While cures for deadly diseases can be attributed to advances in technology, the flip side is that we can now detect abnormalities or anomalies that may ultimately do no harm. What’s more, changing disease definitions and expanded screening are creating a sense of anxiety among people who are not necessarily unwell.
The Conversation recently ran an eight-part series examining the drivers of over-diagnosis, as well as its results, bringing to light and hopefully starting a discussion on this “modern epidemic”.
Ray Moynihan, Senior Research Fellow at Bond University kicked the series off with an article on the growing phenomenon of over-diagnosis, explaining why people are being unnecessarily treated for illnesses that may never harm them:
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.
Read the full story here.
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Monash University’s Robin Bell, Professor and Deputy Director of the Women’s Health Program and Robert Burton, Professor in the School of Public Health and Preventative Medicine evaluated the role of population-wide screening on breast cancer over-diagnosis:
Since the national screening mammography program (Breastscreen) began in Australia in 1991, mortality from breast cancer has declined by 28%. We wanted to know how much of this improvement was due to Breastscreen and how much was due to advances in breast cancer treatment.
This is an important question to ask in light of the recent passionate debate about the benefits and harms of mammographic screening in medical literature as well as in the lay press. We published an analysis that addressed this issue using three different approaches.
Read the full story here.
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David Le Couteur, Professor of Medicine at the University of Sydney, discussed the recent changes in the definition of dementia, and the possibility of over-diagnosing dementia-related diseases:
The pattern of over-diagnosis is the same for many diseases: we screen healthy people and those with minimal symptoms; we use sophisticated technologies that detect early or minor abnormalities that may not progress; and we treat people with these abnormalities on the assumption that this will prevent significant illness and death.
The downside of all this medical intervention is that we’re exposing healthy people to the potential harms of diagnosis, investigation and treatment without any certainty about long-term benefits. Indeed, there’s a growing unease that this trend is being driven by the financial benefits of creating a larger market for drugs rather than genuine health gains.
Read the full story here.
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Jacqueline Savard, PhD Candidate at the University of Sydney, looked at the increase of genetic testing and how it creates a group of “the worried well”:
Genetic testing and screening is increasingly becoming a presence in our lives. Daily news reports discuss new associations between genes and common conditions. And these associations are used to calculate risks for individuals who have the genes for the conditions, but don’t display any symptoms.
In essence, these people become the “worried well”, a group of people not yet ill, but at risk of developing diseases.
Read the full story here.
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Robert Burton and Mark Frydenberg from Monash University teamed up with Christopher Stevenson from Deakin University to discuss the role of prostate cancer screening in the over-diagnosis dilemma:
Scientific oncology started with the creation of the modern microscope, which provided the basis for the modern pathologic study of cancer in the late 19th century, and established the “fatal cancer” myth. As one researcher arguing against breast cancer screening put it, “since then, without pause for thought, the microscopic identification of cancer according to the classic criteria has been associated with the assumed prognosis of a fatal disease if left untreated.”
Read the full story here.
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Jenny Doust, Professor of Clinical Epidemiology at Bond University gave a view from inside primary care:
It’s easy to dismiss general practice as being about minor illnesses requiring little clinical acumen. We see patients with the common symptoms of life – coughs, fevers, backache and abdominal pain. Most of these are transitory and, for the large proportion, medical intervention makes little difference.
The diagnostic skills of a general practitioner, however, need to be as acute as those of House MD. Among all the children we general practitioners see with diarrhoea, we need to be able to pick the one with Crohn’s disease requiring urgent surgery. Among all the women who complain of feeling tired, we need to isolate the one who has life-threatening Addison’s disease. And among all the teenagers with flu-like symptoms, we need to find the one with a lymphoma in his chest.
Read the full story here.
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Rae Thomas, Research Fellow at Bond University, looked at how changing definitions of mental ill health impact over-diagnosis, looking closely at the diagnostic goalposts of ADHD:
Does your five-year-old have difficulty sustaining attention? What about organising tasks or waiting her turn? How was she as a four-year-old? These are three of the 18 criteria (here’s the whole lot) used to differentiate children with attention deficit hyperactivity disorder (ADHD).
There are other questions, such as how often does your child do this? Does it impact him socially or academically? Who is reporting such behaviour? These are critical diagnostic questions that can differentiate problematic and normal behaviour. But they’re not always asked.
Read the full story here.
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The over-diagnosis epidemic from a philosophic and ethical point of view by Stacy M. Carter, NHMRC Career Development Fellow at the University of Sydney. She questioned the risks and responsibilities of both health practitioners and patients in diagnostic testing:
Recently a friend told me a story about her dad. Fit and well, he had a PSA test during a general medical check-up. The PSA test is controversial: many, including its inventor, say it should never be used to screen for cancer.
My friend’s dad’s PSA test started him on a path to prostate cancer diagnosis and surgery. The surgery made him incontinent. Humiliated by accidents, he couldn’t be far from a toilet so could no longer coach soccer or go on his daily long walk with friends. He became socially isolated and sedentary. He put on weight. And he developed diabetes.
Read the full story here.
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The series concluded with Paul Glasziou, Professor of Medicine at Bond University, giving an overview on the over-diagnosis issue, and suggesting ways we can address the epidemic:
Over-diagnosis is a significant problem that’s already common in some areas of medicine, such as screening and some mental health conditions. It is a problem now but a bigger threat for the future: better imaging technologies, more biomarkers, more genetic tests and so on, will gradually expand the amount of over-diagnosis that’s possible.
There are several drivers for over-diagnosis. Of course there’s screening and new screening methods, but there are also areas that are not technology-driven. For instance, the diagnostic criteria in psychiatry where the changing definitions of mental illnesses have expanded the number of children and adults classed as having a mental illness.
Read the full story here.
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A reminder to Croakey readers that TC articles are freely available for republishing under a Creative Commons license.
