Curbing Overdiagnosis

The recent release of the U.S. Preventive Services Task Force (USPSTF) recommendations on prostate specific-antigen (PSA) screening, anticipated as they may have been, necessitated prolonged visits with concerned men demanding explanations for why it was no longer recommended regardless of age.

Discussions about “turning off” screening are frequently more challenging than ones explaining why screening should not be “turned on” at all. But for some of us who continue to screen informed and requesting men, we will be haunted by the imperfection of the PSA as a screening modality. We cannot escape our inability to distinguish between indolent and aggressive prostate cancer with the PSA.

Ray Moynihan of Bond University in Australia and colleagues recently explored the causes and possible solutions to the “overdiagnosis” and “medicalization” of healthy individuals (BMJ. 2012;344:e3502. PubMed PMID: 22645185). At stake is potentially more than $200 billion U.S. dollars spent on unnecessary treatment for early cancers and other diseases based on broader diagnostic criteria that capture low-risk individuals. Also at risk is the health of the healthy.

Technology is a double-edged sword. Sensitive testing modalities detect cancers that may regress, remain indolent, or grow so slowly as to not cause problems if left untreated. The ever increasing use of imaging spurs the detection of incidental findings in up to 40% of patients, who then require additional testing for issues that most often turn out to be benign.

Labeling otherwise mild clinical problems as a “dysfunction” (e.g., sexual dysfunction) increases medication use and the possibility of adverse effects. Mr. Moynihan and colleagues provide a provocative “hit list” of conditions for which sensitive screening and expanding disease definitions result in overdiagnosis and overtreatment. The list includes: 1) asthma; 2) attention deficit hyperactivity disorder; 3) breast cancer; 4) chronic kidney disease; 5) gestational diabetes; 6) hypertension; 7) hyperlipidemia; 8) osteoporosis; 9) prostate cancer; 10) pulmonary embolism; and 11) thyroid cancer.

Combating the overdiagnosis and overtreatment trends will require a cultural shift. Enabled by medical technology, many medical practitioners strongly believe that early detection is beneficial for their patients. Medical advancement is increasingly driven by the question “can we?” instead of the more important question “should we?” But when we can, we sometimes cause harm when we do.

Awareness about the need to address unnecessary care is growing. The “Choosing Wisely” campaign attempts to decrease unnecessary testing and treatments. In September 2013, an international scientific conference called “Preventing Overdiagnosis” will attempt to advance our understanding of how this issue. The conference will be hosted by Dartmouth, BMJ, Consumer Reports, and Bond University. Perhaps we will see you there.

Jon O. Ebbert, M.D., is a professor of medicine and a primary care clinician at the Mayo Clinic in Rochester, Minn. He declares having no conflicts of interest. The opinions expressed are solely those of the author. Contact him at ebbert.jon@mayo.edu.

The recent release of the U.S. Preventive Services Task Force (USPSTF) recommendations on prostate specific-antigen (PSA) screening, anticipated as they may have been, necessitated prolonged visits with concerned men demanding explanations for why it was no longer recommended regardless of age.

Discussions about “turning off” screening are frequently more challenging than ones explaining why screening should not be “turned on” at all. But for some of us who continue to screen informed and requesting men, we will be haunted by the imperfection of the PSA as a screening modality. We cannot escape our inability to distinguish between indolent and aggressive prostate cancer with the PSA.

Ray Moynihan of Bond University in Australia and colleagues recently explored the causes and possible solutions to the “overdiagnosis” and “medicalization” of healthy individuals (BMJ. 2012;344:e3502. PubMed PMID: 22645185). At stake is potentially more than $200 billion U.S. dollars spent on unnecessary treatment for early cancers and other diseases based on broader diagnostic criteria that capture low-risk individuals. Also at risk is the health of the healthy.

Technology is a double-edged sword. Sensitive testing modalities detect cancers that may regress, remain indolent, or grow so slowly as to not cause problems if left untreated. The ever increasing use of imaging spurs the detection of incidental findings in up to 40% of patients, who then require additional testing for issues that most often turn out to be benign.

Labeling otherwise mild clinical problems as a “dysfunction” (e.g., sexual dysfunction) increases medication use and the possibility of adverse effects. Mr. Moynihan and colleagues provide a provocative “hit list” of conditions for which sensitive screening and expanding disease definitions result in overdiagnosis and overtreatment. The list includes: 1) asthma; 2) attention deficit hyperactivity disorder; 3) breast cancer; 4) chronic kidney disease; 5) gestational diabetes; 6) hypertension; 7) hyperlipidemia; 8) osteoporosis; 9) prostate cancer; 10) pulmonary embolism; and 11) thyroid cancer.

Combating the overdiagnosis and overtreatment trends will require a cultural shift. Enabled by medical technology, many medical practitioners strongly believe that early detection is beneficial for their patients. Medical advancement is increasingly driven by the question “can we?” instead of the more important question “should we?” But when we can, we sometimes cause harm when we do.

Awareness about the need to address unnecessary care is growing. The “Choosing Wisely” campaign attempts to decrease unnecessary testing and treatments. In September 2013, an international scientific conference called “Preventing Overdiagnosis” will attempt to advance our understanding of how this issue. The conference will be hosted by Dartmouth, BMJ, Consumer Reports, and Bond University. Perhaps we will see you there.

Jon O. Ebbert, M.D., is a professor of medicine and a primary care clinician at the Mayo Clinic in Rochester, Minn. He declares having no conflicts of interest. The opinions expressed are solely those of the author. Contact him at ebbert.jon@mayo.edu.

The recent release of the U.S. Preventive Services Task Force (USPSTF) recommendations on prostate specific-antigen (PSA) screening, anticipated as they may have been, necessitated prolonged visits with concerned men demanding explanations for why it was no longer recommended regardless of age.

Discussions about “turning off” screening are frequently more challenging than ones explaining why screening should not be “turned on” at all. But for some of us who continue to screen informed and requesting men, we will be haunted by the imperfection of the PSA as a screening modality. We cannot escape our inability to distinguish between indolent and aggressive prostate cancer with the PSA.

Ray Moynihan of Bond University in Australia and colleagues recently explored the causes and possible solutions to the “overdiagnosis” and “medicalization” of healthy individuals (BMJ. 2012;344:e3502. PubMed PMID: 22645185). At stake is potentially more than $200 billion U.S. dollars spent on unnecessary treatment for early cancers and other diseases based on broader diagnostic criteria that capture low-risk individuals. Also at risk is the health of the healthy.

Technology is a double-edged sword. Sensitive testing modalities detect cancers that may regress, remain indolent, or grow so slowly as to not cause problems if left untreated. The ever increasing use of imaging spurs the detection of incidental findings in up to 40% of patients, who then require additional testing for issues that most often turn out to be benign.

Labeling otherwise mild clinical problems as a “dysfunction” (e.g., sexual dysfunction) increases medication use and the possibility of adverse effects. Mr. Moynihan and colleagues provide a provocative “hit list” of conditions for which sensitive screening and expanding disease definitions result in overdiagnosis and overtreatment. The list includes: 1) asthma; 2) attention deficit hyperactivity disorder; 3) breast cancer; 4) chronic kidney disease; 5) gestational diabetes; 6) hypertension; 7) hyperlipidemia; 8) osteoporosis; 9) prostate cancer; 10) pulmonary embolism; and 11) thyroid cancer.

Combating the overdiagnosis and overtreatment trends will require a cultural shift. Enabled by medical technology, many medical practitioners strongly believe that early detection is beneficial for their patients. Medical advancement is increasingly driven by the question “can we?” instead of the more important question “should we?” But when we can, we sometimes cause harm when we do.

Awareness about the need to address unnecessary care is growing. The “Choosing Wisely” campaign attempts to decrease unnecessary testing and treatments. In September 2013, an international scientific conference called “Preventing Overdiagnosis” will attempt to advance our understanding of how this issue. The conference will be hosted by Dartmouth, BMJ, Consumer Reports, and Bond University. Perhaps we will see you there.

Jon O. Ebbert, M.D., is a professor of medicine and a primary care clinician at the Mayo Clinic in Rochester, Minn. He declares having no conflicts of interest. The opinions expressed are solely those of the author. Contact him at ebbert.jon@mayo.edu.