgical Training Group, called for her profession to show more leadership in the discussion. “The onus is on us to protect the screening programme we have, rather than cripple it and render it completely ineffective. It is more important now to ensure the public know that screening is just that — not ideal, but better than nothing,” she said.
Last Wednesday, the HSE held an emergency meeting.
The suspension of the screening programme was suggested, although not agreed. This reflects the extent of the alarm among those in healthcare.
The extreme concern of the medical profession was triggered by a ruling in the High Court last Friday week in relation to cervical screening which has potentially profound implications for the screening of all diseases and other medical tests as well.
This is a highly sensitive issue for many people — as someone whose father died of cancer I am but one of many, if not a majority, of people who know at first hand the anguish this disease can cause to entire families. But clarity is needed on the facts where there is clarity, and what the implications are of those facts.
There has been insufficient articulation of what is known and what is not known going all the way to the Minister of Health, Simon Harris, and the Taoiseach, Leo Varadkar, who is a medical doctor by profession.
Screening for various diseases, including cancers, can result in early signs being picked up before they become harmful and/or life-threatening. These tests have been rolled out across the world in recent decades. Hundreds of thousands of people, perhaps even millions, are alive today who would otherwise be dead if screening had not been put in place.
Nobody disputes that fact. That there is unanimity in the medical profession on this is the very reason screening has become so ubiquitous internationally.
There is also unanimity that screening is not foolproof. On some occasions, screening professionals will judge that something is concerning, but which turns out to be nothing. Following up with such patients involves further checks. It may require invasive testing or even surgery. This brings its own worry and disruption and can mean that someone with no illness gets unnecessary or even harmful treatment when someone in need of treatment doesn’t get it.
On other occasions, screeners will miss early signs that something is awry because many tests do not give simple negative and positive results. Some of those people whose early signs are missed will go on to fall ill. In the worst-case scenario people die.
Ruth Morrissey is terminally ill with cervical cancer despite having two smear tests in 2009 and 2012. Last Friday week a High Court judge, Mr Justice Kevin Cross, found her tragic case was the result of negligence. He said medics reading smear tests must have “absolute confidence” in their decisions when saying an individual smear test does not warrant further investigation of any kind. It is this high bar that has the medical profession so concerned. Seeking absolutes in any area where medical judgment is not clearcut is wrong and dangerous, they believe.
Contrary to some claims last week, Mr Justice Cross did not invent the “absolute confidence” test himself. He relied on a case in the British courts two decades ago as a precedent for his judgment in which the “absolute confidence” bar was introduced for cervical screening (the women involved were found to have been victims of negligence by a British healthcare provider).
Where there has been little discussion over the course of the week is what happened in the neighbouring jurisdiction once the “absolute confidence” bar was introduced. This was harder to establish than one might imagine. However, numerous contacts with doctors, agencies and charities in the UK involved in healthcare, cancer and cervical cancer screening pointed to no major changes to screening after the “absolute confidence” bar was introduced there almost two decades ago.
This offers some reassurance — but not nearly enough. Ireland is different from the UK in a number of respects.
From speaking to multiple people in healthcare over the past week, it is clear those involved in screening services are at a low ebb.
The controversies around the Irish cervical screening programme in recent times have led to a widely held misperception of wholesale wrong-doing despite there being no evidence Irish rates of misread smears are different from peer countries. They feel they are being accused of being culpable in people’s deaths when they have not been.
Professionals are talking about moving out of the screening field for fear that they may end up vilified in court cases. This is not happening in the British system.
There is also the issue of resources. As always with issues of health, appearing to put a monetary value on life can be viewed as insensitive or worse. But allocating available resources efficiently is about saving as many lives as possible.
Currently the cervical screening programme costs €32m annually. If the awards that have been made recently were to multiply, awards and legal fees would exceed the cost of the programme. Some fear they could end up costing multiples of the programme itself.
If medical litigation were to widen out to other areas and judges were to interpret the “absolute confidence” bar liberally, much more of the healthcare budget could be spent on awards and legal fees than is already the case.
In terms of the rate of litigation, the amounts often awarded in compensation cases and high legal fees, this jurisdiction is different from our neighbour. It is for these reasons there is such concern in the medical profession.
The State Claims Agency, which manages cases taken against all branches of the State, was dealing with almost 10,000 claims as of the end of 2017 (the latest figures available and long before the Cross judgment loomed into view). The estimated liability, which comprises mostly medical cases, stood at €2.7bn, a figure similar to the cost of the Government’s broadband plan which caused so much controversy.
Last Friday, at the beginning of a process to appeal the judgment, the judge in the case accused doctors and others of reacting “hysterically” to his ruling a week earlier. The medical profession is a formidable lobby group which is validly blamed for resisting reforms that would address failings in the wider system, but to accuse its members of being “hysterical” on this issue was more than unwise.
If medics stand accused of anything it is a failure to communicate clearly and repeatedly how screening works, its weaknesses and how it has saved many lives.
‘It is clear those involved in screening services are at a low ebb’
DECISIONS made in Irish courts must be open to public scrutiny, and judges themselves cannot be exempt from criticism. Some of the opprobrium directed at Mr Justice Kevin Cross following the award of €2.1m to Ruth Morrissey and her husband Paul after she sued the HSE, Quest Diagnostics and Medlab Pathology over consecutive misreadings of her smear tests in 2009 and 2012 has, however, been excessive.
The concern which has been expressed is that, by asserting in his ruling that there must be “absolute confidence” in the cervical smear test system to rule out false negative results, he has put the entire screening programme at risk, since absolute confidence is impossible. There will always be false negatives and false positives in any cancer screening programme, and, as the Royal College of Surgeons has pointed out, enforcing an impossible standard would lead to “additional unnecessary tests and procedures on patients who do not have cancer”. For all this, Mr Justice Cross has been pilloried on social media and by many senior doctors. He himself has now spoken up to describe some of the criticism directed at him as “hysterical”.
Regardless of whether his ruling was wise to lay down a standard which many medical authorities regard as unattainable, he is correct about the reaction. This is an emotive issue, but it needs patient detachment to navigate a way through it, not sloganeering, and that seems to be increasingly impossible in the current political climate, where populism stokes dangerous simplicities.
This is not the fault of Irish courts. They have merely been saddled with the task of sorting out the tragic mess which has been made of these women’s lives. The medical establishment must not allow itself to be seen to resist demands for higher standards of care. Ruth Morrissey’s slides contained abnormalities which the High Court has found should not have been passed as negative. While 100pc accuracy is impossible, such a failure of the screening system is unacceptable. Doctors can be no more exempt from robust criticism than judges.
Similarly, while Health Minister Simon Harris is right to call for “cool heads”, it is worth remembering that it is the Government which has forced women such as Ruth Morrissey to seek redress from the courts, rather than coming to generous and humane settlements with them. Squabbles about the extent of the State’s liability should never have taken precedence over doing the right thing. Campaigners Vicky Phelan and the late Emma Mhic Mhathuna were both able to reach settlements with the HSE and the US labs in their cases. That should have set the template for all the women involved in this shocking saga.
What matters now is that a way is found to move on from the High Court ruling while ensuring that the cervical cancer screening programme continues to do what it is designed to do, which is catch potentially fatal disease at an early stage and save women’s lives. Quest Diagnostics is to appeal the decision to the Supreme Court, and it is essential that this is expedited as soon as possible in order to find a workable legal and medical definition of “absolute confidence” which can restore faith in the cervical cancer screening programme.