9-part series on over-diagnosis (short reads from a health care journalist)

Over-diagnosis happens when people are diagnosed with diseases or conditions that won’t actually harm them. 

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From the 3 October 2012 blog article by Gary Schwitzer at HealthNewsReview.org

Ray Moynihan, a terrific health care journalist who is now pursuing his PhD on overdiagnosis and working as a Senior Research Fellow at Bond University in Australia, kicks off the first of a nine-part series, “Over-diagnosis Epidemic” on TheConversation.edu.au website.

The first part is an introduction, “Preventing over-diagnosis:  how to stop harming the healthy.”

“To put it simply, over-diagnosis happens when people are diagnosed with diseases or conditions that won’t actually harm them. It happens because some screening programs can detect “cancers” that will never kill, because sophisticated diagnostic technologies pick up “abnormalities” that will remain benign, and because we are routinely widening the definitions of disease to include people with milder symptoms, and those at very low risk.”

Other colleagues author the subsequent parts in the series:

Part two: Over-diagnosis and breast cancer screening: a case study

“…But what we found was that the greatest relative reduction in breast cancer mortality (44%) occurred in the youngest age group. These women (aged 40 to 49 years) are not invited for screening. In contrast, women aged 60 to 69 years, who areinvited to screen, had the smallest relative reduction in mortality (19%).

Given that three times as many women aged 60 to 69 (about 60%) participated in Breastscreen (compared to 20% of women aged 40 to 49 years), our finding is not consistent with screening having a major impact on the reduction in breast cancer mortality since 1991.”…

Part three: The perils of pre-diseases: forgetfulness, mild cognitive impairment and pre-dementia

“…Most studies show that only one in ten cases of mild cognitive impairment progress to dementia each year, and many improve. One study that followed outcomes for ten years concluded – “The majority of subjects with MCI do not progress to dementia at the long term.”…

Part four: How genetic testing is swelling the ranks of the ‘worried well’

“..A major concern with such tests is that they’re the beginning of a path toward over-diagnosis, where the potential to develop a disease or being at risk for the disease is strong enough to constitute a label of sickness.

Over-diagnosing includes, but is not limited to, widening disease definitions, early detections of abnormalities that may or may not cause symptoms or death and the use of increasingly sensitive technologies that detect “abnormalities,” the causes and consequences of which are unknown at this time…”

Part five: PSA screening and prostate cancer over-diagnosis

Part six: Over-diagnosis: the view from inside primary care

“..The most common reason general practitioners are sued is because of missed diagnoses. Missed diagnoses also invoke a strong sense of professional failure. So how can general practitioners manage in this sea of uncertainty?

One way is to perform more tests. This is also popular with patients, who perceive that tests ensure nothing serious is missed. What is not well understood by patients (and sometimes also by clinicians) is the potential harm from testing.

The most obvious harm is the cost and resources required; we would quickly overwhelm the health system if we performed an MRI on every patient with back pain. A strong system of primary care results in a health-care system that’s both more efficient and less costly because primary-care physicians are skilled at filtering those with severe disease needing further tests, from those with self-limiting illnesses…

…

The greatest harm from the increased use of testing, however, is not costs, resources or false positives. Rather, it’s the problem of over-diagnosis.

Clinicians and patients both believe that finding a disease earlier in its process means it will be more successfully treated. But there’s increasing evidence that finding disease early or at a milder stage has paradoxical harmful effects, even reducing survival and quality of life.

Wider availability of more sophisticated tests results in “incidentalomas”, incidental findings that would not have otherwise been diagnosed. The detection of thyroid cancers, for instance, has more than doubled in the past 30 years. But most of these diagnoses are incidental findings from imaging…”

Part seven: Moving the diagnostic goalposts: medicalising ADHD

Part eight: The ethics of over-diagnosis: risk and responsibility in medicine

Part nine: Ending over-diagnosis: how to help without harming

 

 

Related articles

• #Preventing #over-diagnosis #good #healthy (leggotunglei808.wordpress.com)
• What good is a diagnosis? (wisecounsel.wordpress.com)
• Biopsies may misdiagnose eosinophilic esophagitis (yvonnebergeron.wordpress.com)

 

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BMJ special reports on overtreatment

From the 4 October 2012 blog item by Gary Schwitzer at HeatlthNewsReview.org

BMJ editor Fiona Godlee published an editor’s note, “Overtreatment, over here,” kicking off a discussion in her journal.   She begins:

“How much of what we offer to patients is unnecessary? Worse still, how much harm do we do to individuals and society through overtreatment? In the 30 years since Ivan Illich wrote his seminal and, at the time, shocking book Medical Nemesis, the idea that medicine can do clinical and societal harm as well as good has become commonplace. But are we doing enough to bring medicine’s harmful hubris under control?”

US journalist Jeanne Lenzer writes in that same edition, “Unnecessary care: are doctors in denial and is profit driven healthcare to blame?” A BMJ subscription is required for full access.

But you don’t need a subscription to watch a well-done BMJ video featuring Lenzer, colleague Shannon Brownlee, acting director of the New America Health Policy Program and author ofOvertreated: How Too Much Medicine is Making Us Sicker and Poorer, David Himmelstein, professor at the City University of New York School of Public Health, Vikas Saini, a Harvard cardiologist and president of the Lown Cardiovascular Research Foundation, and Patty Skolnik of CitizensForPatientSafety.org.

Related Resources

• Choosing Quality Care (Agency for HealthCare Quality and Research)
  including
  • Explore your treatment options
  • Questions are the answer (communication tips and advice)

 

 

 

Related articles

• Doctors speak out about unnecessary care as cost put at $800 billion a year (engineeringevil.com)
• The Agenda: Overtreatment Is Taking a Harmful Toll (well.blogs.nytimes.com)
• Letters: Overtreatment as Myth (2 Letters) (nytimes.com)
• Is Preventative Medicine Really Overtreatment? (jflahiff.wordpress.com)
• [Reblog] How hospitals recoup the cost of buying robotic surgery systems (& questions to ask surgeon before consenting to robotic surgery) (jflahiff.wordpress.com)

“What Doctors Don’t Tell You” magazine – reviewed in BMJ and Quackometer

From the blog item by Gary Schwitzer at HealthNewsReview.org

Dr. Margaret McCartney, who helped launch the PrivateHealthScreening.org site we wrote about yesterday, has a piece in the BMJ this week, “What a new consumer health magazine doesn’t tell you.”  (Subscription required for full access.) Excerpts:

“It looks just like any other magazine on the shelves of the newsagent aimed at middle aged women: glossy, 100 pages, with a smiling, confident looking woman on the cover. What Doctors Don’t Tell You, a monthly magazine that launched in September 2012, claims to explain how to “discover treatments that are safer and more effective.” …

In the October issue’s news section the article “Thyme is better for acne than creams” starts, “Thyme is more effective than prescription creams for treating acne . . .The herb outperformed pharmaceuticals in a series of laboratory tests, killing the actual bacteria that cause acne . . . Not only is thyme more effective, but it’s kinder on the skin too, say the researchers. Most pharmaceuticals cause a burning sensation and irritation to the skin, whereas thyme and other herbal preparations have none of these side effects.” The article references the Society for General Microbiology’s spring conference in Dublin this year. This research was reported through a press release; it was an in-vitro model; and the researchers did not compare side effects with current prescription creams.

Another article says, “Army personnel with noise deafness and tinnitus are commonly deficient in B12, but enjoy an improvement in symptoms after taking B12 vitamins.” The study referred to contained 12 patients receiving vitamin B12 and was not a randomised controlled trial.

The editorial on Gardasil, headed “Lock up your daughters,” warned that “your doctor and your daughter’s school nurse are not likely to tell you about the 100-plus American girls who suddenly died after receiving an HPV [human papillomavirus] vaccine.” Although there are valid concerns about the long term efficacy of HPV, to suggest that it has led to death is alarmist and does not reflect or explain the evidence collated by the Food and Drug Administration. Informed choice has to be about fair information, not scaremongering; we should hardly wish for a repeat of the measles, mumps, and rubella (MMR) vaccine debacle.

Although medical journals carry advertisements for drugs, the ones in this magazine are an extraordinary shrine to non-evidenced based medicine. …

It is right to criticise medicine, but the same standards must be applied to all interventions, “alternative” or not. We now realise how important it is to ensure that fair evidence, free of bias, is used in making medical decisions. There is no point in substituting bad medicine for bad science, and it is not clear from this magazine where the hierarchies of evidence stand, and the limitations and uncertainties that arise in research are not consistently explained. The magazine’s liability statement—“the publishers cannot accept any responsibility for any damage or harm caused by any treatment, advice or information contained in this publication”—should perhaps be better printed on the cover, in an unmissable font.”

She’s not the only one giving What Doctors Don’t Tell You a critical eye. The Quackometer blog refers to “Fifty Shades of Quackery.”

I’ll show you a screenshot from that blog that should be titillating enough to send you there to see more.

“It looks just like any other magazine on the shelves of the newsagent aimed at middle aged women: glossy, 100 pages, with a smiling, confident looking woman on the cover. What Doctors Don’t Tell You, a monthly magazine that launched in September 2012, claims to explain how to “discover treatments that are safer and more effective.” …

In the October issue’s news section the article “Thyme is better for acne than creams” starts, “Thyme is more effective than prescription creams for treating acne . . .The herb outperformed pharmaceuticals in a series of laboratory tests, killing the actual bacteria that cause acne . . . Not only is thyme more effective, but it’s kinder on the skin too, say the researchers. Most pharmaceuticals cause a burning sensation and irritation to the skin, whereas thyme and other herbal preparations have none of these side effects.” The article references the Society for General Microbiology’s spring conference in Dublin this year. This research was reported through a press release; it was an in-vitro model; and the researchers did not compare side effects with current prescription creams.

Another article says, “Army personnel with noise deafness and tinnitus are commonly deficient in B12, but enjoy an improvement in symptoms after taking B12 vitamins.” The study referred to contained 12 patients receiving vitamin B12 and was not a randomised controlled trial.

The editorial on Gardasil, headed “Lock up your daughters,” warned that “your doctor and your daughter’s school nurse are not likely to tell you about the 100-plus American girls who suddenly died after receiving an HPV [human papillomavirus] vaccine.” Although there are valid concerns about the long term efficacy of HPV, to suggest that it has led to death is alarmist and does not reflect or explain the evidence collated by the Food and Drug Administration. Informed choice has to be about fair information, not scaremongering; we should hardly wish for a repeat of the measles, mumps, and rubella (MMR) vaccine debacle.

Although medical journals carry advertisements for drugs, the ones in this magazine are an extraordinary shrine to non-evidenced based medicine. …

It is right to criticise medicine, but the same standards must be applied to all interventions, “alternative” or not. We now realise how important it is to ensure that fair evidence, free of bias, is used in making medical decisions. There is no point in substituting bad medicine for bad science, and it is not clear from this magazine where the hierarchies of evidence stand, and the limitations and uncertainties that arise in research are not consistently explained. The magazine’s liability statement—“the publishers cannot accept any responsibility for any damage or harm caused by any treatment, advice or information contained in this publication”—should perhaps be better printed on the cover, in an unmissable font.”

She’s not the only one giving What Doctors Don’t Tell You a critical eye. The Quackometer blog refers to “Fifty Shades of Quackery.”

Related Resource

• Patients want to understand the medical literature (with links to resources for patients)(jflahiff.wordpress.com)

• patientINFORM plain language summary Web sites are provided by participating publishers to help patients or their caregivers more fully understand the implications of research and to provide links to the full text of research articles they’ve selected from participating journals. The publishers allow readers following links from patientINFORM material on the health organizations’ sites to access the full text of these articles without a subscription, and they provide patients and caregivers with free or reduced-fee access to other articles in participating journals.
• “Summaries for Patients” are brief, non-technical summaries of studies and clinical guidelines published inAnnals of Internal Medicine. The Summaries aim to explain these published articles to people who are not health care providers.
• Consumer’s Guide to Taking Charge of Health Information (Harvard Center for Risk Analysis)
• How to Evaluate Health Information on the Internet (US National Cancer Institute)
• Quackwatch (a private corporation operated by Stephen Barrett, MD)

• …And a Rumor Control site of Note (in addition to Quackwatch)

   National Council Against Health Fraud National Council Against Health Fraud is a nonprofit health agency fousing on health misinformation, fruad, and quackery as public health problems. Links to publications, position papers and more.

Related articles

• What Doctor’s Don’t Tell You and the HPV Vaccine (jdc325.wordpress.com)
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