Tackling the over-diagnosis trend

A local doctor helps wind back the harms of too much medicine.

IT'S PRETTY EASY TO FEEL WORRIED about health care. Doctor shortages. Unvaccinated children. Fentanyl overdoses. Neglected seniors. Wait lists. Zika virus. The things that concern us about our health and medical care make for a long and overwhelming list. And the one-word response to the slow and sometimes inept nature of our health care system always seems to be “More.” We need: more doctors, more nurses, more vaccinations, more operating rooms, more long-term care, more overdose prevention medications, more funding, more, more, more.

At the same time, and out of the glare of marquee health headlines, there’s a growing movement that sees many major problems in health care in another light. This movement maintains that a lot of health care turmoil is due to medical excessiveness—particularly the overuse and inappropriate use of medical interventions. It warns that for people who are otherwise healthy, overdiagnosis and overtreatment are real and worrisome problems and despite some clear underserviced areas of the medical system, there is a need to wind back the harms of too much medicine. Currently, pockets of resistance are springing up around the world attempting to put the brakes on medical overuse, overdiagnosis, and overtreatment and there are even international conferences of resistors meeting to discuss what to do about this problem.

One of the resistors is Dr. Jessica Otte, a physician who took a small break from treating her mostly elderly patients in Nanaimo to go to Barcelona last month to present at the annual Preventing Overdiagnosis conference. She was one of over 400 researchers, health policy makers, clinicians and consumer activists who came together to discuss, debate and ultimately try to strategize ways to rein in the worst excesses of medicine.

Otte exudes enthusiasm and energy, the kind of articulate and thoughtful doctor you’d want at the bedside to help sort out your elderly grandmother’s medications. While she could have come to Barcelona to talk about what she does everyday—overcoming the challenges of reducing the medication burden of frail seniors, for example—this time she facilitated a workshop about the many organizations around the world that are working to prevent overdiagnosis and overtreatment. (In the interest of full disclosure, I was in Barcelona, too, working on a different campaign and Otte invited me to be part of her presentation, though I assure you, she did all the work.)

 
As I listened to her talk about the dozens of groups around the world tackling overdiagnosis, I looked out over a packed audience that included people from every country in Europe, Canada, the US, and even China. It struck me what a global concern this has become. Then something else dawned on me: The person who probably has the best grasp in the world on the global movement to prevent overdiagnosis lives in Nanaimo. Now, how cool is that? (See Dr Otte’s website www.lessismoremedicine.com.)

Among the many organizations and researchers tackling overdiagnosis, cancer screening is a particularly strong focus. This is due to the fact that although we once believed that early detection was key to fighting aggressive cancers, it hasn’t borne out. When you screen healthy populations for cancers you inevitably capture a large numbers of people with “pseudo disease.” Through an X-ray or blood test you may capture something—a shadow, a nodule or something else unusual—that will be labelled as cancer, but will never go on to hurt the person. Yet the very nature of the testing means you’ll turn that person into a patient, and treat them anyway, sometimes with disastrous consequences.

 
In Barcelona over three days there were whole workshops discussing just the overdiagnosis that comes with particular types of cancer screening. For example, one group of researchers from Korea, experts on thyroid cancer overdiagnosis, presented a study that showed when thyroid cancer screening took off in Korea in the early 1990s (because there was a new ultrasound test paid for by the government), the rate of thyroid cancers grew by 1500 percent over the next 20 years. The ultimate kicker: Despite the near “epidemic” rate of people in Korea being told they had thyroid cancer, the actual death rate remained unchanged over that nearly 20-year span. Which is to say, all the screening, treating and surgery on those unsuspecting Korean patients didn’t change one iota the number of Koreans who ultimately died of thyroid cancer.

 
This is one example, and there were oodles of them at this conference, of how putting a screening program under strong scientific scrutiny can reveal a motherlode of pseudo disease, the treatment of which causes untold suffering to no overall benefit.

Barcelona saw numerous workshops around the two most popular yet most overdiagnosed types of screening in Canada: Prostate cancer screening and mammographies for breast cancers. It’s clear that both those types of screening programs are undergoing a deep global rethink. Countries like France have pledged to “radically redesign” its mammography screening programs because of all the harms related to overdiagnosis. Just last month, the storied New England Journal of Medicine published a damning study of mammography which found that women were more likely to be overdiagnosed with breast cancer screening than to find a tumour that was going to go on to get large and possibly hurt them.

 
But perhaps the poster child for overdiagnosis is the PSA test, a blood test which is used as a screening test for prostate cancer. For over two decades, men have been told that, once they reach the age of 50, they should get a PSA test. A study last month in the New England Journal of Medicine showed how bad that advice is. It looked at a study of more than 1,600 men in the UK, aged 50 to 69, diagnosed with localized prostate cancer (via a “high” PSA or prostate specific antigen reading). Many things could affect a PSA reading, but once you get a high reading and are diagnosed with prostate cancer, you are advised to get surgery, have radiation, or just “do nothing” and wait and see what happens.

The researchers did a randomized trial. Dividing the men into three groups of roughly equal size, the first group were given radiation, the second had surgery, and the third were given “active monitoring,” which is to say the last group essentially had no treatment whatsoever. The trial followed these three groups of men for 10 years, and found that 99 percent of them were still alive, regardless of which path they were on. Those men who had surgery and radiation didn’t live any longer than those who avoided such treatment. And they didn’t live any healthier either, as some of those treated faced the adverse effects of the treatment. Sadly, there are thousands of men in Canada and several million in the US who have been made incontinent or impotent due to the overdiagnosis that comes with the last 20 years of PSA testing.

 
This is the real face of overdiagnosis and the problem is that most men may never be told that they are about to get a life-altering test. The conversation they needed didn’t happen.

 
Of course, there are few absolutes, and appropriate health care is really about having the right conversation. Otte spoke to me about the campaign she is most familiar with, the Choosing Wisely Canada campaign originally started to foster discussions between physicians and patients around unnecessary and harmful tests, treatments, and procedures. Doctors themselves recognize the problem, and one study in the US found that 75 percent of doctors report prescribing an unnecessary test or procedure at least once a week and about half the doctors surveyed said that patients are simply receiving too much medical care.

 
Otte tells me: “The broad idea is that more is not always better in health care; when someone is sick, they need help, but when they are healthy we should encourage them to stay that way and not try to turn them into patients.” She pauses to add, “If we would address overuse, harm, and waste in the medical system, we will have the resources to tackle areas of significant need, like treating poverty, food insecurity, and inactive lifestyles.”

I asked for another example of where she sees waste and overdiagnosis. Without a pause she points to a single recommendation: “Do not screen for thyroid function in a patient who doesn’t have any symptoms.” Why? “Well,” she says, “we often over-order that test and are surprised when the result is high or low. We label people with minor abnormalities as having a disease. Attaching labels and diagnoses to people is not always helpful, as for the rest of their life they can never feel truly healthy again.”

Jessica Otte, like many of her colleagues in Barcelona, recognizes that part of the problem with overdiagnosis is the strong motive of health care workers to do good, to not miss anything. But doing something can be more harmful than doing nothing beyond having an educating, reassuring discussion.

 
Alan Cassels is a Victoria author and pharmaceutical policy researcher. He has written four books on the medical screening and pharmaceutical industry including the latest, The Cochrane Collaboration: Medicine’s Best Kept Secret.