Dialogue: Politics invasive cancer in health

By JOHN ROUGHAN

Years ago, just after the report of the Cartwright inquiry, a feminist of impeccable credentials muttered privately that cervical cancer was not the greatest scourge known to woman.

I was taken aback, having just written a contribution to the chorus of support for Dame (to be) Sylvia Cartwright's indictment of the undertreatment of cervical abnormalities at National Women's Hospital. And it was appalling, insofar as it was symptomatic of the patronising attitude that left patients in ignorance in those days.

But the Cartwright report had been faintly disturbing for another reason. I remember scouring the pages for a figure of fatalities attributable to the treatment and, finding none, suppressed a twinge of suspicion that something not entirely sound was afoot.

At the time, the latter 1980s, the cost of new drugs, diagnostics and wonderful advances such as microsurgery were just beginning to burst public health budgets. Governments everywhere were discovering that the more money they put in, the more health professionals raised the level of service. Public demand, as it always is for a free good, was practically infinite.

Rationing is an invidious political task. Health funding authorities were faced with comparing the benefits of all services to ensure the funds were used where they were most needed and effective. Pharmac was set up and has done a splendid job objectively allocating drug subsidies. But in other health services rationing was, and remains, haphazard. Money still goes where professionals and patient advocacy groups make the most noise.

Scarcely any professionals would cite cervical cancer as a major health problem. In the latest year for which the Cancer Society has figures, it accounted for just 96 deaths. Lung cancer, at the top of the list, killed 1406 people that year.

Bowel cancer is the next most common, followed by breast, prostate, pancreas, stomach, lymph system, oesophagus ... You go way, way down the list to find cervical cancer. Yet of all those organs, New Zealand has a population screening service for just two - breast and cervix.

The reason, I'm told, is that apart from skin, those are the only cancer-prone organs that are reasonably accessible in their entirety. Men will not know this, but a cervical smear means the whole thing. It can't be pleasant.

And there is not much evidence that screening is making a difference. There were 85 deaths from cervical cancer in 1989, the year before the programme began, Five years later there were 96.

The Cartwright inquiry, though, made a great deal of noise. Once it had crucified the National Women's oncologist, Professor Herbert Green, it looked for a mission more constructive and settled upon a National Cervical Screening Programme. Politically, there was no resisting it, although health officials plainly knew that it would be a lemon.

A little of the lemon has been exposed now by women whose tests were read in Dr Michael Bottrill's laboratory at Gisborne. The ministerial inquiry into their complaints has produced one telling piece of evidence.

Away back in April, in the first week of the inquiry, the Ministry of Health's chief medical adviser, Dr Bob Boyd, conceded to a panel member, Professor Maire Duggan, that the incidence of cervical cancer had been exaggerated at the start of the screening programme.

The reason, he believed, was to win the backing of politicians. He also conceded that words such as "eliminate" and "prevent" should not have been used in promotional material. "You shouldn't offer the population the belief that the programme will eliminate cancer," he said.

Yet that is precisely what most of those at the Gisborne inquiry continue to believe.

When it reconvened on Monday after a six-week hiatus, a witness with a guitar and a yellow flower pinned to her lapel sang a song for a woman who had died since giving evidence in May. Then Stuart Grieve, QC, a criminal prosecutor in Auckland for many years, accused pathologists of "closing ranks" because they had seen no reason to review Dr Bottrill's work.

It can easily be forgotten that the panel has yet to say the well-publicised underreporting of abnormalities by the Bottrill laboratory was, in fact, unusual. The evidence continues to be equivocal. The woman mourned at the inquiry on Monday, for example, had received a clear test result from the Gisborne Hospital pathologist too.

Still, you can see where the inquiry is going. Regardless of whether Gisborne was an isolated problem, we are likely to get specialised laboratories and training courses and an elaborate array of monitoring committees. But at what price? We are not talking dollars alone.

A fair amount of emotional blackmail is brought to bear in the contest for public health funds. Every life is important but yellow flower people forget that the lives they know and love are not the only ones to be considered. For every life saved by a foolproof screening programme, if such a thing is possible, two or three could be lost for a lack of funds elsewhere.

Right now women in this country are urged to get a check for cervical cancer every three years. It produces slides that can be hard to read. When in doubt, a pathologist is likely to err on the bright side. Wouldn't you?

That is the trouble with population screening. Unless it is highly reliable it can do untold harm. Is it really worth it?