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Too much medicine harming patients, experts warn


Neelima Choahan 18/10/2018 4:03:29 PM

Overdiagnosis is a complex challenge that needs to be tackled at many levels.

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Professor Paul Glasziou says increasing numbers of patients are being over-diagnosed and treated for conditions that would never have caused them health problems in their lifetime.

Patients are being over-diagnosed and treated for conditions that would never have caused them health problems in their lifetime, experts warn.
 
GP Paul Glasziou, a Professor of Evidence-Based Medicine at Bond University, told newsGP the problem is especially prevalent in the case of over-detection of cancer.
 
‘Overdiagnosis is where you are labelled with having a condition that would never have caused you health problems in your lifetime,’ Professor Glasziou said.
 
‘Specifically with prostate cancer, breast cancer, thyroid cancer and renal cancer, all have significant over-detection rates that vary between 40% and a couple of 100% for thyroid cancer.
 
‘So only one out of three things diagnosed with thyroid cancer are real cancer in the sense that something that would have harmed a person in their lifetime.’
 
Professor Glasziou said thyroid cancer has increased more than three times in Australia over the last two decades, with that increase attributed to overdiagnosis. He said human beings have a large reservoir of dormant cancers that are not progressing, or would even regress and never become a malignant type of cancer that would harm a person.
 
But these are now being detected due to modern medicine practices.
 
However, the reasons behind the phenomenon are complex.
 
‘For prostate cancer it is because of the screening; PSA [prostate specific antigen test] largely has led to an overreaction of that reservoir of dormant cancers,’ Professor Glasziou said.
 
‘Thyroid cancer is trickier because there are number of pathways, but it includes people doing unnecessary ultrasounds for raised thyroid function test when there is no palpable nodule.
 
‘But if you have just got raised thyroid function … you shouldn’t ultrasound the thyroid. Because there is a chance that you will pick up a small nodule that you couldn’t feel, which then has to be investigated.
 
‘It is those that are turning out to be these tiny benign so-called cancers which don’t harm people.’
 
Professor Glasziou said improvement in technology and the belief that ‘earlier is always better’ are some of the other reasons for the increase.
 
‘Earlier is not necessarily better. In fact, most times it is not,’ he said.
 
‘Prior to the 1950s, where hypertension became a thing that you should detect, there was little in the way of screening.
 
‘But in the last 50 years we have gradually ramped up the idea that screening is a good thing to do. Mostly, it is not, and we are now reaping the harm of it, which is the overdiagnosis.’
 
He said other forms of overdiagnosis are to do with the changes in the definitions, including psychiatric conditions, which means an expansion in the numbers of those diagnosed.
 
Professor Glasziou believes GPs need to familiarise themselves with the RACGP’s Red Book, which spells out the conditions that should be screened.
 
The RACGP also has a position statement on Too Much Medicine supporting optimal medicine in which the benefits of tests and treatments are carefully weighed against their harms to prevent injury and wastage.
 
Earlier this week, an Australian alliance of consumer, clinical, research and public organisations, wrote in The Medical Journal of Australia about a national action plan to prevent overdiagnosis and overtreatment in Australia.
 
Being formulated under the Wiser Healthcare research collaboration, the plan will investigate concerns about cancer, cardiovascular disease and musculoskeletal disorders, with a particular focus on overdiagnosis caused by imaging.
 
Researchers wrote that reversing the harm of too much medicine is becoming a healthcare priority, with the problem described as a ‘modern epidemic’ in the US.
 
Cultural beliefs that more tests and treatments are better, financial incentives at the health-system level, and public expectations that clinicians will ‘do something’ are some of the reasons behind the growth, according to the researchers.
 
They said evidence-based public awareness campaigns, reformed system incentives to reward quality rather than quantity, better management of the problem of expanding disease definitions, and better evaluation of the accuracy and utility of diagnostic tests are some of the steps needed to tackle the issue.
 
Professor Glasziou said although overdiagnosis cannot be eliminated, it can be reduced.
 
However, there is no single solution.
 
‘There is a spectrum of gates you use in order to reduce this problem,’ he said.
 
‘You need to think at the systems level, at the clinical level and at the patient level … getting patients involved in understanding earlier is not necessarily better.’
 
Part of the problem is described as ‘defensive medicine’.
 
‘I think we just need to be more parsimonious in the way that we test, using a process of slower diagnosis and not necessarily doing all the tests that we can think of, but being more selective and thoughtful in the testing process,’ he said.
 
‘And not being so defensive … meaning that we don’t want to miss anything.
 
‘This is difficult for GPs to do. It is difficult, in fact, for any clinician to do. I think something needs to change in the way that we train people. Because we need to train them in how to be more selective in their testing processes.’


THE AUTHOR:


overdiagnosispsa testingtoo much medicine

Eugene
I think more clinical vignettes to serve as examples of what is being recommended would be quite useful in this area
20/10/2018 1:26:24 AM

Chris D Hogan
Over diagnosis or rather over investigation is indeed a real issue. This is not only because of the detection of inert disease but also of the detection of false positive results.
I have been involved as an advisor on a Gastroenterological Society of Australia - GESA- project on the definite diagnosis & successful treatment of Irritable Bowel Syndrome. This has resulted in a web based algorithm that can be found at IBS4GPS.com. This lists a variety of tests which are not only expensive & unhelpful but some also tests that are invasive & not without risk
19/10/2018 6:57:28 PM

Emma
Likewise, under-diagnosis and failure-to-diagnose is a real risk to human health. For example, BreastScreen. With the exception of WA, women who are screened through BreastScreen are not informed by BreastScreen if their breasts are dense. Having dense breasts increases the risk of developing breast cancer and hinders the identification of a cancer in dense tissue. It is an open secret that a sizeable number of breast cancer patients have suffered delayed diagnoses via BreastScreen because of this.

GPs are best-placed to explore/enquire about a woman's breast density. In jurisdictions, such as WA, that require reporting of breast density, women with dense breasts are encouraged to consider further testing such as 3D mammogram and US. Many GPs do not take this initiative with or on behalf of their patients.
19/10/2018 2:02:27 PM

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