The BMJ Editor's Choice
Too much chemotherapy
发布：Fiona Godlee, Editor in Chief, The BMJ
People with cancer are living longer now than 40 years ago. This is clearly good news. But how much of this improvement can we attribute to drug treatment? Not much, concludes Peter Wise this week in an article I humbly suggest all oncologists should read (doi:10.1136/bmj.i5792). The nearly 20% improvement in five year survival over the past four decades is probably mainly due to improved early diagnosis and treatment rather than developments in cytotoxic chemotherapy, he says. And patients are being badly misled by over-enthusiastic accounts of what chemotherapy can achieve. Many expect a cure. In reality they will gain on average only a few months of extra life.
The roots of this over-enthusiasm are sadly familiar but worth recounting in the specific highly charged and intensive context of cancer. Wise, a medical ethics consultant and former consultant physician, doesn’t mince his words. Unrepresentative, industry funded trials that use surrogate endpoints are part of the problem. So too are regulatory failures, perhaps explained by regulatory capture in which “the regulator risks being regulated by the industry that it has been appointed to regulate.”
Unjustified enthusiasm for cancer drug treatments comes at huge cost, financial and personal (including treatment related deaths and reduced quality of life), and increased risk of dying in hospital rather than at home. Many patients don’t realise that opting for supportive rather than active treatment—often called “refusal”—is an option and may give them longer as well as better quality life than chemotherapy. Conflicts of interest among clinicians compound their reluctance to have tricky conversations.
If improved survival is indeed largely due to early diagnosis and treatment, how is this best achieved? Many patients visit their GP with vague or non-specific symptoms. How should these be investigated and followed up without causing unnecessary alarm or wasting precious resources? As Brian Nicholson and colleagues explain (doi:10.1136/bmj.i5515), “safety-netting” aims to ensure that patients don’t drop through the healthcare net and are monitored until symptoms can be explained. But there is little evidence on whether this works or how to do it well. In particular, how much responsibility should patients be expected to take in chasing up and understanding test results? The authors encourage a sharing of this responsibility between clinicians and patients, but also clear communication and robust systems to prevent patients falling through the net.
Wise concludes with a call for higher bars for drug approval for new and existing drugs. Ethical cancer care demands empowerment of patients, he says, with accurate, impartial information followed by genuinely informed consent. And funds and attention should shift to prevention, early detection, prompt and radical treatment of localised and regional disease, and early provision of supportive care. Only then will cancer care serve patients rather than governments and industry.
BMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i6027 (Published 10 November 2016)
Cite this as: BMJ 2016;355:i6027
In search of a good nanny
发布：Sophie Cook, clinical reviews editor, The BMJ
Nannying, like medicine, is a vocation. The good nanny was everything a family could wish for: she cared for, helped, and guided her family to make their own decisions, knowing when to interfere and, crucially, when to butt out.
This week Simon Capewell and Richard Lilford debate whether, when it comes to states, nannying makes us healthier and whether information or legislation is the way to change health behaviour (doi:10.1136/bmj.i6341). Lilford explains, “There can be no autonomy if the state, rather than the individual, is the custodian of personal values.” He warns, “The nanny state’s impatient and sometimes self righteous zeal could do more harm than good.” Capewell argues that, on the contrary, a “nanny state means ensuring a healthy environment for all” and underpins every health determinant in Ivan Maslow’s hierarchy of needs, such as safety and love, to allow us to enjoy our health and fulfil our true potential.
One group lacking many fundamentals of Maslow’s pyramid is homeless people, who often struggle to access healthcare. Anne Gulland describes how some successful UK projects have broken down barriers to services (doi:10.1136/bmj.i6511). Helpful tips include drop-in clinics, more flexible appointment times, and awareness that lack of a permanent address is not a barrier to registering with a GP.
From a group that struggles to access healthcare to a group offered it in abundance: pregnant women. Karin Nelson and colleagues look at the role of electronic fetal monitoring in labour and at how an intervention that was initially introduced to reduce cerebral palsy (it has not) has subsequently been linked to increased rates of caesarean delivery and litigation (doi:10.1136/bmj.i6405). They call for doctors, courts, and the public to recognise the lack of proof for routine electronic monitoring and remind us that technologies in healthcare can have unintended consequences.
And finally, as we approach the end of a turbulent year in the NHS Margaret McCartney tells us it’s a sense of vocation that keeps it going (doi:10.1136/bmj.i6526), with doctors committed to going the extra mile. But this commitment also means that professionals can be exploited, she says, and that vocation “needs to be ballsy and capable of rebellion.” Will 2017 bring the “righteous vocational fury” she is hoping for?
BMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i6565 (Published 08 December 2016)
Cite this as: BMJ 2016;355:i6565
At your next conference ask where the patients are
发布：Fiona Godlee, editor in chief
It may not feel like it just now, but what we have is doctor centred care. Perhaps also institution, manager, and nurse centred care. What we don’t yet have is patient centred care, despite this being obviously what healthcare should be. But things are slowly shifting in the right direction, and The BMJ aims to help keep up the momentum.
An editorial last week summarised where we’ve got to with The BMJ’s patient partnership strategy (doi:10.1136/bmj.i4550), and there’s good progress to report. We now have patients as peer reviewers of research articles and contributing to education articles; we require authors to state how patients were involved in their research or in creating an article; and we are publishing a rich array of patients’ commentaries.
These efforts mirror progress elsewhere, with patients increasingly involved in designing and implementing clinical care and research. But some parts of the healthcare ecosystem have proved more resistant to change. It’s now 25 years since the International Aids Conference first included patients in its discussions, but as Larry Chu and colleagues point out (doi:10.1136/bmj.i3883), involvement of patients in medical conferences remains the exception rather than the norm. Done well, it widens the focus of presentations, encourages more patient relevant outcomes in research, and prompts improvement in the design and delivery of care, they say. Above all, it changes the culture of a conference. Although the drive has come from patients, the medical community has much to gain.
So, what does doing it well look like, and how can organisers overcome the barriers to patient involvement? With five years’ experience of running a large academic medical conference in which patients play a central part, Chu and colleagues are well placed to advise. It’s not enough, though essential, to have patients on the steering and programme committees from the start, they say. Organisers need also to encourage patients to attend, comment, and speak. This means making sure that patient delegates are properly looked after and supported so they can contribute on an equal footing to other participants. This is not window dressing and must not be tokenistic. Crucially, it brings patients “closer to the conversations driving the future of healthcare.”
As for The BMJ, we are proud to be the first medical journal to have earned the Patients Included stamp of approval (https://patientsincluded.org; http://bit.ly/patient-partnership), but we know there is more to do. Our patient panel meets this week to grade our work so far and tell us what it wants us to do next.
BMJ Blogs Amy Price: The evidence informed patient (http://blogs.bmj.com/bmj/2016/09/14/amy-price-the-evidence-informed-patient); Neil Betteridge: Effective involvement of patients at medical meetings (http://blogs.bmj.com/bmj/2016/09/14/effective-involvement-of-patients-medical-meetings-a-case-study); Dan Smyth: Patient involvement in the European Respiratory Society Congress 2015-16 (http://blogs.bmj.com/bmj/2016/09/14/patient-involvement-in-the-european-respiratory-society-congress)
BMJ 2016; 354 doi: http://dx.doi.org/10.1136/bmj.i5123 (Published 22 September 2016)
Cite this as: BMJ 2016;354:i5123