BMJ  2003;327 (16 August), doi:10.1136/bmj.327.7411.0-g

Editor's choice

Showing discrimination

A best selling treatment proves not to be so wonderful after all—and the recriminations start. The Lancet has just published a study showing that use of combined hormone replacement therapy doubles the risk of breast cancer (p 359), while the New England Journal of Medicine reports more results of the Women's Health Initiative trial that was stopped last year (p 359): it shows that HRT does not, as once thought, protect against heart disease.

On p 400 Jocalyn Clark describes how, when the Women's Health Initiative study was halted last year, one pharmaceutical company's public relations operation went into overdrive to reduce the effect of such adverse news. But the "spin" had started much earlier. Clark describes how Forever Feminine, an influential book extolling the virtues of HRT as a fountain of youth and published in the 1960s, had been secretly funded by the manufacturer of HRT. In the meantime, the voices who maintain that HRT is still useful for treating menopausal symptoms inevitably sound faint—because the drug has been presented as much more than that. It reminds me of benoxaprofen, another drug that died partly because it was overhyped. Pharmaceutical companies may think that there is no such thing as overmarketing, but HRT may make them think again—that marketing has risks as well as benefits and needs as much discrimination as any other aspect of their activities.

Surgeons who make innovations know that they are doing something risky. Kurt Semm, who died last month, performed the world's first laparoscopic appendectomy in Kiel (p 397). When he described this operation at a surgical meeting the president of the German Surgical Society called for his suspension: performing surgery without being able to see the whole operation site was considered experimental and unethical, and Semm's colleagues were sceptical. Yet Semm persisted, and laparoscopic surgery spread, helped by his establishment of several standard operations, his books, and his insistence on good training.

Meanwhile, in the search for discrimination, this issue has several offerings, not all of them positive. On p 375 Dallas English and colleagues show that the use of an algorithm and instant camera did not improve general practitioners' ability to distinguish malignant melanomas from benign lesions. The ratio of benign lesions to melanomas they excised was no less than that of colleagues who did not use the algorithm. Similarly, Mari Lloyd-Williams and colleagues found that simply asking British patients in palliative care "Are you depressed?" did not discriminate well. This contrasts with American patients, where the question had "perfect sensitivity and specificity and 100% positive predictive value." In the British study it correctly identified only about half the depressed patients and three quarters of the non-depressed. On a more positive note, however, Daniel Hind and colleagues' meta-analysis shows that two dimensional ultrasound helps clinicians accurately place central venous lines (p 361).

(jsmith{at}bmj.com)

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