The problems with Movember

as facial hair now sprouts forth, let us examine the health advice that Movember is offering on its website.

Useful points:

here, they give a good rundown on what you can do to reduce your risk of avoidable premature death or illness; essentially it is this. Don’t smoke, keep to a healthy weight, do some exercise you enjoy – preferably, social and preferably daily; eat a varied diet, mainly plants, and have work you like.

Not at all useful is this webpage, a ‘health checklist by age’.

Last year, @petedeveson wrote this article about the lack of evidence for the health checks they advocate. I was especially concerned about last years advocating of PSA screening, and took up his offer to speak to the PR department of Movember on a joint phone call. I offered evidence based information, such as the complex nature of most screening tests and the problems of overdiagnosis, overtreatment and the need for fair information. I said I’d be happy to speak to them again. No luck!

They have now produced a document suggesting that men aged 40 and above have a baseline PSA test. They do not mention any of the problems with PSA testing – namely that it doesn’t work well as a screening test, and is not part of an NHS Screening programme. PSA screening means that men who would never have been maimed by an indolent prostate ‘cancer’ are, however, harmed by treatment for it. Movember present PSA testing as something a good citizen would do, not something which performs very poorly. Nor do they link to information such as decision aids for PSA screening (which, incidentally, tend to lead to more men not wanting the test.)

There are lots of other problems with Movembers’ screening  information. They advise a blood pressure to be measured every 2 years. The NHS says men over 40 should have it checked every 5 years. They say mens’ cholesterol should be checked from age 20. The NHS says from age 40 in someone otherwise well, and even then, cholesterol is only one factor of a cardiovascular risk assessment – which includes things like smoking. I think – I’m not sure from their wording – that they are recommending flu vaccination in men aged 20 and above, again, this isn’t recommended by the NHS unless there are other health problems such as asthma. (There is also the additional ‘problem’ of Cochrane but we will leave that meantime). There is good information about what the NHS recommends in terms of vaccination, here. From age 50, Movember recommend diabetes screening, again, despite the lack of the NHS recommending this and this recent large RCT.) They also recommend annual bowel screening, although the NHS offers it every 2 years from age 60 (not because the NHS is stingy, but because this is where the balance of risk and harm is most favourable.) As for aortic aneurysm screening, they say this is ‘only relevant for men who have smoked’ – in fact the NHS invites all men aged 65, smokers or not.

In other words, their advice is contrary to NHS advice. This is unfair on men, and on the NHS, who have to use their resources to mop up this kind of poor information.

I urge Movember to pull their health check ups page, use evidence based advice, and concentrate on some of the real unmet health needs of men – what about suicide, alcohol, and car crashes, for example. Not as sexy as proactive (unnecessary and potentially harmful) health checkups – but likely to be of far greater benefit if properly addressed.

 

13 Responses to “The problems with Movember”

  1. darrinsearancke November 4, 2012 at 9:37 pm #

    digital rectal I’m afraid…

  2. PedroStephano November 5, 2012 at 9:21 am #

    About time someone made this correlation. Deaths in car crashes! I would argue that from a Risk Analysis and a HealthNSafety point of view (sorry for the buzzwords – I know – sigh) that a very very high percentage of these are completely preventable.
    But we shan’t go there shall we?

  3. dearieme November 5, 2012 at 10:22 am #

    “Don’t smoke” … agreed.
    “keep to a healthy weight” … tautological.
    “do some exercise you enjoy” … yet when I was very ill indeed I took no exercise for nine months and my heart spontaneously recovered from the heart failure which I had been told would almost certainly kill me. Was it me? Was it luck? Is the common advice to take exercise too sweeping? Is it based on mere correlative studies?
    “eat a varied diet” … that’s my policy, not least because I suspect the evidence for anything else is weak.
    “mainly plants”: for me – plenty of fish, meat (especially offal) and, of course, Vitamin Bacon. I wouldn’t fancy an American diet of scrawny chicken and unhung beef.

  4. steve November 6, 2012 at 1:17 pm #

    I want to look specifically about what they say about prostate cancer and PSAg testing.

    Here’s their opneing shot:

    Prostate Cancer

    THE STATS

    • 1 in 9 men will be diagnosed with prostate cancer in their lifetime – a new case is diagnosed every 15 minutes.
    • One man dies from prostate cancer every hour.
    • This year 40,000 men will be diagnosed and 10,000 will lose their lives to the disease.
    • Prostate cancer is the most common cancer in men
    • The incidence rates are 3 times higher in African Caribbean men.
    • Men are 2.5 times more likely to get prostate cancer if a father or brother has had it

    So far, so good. This is followed by some advice on screening:

    SCREENING
    “The purpose of screening is to detect prostate cancer at its earliest stages, before any symptoms have developed.

    Typically, prostate cancer that’s detected by screening is in the very early-stages and can be treated most effectively. A doctor can screen for prostate cancer quickly and easily in their office using two tests:

    The PSA Blood Test
    PSA is a protein produced by the prostate and released in very small amounts into the bloodstream. When there’s a problem with the prostate—like the development and growth of prostate cancer—more and more PSA is released. It eventually reaches a level where it can be easily detected in the blood. During a PSA test, a small amount of blood is drawn from the arm, and the level of PSA is measured.

    The Digital Rectal Exam
    During a DRE, the doctor inserts a gloved, lubricated finger into the rectum and examines the prostate for any irregularities in size, shape, and texture. Often, the DRE can be used by urologists to help distinguish between prostate cancer and non-cancerous conditions.

    The question of screening is a personal and complex one. It’s important for every man to talk with his doctor about whether prostate cancer screening is right for him.

    There is no unanimous opinion in the medical community regarding the benefits of prostate cancer screening. Those who advocate regular screening believe that finding and treating prostate cancer early offers men more treatment options with potentially fewer side effects.

    Ultimately, decisions about screening should be individual and based on a man’s level of risk, overall health, and life expectancy, as well as his desire for eventual treatment if he is diagnosed with prostate cancer. When to start screening is generally based on individual risk, with age 40 being a reasonable time to start screening for those at highest risk (genetic predispositions or strong family histories of prostate cancer at a young age). For otherwise healthy men at high risk (positive family history or African American men), starting at age 40-45 is reasonable.

    It’s important for men to create a proactive prostate health plan based on your lifestyle and family history, as well as to discuss these tests with your doctor to make the screening decisions that are best for you”.

    All sounds pretty reasonable right? Wrong.

    My first issue is that they say there in no unanimous opinion in the medical community regarding the benefits of prostate cancer screening screening. That statement is disingenuous at two levels. Firstly there is almost no unanimity in the medical community about anything! Secondly there is a general consensus that generalised PSAg testing does not work as a screening test.

    Next they mention those who advocate such screening – but mention nothing about the majority of doctors who don’t think generalised screening is a good idea.

    They urge particular caution with high risk individuals and this is good.

    But there is no mention at all that PSAg testing is not diagnositic or that PSAg can be raised for other reasons (i.e it’s not tumour-specific) or that two thirds of men with an elevated PSAg do not have prostate cancer detectable at biopsy. They shoud mention these things but they don’t.

    Nor do they mention that a rectal examination which feels absolutely normal does not rule out cancer.

    The harder we look for cancer – any cancer – the more we will find. Yes, prostate cancer can hurt you and it can kill you. But so too can the investigations and treatment for prostate cancer – impotence, urnary problems and death. So really wouldn’t want to put yourself through that if you didn’t have cancer.

    There are about 10,000 deaths in the UK from prostate cancer each year and the vast majority fo these occur in elderly men. But even if we take the figure of 10,000 at face value that’s 10,000 out about 25 million adult males – or about 1 in 2500 adult males (or about 0.04%). Yet nearly 4 times as many men are diagnosed with prostate cancer.

    And remember, 80% of 70 to 79 year olds who die of something else will have evidence of prostate cancer in their prostates at autopsy. Even for 50 to 70 year olds the figure is around 60%. If the lifetime risk of death from prostate cancer is only about 2 to 3% (which it is) then the fact that prostate cancer is so common at autopsy clearly leaves the door open for screening to produce mass over-diagnosis.

    The logic of doing PSAg is that an abnormal test will lead to the next stage of investigation – biopsies. Generally, however, there is no specific target so multiple biopsies have to be taken. A typical biopsy will take less than 0.5% of total gland volume. So even multiple biopsies (usually 6) will only sample small proportion of the gland. But clearly the more biopsies we do the more likely we are to find smething positive.

    Prostate cancer ocurs at all levels of PSAg. Even a “normal” score of <2 carries with it a 10 – 15% chance of prostate cancer. There is no level for PSAg which equates to no cancer. A score more than 4 carries with it a 30% chance of cancer (but that's a 70% chance of no cancer). But even a score between 3 and 4 carries a 27% risk.

    If we use a cut off of more than 4 and apply it to men in their 60s that means we would be looking at biopsing about 5% of this population (about 150,000 men in the UK of whom 50,000 would have positive biopsies). If we reduced the cut of to a PSAg of 2.5 we would be doing biopsies on 750,000 men of whom about 250,000 woud be positive. So just by lowering the threshold we would increase the diagnoses of prostate cancer 5 fold.

    Screening for cancer, by nature, tends to find more of the slow growing indolent tumours as the fast-growing aggressive ones often present during the screening interval.

    When PSAg testing was introduced in the early 1990s the number of diagnoses of prostate cancer doubled in two years and about 10 times as many many were being diagnosed with prostate cancer as were actually dying from it. Since PSAg testing was introduced the incidence of death from prostate cancer has fallen from about 30 per 100,000 to just over 20 per 100,000 (a relative fall of 30% but an actual fall of less than 0.01%). We cannot say that this fall is down to screening – it may be more about more effective therapy.

    I think Movember need to be more open about the beneits or otherwise of screening for prostate cancer.

  5. jb pittard November 6, 2012 at 1:30 pm #

    today’s online Pulse
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    Care UK buys largest GP out-of-hours provider

    6 November 2012 | By Helen Mooney
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    Comments (1) Save
    Private healthcare provider Care UK has bought the UK’s largest GP out-of-hours provider, Harmoni, forming an organisation providing unscheduled care to over 15m patients.

    Harmoni has been the most successful out-of-hours provider so far in winning the Government’s NHS 111 contracts and in some areas won the contracts over Care UK who bid for several contracts in partnership with Capita.

    The news comes after the revelation last month that Department of Health director of improvement and efficiency Jim Easton is to join Care UK as managing director.

    Care UK chief executive Mike Parish said, ‘We understand the urgency with which the NHS needs to be able to reduce unscheduled and inappropriate hospital admissions of patients who can and should receive treatment elsewhere.

    ‘Bringing Harmoni into Care UK’s healthcare organisation will help us to help commissioners within the NHS make the most effective use of their resources, making sure that unscheduled treatment, including out of hours needs, takes place in the most appropriate setting.

    ‘Harmoni is busy mobilising its new NHS 111 call services, which enable patients to use a single, simple contact point to access unscheduled care and which will allow us as a partner within the NHS to direct those patients to the right local service, which is often not an acute service.’

    Harmoni’s managing director Edmund Jahn said : ‘Becoming part of the Care UK family is hugely positive news for our patients, our commissioners and the colleagues who deliver high quality care across all our services. It gives all our services a strong and sustainable platform for the future as we work within Care UK to support the NHS.’

    NHS 111 contracts won by Harmoni include all but two of the seven primary care trust clusters in the South West. In Kent, Surrey and Sussex, Harmoni will deliver the service in partnership with South East Coast Ambulance Service Foundation Trust.

    Harmoni started out as a GP co-operative in Harrow in 1996. Care UK runs over 50 primary care service – including GP and walk-in services, out-of-hours and diagnostics centres – and six hospitals that carry out elective NHS work.

    READERS’ COMMENTS (1)

    jb Pittard | 06 November 2012 1:09pm

    Fixed pricing and the only way private equity can take 20% + as profit is a combination of reduced overheads and demand.So lower paid front line staff with less job security and benefits including pensions; along with demand management( and good luck with that).
    The unravelling of the universality of “free” care seen with dentistry now erodes medical services. The non union areas of course will be cherry picked first.
    The 2015 election will be the final determinant of this process. A further 5 years will see £15+bn of taxation funds vacuumed out of patient care and into private profits. All in it together?Doesnt feel like it.

    Unsuitable or offensive? Report this comment

  6. Michael Woodhead November 6, 2012 at 11:34 pm #

    This is a worry, especially as the peer pressure to take part in/suport Movember is approaching that for wearing a Poppy. Who is behind the Movember campaign? Any of the usual suspects promoting Psa screening and surgical interventions?

  7. Chris Hiley November 7, 2012 at 6:03 pm #

    I must extrude a Movember post soonish….. They are an expert fundraising operation, not public health experts, so their noodlings on men’s health are ….. noodlings. Their head honcho lives in California, alongside his lifestyle, so no one has bothered to make their advice UK context sensitive.

    In the stuff I’ve seen, the UK intention is to present prostate cancer as if it synonymous with men’s health. It clearly isn’t. Prostate cancer is a particularly useless model for men’s health, so while it does need a special approach, I’d say absolutely NOT the template as applied. It doesn’t work. PCa risk factors are largely immutable, there’s no early warning symptoms, no socio economic influences worth looking at, and the ‘screening’ is ….. cccrrraaapppp.

    Prostate cancer IS interesting for having the highest mean age of death of any of the cancers, so it could be used as a novel Trojan horse to tackle health in older men but no, not in Movember world. Ageing men (the over 75’s) are not Movember’s agenda, so have never met. Movember raise awarness of prostate cancer in the under 40s. As long as they can keep that awareness going, and up to date for the next 35 years it’ll all work out fine.

  8. Theora November 11, 2012 at 12:34 am #

    At least some of those recommendations are the current standard in the US (e.g. blood pressure screening every 2 years and annual flu jab).

    It’s beyond the scope of your article here, but I’ve been wondering for a long time and don’t know who else to ask: how does one make sense of the varying screening and vaccination requirements across different countries? Surely there’s not such a physical difference between an American and a Briton that one needs an annual flu shot and the other doesn’t? American children are told to get a varicella vaccine; British children are not. American women are recommended to get annual cervical screening starting at 21; British women are invited at age 25. How can a layperson make any sense of these differences?

    FWIW, my husband is British and I am American. We previously lived in the UK, now in the United States.

  9. Lucie November 11, 2012 at 1:15 am #

    Hi Theora,
    As a junior doctor in the NHS I have many guidelines come and go. I would like to think these are usually due to using the best available evidence and would note that infectious disease advice can be quite different regionally simply due to different bacteria or viruses being conmon in ine part of the world, or different social or cultural differences in the human population putting them at special risk.
    however on a more cynical note often the drivers for change are political, legal or financial. In the NHS cost-effectiveness has a high priority for obvious reasons, while in countries with private healthcare clinical practice can sometimes be ridiculously over extravagant, both to maximise revenue but also for fear of lawsuits if anything is missed. This ‘defensive medicine’ is certainly nit always in tge patients best interests as having unecessary tests or treatments can be dangerous.
    How often should blood pressure be measured in someone not known to have high BP? It’s a matter of opinion and somewhat arbitrary, but the recent UK guideline switch to 5 yearly does seen likely to prevent a lot of needless anxiety due to constantly rechecking the BP of healthy individuals.
    Vaccines are always a risk/benefit decision; the added benefit is that the ‘herd immunity’ from vaccines means the disease is largely absent and therefore those who are NOT protected (either through vaccine failure, being too young to have vaccine, the immunocompromised, or not being vaccinated) are still much less likely to be exposed to anyone with the disease. This is important for diseases such as chickenpox where newborns are not immune and can become seriously ill; while older children with a more mature immune system simply fight it off with no complications in the vast majority of cases. I was not aware the US now recommends chickenpox vaccine; you would need to ask your physician how effective it is, and how common serious side effects such as anaphylaxis are. Hope this sheds some light on your query? People all over the world may be the same but there are some valid reasons to take societal differences into account

  10. Paul November 11, 2012 at 2:42 pm #

    Being to lazy currently, are the advisories different for each country Movember is running in? If not then all your quoting of NHS could be out of context. Movember started in Australia.
    When I was there (2006 I think) in the UK there was a campaign to reduce red meat consumption. In Australia they were promoting red meat like nobodys business.

    The advisories may be correct to AU standards (each country has their own stances, who is to say who is right or wrong?) but out of line with UK?

  11. Margaret McCartney
    margaretmccartney November 11, 2012 at 4:44 pm #

    Hi Paul
    this is the movember UK site http://uk.movember.com/mens-health/health-checklist/ – it’s the one designed for the UK.

  12. Ashley November 13, 2012 at 7:47 am #

    Ugh I don’t know which is worse: Movember participants not sharing any discourse about prostate cancer (the vast majority) or those perpetuating misinformation. Awareness indeed. What a mess.

    Thanks for this. Everyone needs to stop stroking their moustaches and read it.

  13. Chris Hiley November 15, 2012 at 1:16 pm #

    Me again. I have just been reading Movember Europe’s first accounts from the Charity Commssion website. Do visit. ‘Movember Europe’ is Movember’s ID in the UK. Read the accounts. For the first time you get a sense of the vast sums raised in the UK (£22m last financial year) and their charity/company/entity stylings. It sure gets complicated, running a multi million pound business/charity/company. I thought Movember was just a neat fundraising mechanism.

    The Board of Trustees for the UK’s ‘Movember Europe’ all live in Australia, as far as I can make out, save the lucky lad in California, as already mentioned. That’s above board so I’m not implying anything but I AM thinking ‘oh, quite remote from the UK, then?’… Wherever they are, as far as I can make out none have a health professional background or a history in men’s health/public health/health promotion or any specific UK knowledge of our health services. There is a prostate cancer scientist but her CV looks distinctly non-clinical to me, fine for the role she has but not fine promting health advice to men.

    I have not yet spotted any Movember UK health staff campaigning on men’s health issues – whether knowledgeably or not is a secondary question…. I’ve not met any around and about either, I can’t put a name to any face, nor know anyone else who can. I might be in the wrong places of course, so HAS ANYONE ELSE? They do crop up as exemplars of expert fundraisers and have staff that fulfill that function – but Movember don’t have a profile as health experts that I recognise – so where does their advice come from? They aren’t a member of the Cancer Campaigning Group, which all major cancer charities are…..

    Has anyone else actually met a Movember UK person advocating in a ‘health and men’ context, outside of a fundrasing Mo event ?

    So. Question.

    Which UK based health experts are advising/have advised Movember UK about best evidence based practice and recommendations for UK men on health screening?

    If you get no replies Maragart it’s probably because there’s no one home to answer.

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