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Overdiagnosis: Bad for You, Good for Business

SPH Bicknell lecturer says too much treatment makes people sick

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After the criteria used to define osteoporosis were expanded in 2003, seven million American women were turned into patients virtually overnight. Diagnoses of high blood pressure, diabetes, and cancer also have skyrocketed over the past few decades—yet the number of deaths from those diseases has been largely unaffected.

While conventional wisdom holds that early diagnosis is good, H. Gilbert Welch, a professor of medicine and director of the Center for Medicine and the Media at the Dartmouth Institute for Health Policy and Clinical Practice, views it as a major problem for modern medicine, with myriad social, medical, and economic implications. In his new book, Overdiagnosed: Making People Sick in the Pursuit of Health (Beacon Press, 2011), Welch and coauthors Lisa Schwartz and Steven Woloshin write about the hazards of looking too hard for illnesses in healthy people, including additional procedures that carry no benefit, but may cause harm, higher health care costs, and psychological detriments.

Welch will elaborate on the downside of the growing penchant for early diagnosis this Friday, October 28, when he delivers the 2011 William J. Bicknell Lectureship in Public Health at the BU School of Public Health. He has been a practicing physician for 25 years, during which time he has posed some hard questions about his own profession.

Welch’s talk, titled Making People Sick in the Pursuit of Health, comes just weeks after a government panel recommended that healthy men should no longer have a standard PSA blood test to screen for prostate cancer, because the test does not save lives overall and often leads to treatments that needlessly cause pain, impotence, and incontinence in many.

“The biggest problem is that overdiagnosis triggers overtreatment, and all of our treatments carry some harm,” says Welch.

In a study published this week in the Archives of Internal Medicine, Welch and Dartmouth researcher Brittney A. Frankel concluded that most women with mammogram-detected breast cancer had not “had their lives saved” by screening. While Welch noted that some women clearly are helped by mammography screening, their analysis found that the lifesaving value of the test was questionable. Among the 60 percent of women with breast cancer whose disease was detected by screening, only about 3 percent to 13 percent were actually helped by the test, according to the study.

The Bicknell lecture is followed by a panel discussion with Deborah Bowen, an SPH professor and chair of the department of community health sciences; John Fallon, senior vice president and chief physician executive of Blue Cross Blue Shield of Massachusetts; and Kenneth W. Lin, a Georgetown University School of Medicine assistant professor of clinical family medicine.

BU Today recently spoke with Welch about the medical practices that give him pause.

BU Today: What is overdiagnosis?

Welch: Let me start by saying I’m a conventionally trained physician. I teach, do research, and see patients. I believe American medicine can be very beneficial for sick patients. My concern is about what we are doing to people who are well.

Overdiagnosis occurs when we doctors make diagnoses in individuals who are not destined to ever develop symptoms—or die—from the condition diagnosed. It’s a side effect of our relentless desire to find disease early through annual checkups and screening.

What’s the problem with wanting to know if there’s a cancer or disease lurking in our bodies?

The problem is, we all harbor abnormalities, and our tests are increasingly able to find them, yet most of these abnormalities will not go on to cause disease. But because clinicians don’t know which will and which will not, we tend to treat everybody. That means we are treating those who cannot benefit because there’s nothing to fix, and these people can be harmed.

What’s the harm?

Well, simply being given a needless diagnosis can adversely affect your health. The truth is that health is more than a physical state of being; it’s also a state of mind. It’s hard to feel well when we doctors are constantly saying something is wrong.

But the biggest problem is that overdiagnosis triggers overtreatment, and all of our treatments carry some harm. These range from the headaches of renewing prescriptions and scheduling appointments and keeping them to the physical harms of drug side effects, surgical complications, and even death.

Can you give an example of testing that leads to overdiagnosis and overtreatment?

The poster child for the problem is prostate cancer screening: 20 years ago, a “simple blood test” was introduced; 20 years later, over one million Americans had been treated for a cancer that was never going to bother them. The test was the PSA. It’s able to detect minute quantities of prostate-specific antigen—minute as in one-billionth of a gram. Turned out a lot of men had “abnormal” PSAs. Many were found to have microscopic cancers—far more than would ever suffer from prostate cancer. So they were overdiagnosed.

Does it matter? Absolutely. Most were treated with either radical surgery or radiation. Roughly a third suffered side effects of treatment—generally related to bowel, bladder, or sexual function. And a few have died from it.

You’ve talked about health conditions defined by numbers, or benchmarks—like high blood pressure, high cholesterol, diabetes, and osteoporosis—numbers that distinguish between who’s healthy and who’s sick. Aren’t those numbers based on sound science?

Yes—and no. Yes, in that we know these conditions can be important and that treatment can help—i.e., treating really high blood pressure is one of the most important things we doctors do. But no, in that the “rule” by which health conditions are gauged—the number which, if you are on one side of it, you are well, but if you are on the other side of it, you are sick—has been regularly changing. For example, a fasting blood sugar of 130 was not considered to be diabetes before 1997, but now it is. And these numbers are always changing in one direction: the direction of labeling more and more people as abnormal.

The problem is that these newly created patients stand to benefit the least from intervention. Yet they face roughly the same amount of harm from intervention. In other words, the net effect of intervention may be harm. For example, as we recently learned in diabetes, while trying to move people with mildly elevated blood sugars towards “normal,” the death rate increased.

The generic problem is one of balance. Doctors tend to focus on those we might conceivably help, even if it’s only one out of 100 (the benefit of lowering cholesterol in those with normal cholesterol but elevated C-reactive protein) or one out of 1,000 (the benefit of breast and prostate cancer screening).

We believe this is what our patients, and the public, care about. But it’s time for everyone to start caring about what happens to the other 999.

Who benefits from overdiagnosis?

A lot of people: pharma, device manufacturers, imaging centers, and even your local hospital. The easiest way to make money isn’t to build a better drug or device—it’s to expand the market for existing drugs and devices by expanding the indication to include more patients. Similarly, for hospitals, the easiest way to make money isn’t to deliver better care; it’s to recruit new patients—and screening is a great way to do this.

Why has there been so much emphasis on screening? Do you think it’s been driven by what the public wants—early warnings—or what the medical profession has imposed?

The simplest explanation is that the medical and public health communities have systematically exaggerated the benefits of early detection and downplayed (or ignored entirely) its harms.

There is a complex web of root causes. Some of it is about money; some of it is about true belief. And my colleagues would want me to point out the legal asymmetry doctors face: while we are punished for underdiagnosis, we are never punished for overdiagnosis.

Finally, there is the particularly misleading influence of survivor stories. I hate to say this, but the truth is that most screen-detected breast and prostate cancer “survivors” are, in fact, more likely to have been overdiagnosed than truly helped by early detection. Ironically, the more overdiagnosis a screening test causes, the more people who feel they “owe their life to the test,” the more likely the rest of us are to have heard their stories—and the more popular screening becomes.

Would you advise patients who are offered testing for various conditions, based on family history or other indicators, to refuse the tests?

No. Instead, I want them to understand that there are real choices here. The decision about whether or not to look for something to be wrong is not a “no-brainer.” They should understand the two sides to early detection: while it may help you, it may also hurt you.

The 2011 William J. Bicknell Lectureship in Public Health is this Friday, October 28, from 9 a.m. to noon, on the BU Medical Campus, at 670 Albany St., first floor auditorium. The event is free and open to the public and is preceded by a continental breakfast at 8:30 a.m. The William J. Bicknell Lectureship in Public Health at the School of Public Health is named in honor of William J. Bicknell, SPH chair emeritus and a professor of international health and a School of Medicine professor of sociomedical sciences and community medicine.

Lisa Chedekel can be reached at chedekel@bu.edu.

13 Comments

13 Comments on Overdiagnosis: Bad for You, Good for Business

  • LEE SMITH on 10.26.2011 at 8:10 am

    Each of us needs the data and the information and the ability to get multiple opinions to chose what course to follow. This often begins with screening which we dare not ignore since underdiagnosis (e.g. metasticizing prostate cancer) is at least as bad as overdiagnosis. This is too important a decision, and too controversial, to leave to MDs, ALL OF WHOM have their own agendas — be it fortune and/or fame and/or improving the world. Take PSA testing — USPSTF has a piece of the truth, but so clearly does the American Urological Association and each of us needs to synthesize the opinions and the data these groups present.

  • Nathan on 10.26.2011 at 10:05 am

    So the solution is …. ? In 1991 or 1992, I read up on Prostate Cancer, one of the newer entries in the disease of the month club, and quickly determined that the treatment was worse than the disease for most men. This has remained the conventional wisdom from the science side of medicine for 20 years. New generations of politicians, hospital administrators and GP physicians have entered the workplace amd NOTHING HAS CHANGED. While professor Welch has diagnised the problem, the closest he comes to a solution is to suggest medical consumers be skeptical of the actions of the entire medical community. Can we do better? Should Medicare and Medicaid stop funding these actions (influencing insurance carriers to follow suit)?

  • Jenna on 10.26.2011 at 12:46 pm

    I would love to know who specifically came up with this data. From personal experience I don’t think doctor are diagnosing enough. Doctors are stupid when they do not know what the patient is suffering from. So they either tell the patient its all in his or her head (which I believe causes more harm than good because the patient ends up more frustrated) or the doctor makes up something. People aren’t dying as a result of increasing diagnosing because we now have a pill to fix everything which prolongs death. If someone has high blood pressure that should be a signal for the doctor to tell the patient so the patient can make necessary adjustments.

    Personally I think this was funded by the government and insurance agencies so they don’t have to pay for extra things. I bet any amount of money politicians and CEO’s of the insurance companies get regular check ups.

  • Patrick on 10.26.2011 at 2:18 pm

    Jenna, you would do well to educate yourself on the issue at hand before commenting. While a certain amount of governmental distrust can be healthy, and anecdotal evidence is compelling, you should not base your conclusion around either. Your comment makes it appear that you did not read the article. For one, there is a link to the study in the introduction. I cannot examine it right now, but I am sure you will find the answer to your question about who specifically came up with the data within.

    The point of the article is that, yes, people are in fact experiencing adverse health effects by treating conditions that will hurt the patient less than the treatment. The example given for this is prostate cancer. When finding microscopic cancers that may not cause harm, doctors will prescribe chemotherapy and radiation, just to be safe. This wouldn’t be an issue if we actually had the magic pill that you alluded to, but modern medicine isn’t there yet. (I’m not sure if you were referring to something specific, clarification on that point would be nice.) Unfortunately, it is an issue, as the treatment for cancer is essentially poison. It’s a necessary evil if your life is in danger, but if you are healthy, then it is an undue burden on yourself and your family.

    Your anecdote about the condition that mystefies doctors even serves to illustrate this point. What happens if the doctor is too proud to admit he has no idea what’s wrong? He makes something up. This condition (that you don’t actually have) is accompanied by a treatment, which will have side effects. He is causing more harm by overdiagnosing whatever he says the issue is.

    The idea that this is a government study designed to have the insurance companies save money is an insult to the scientific community. Double-blind studies are done for a reason. But the governament is not in the pockets of the insurance companies, whatever the tweets ending in #OWS say. The real isse is the prescription drug lobby, which not only affects the government, but goes right down to your local doctor, who receives greater rewards for each person he diagnoses and prescribes. Wouldn’t that contribute to overdiagnosis? The power of the insurance companies is infetesimal compared to the power of the drug companies.

    • LEE SMITH on 10.26.2011 at 4:06 pm

      Patrick: consider two horrible situations; 1. Based on a troubling PSA reading Mr. A. jumps into a radical prostatectomy, gets terrible side effects (maybe even death) and guess what — no cancer is found in his prostate so it was a false alarm. 2. Based on the USPSTF recommendations, Mr. B avoids PSA screening, develops metasticizing incurable prostate cancer, it spreads to his bones and body and he has a horrible life fighting and finally dying from a prostate cancer that could have been detected before it metasticized had he undergone and followed up upon routine PSA screening. Fortunately modern urological practices (which were not included in the recent screening studies — studies which were uncontrolled and contaminated) help men to avoid these two horrible extremes and seek a middle road, where PSA testing is followed up when appropriate by biopsies, where pathology results are used to get an estimate of likely outcomes, where several medical opinions are sought, where active surveillance can occur, etc etc. If you want to learn about prostate cancer who would you consult — mass statisticians using flawed outdated surveys who treat you like and average number, or urologists and oncologists who have experience with hundreds of cases and a command of data specifically related to the disease being evaluated. Imagine, no urologists or oncologists were even on the USPSTF — do you really want this committee to decide your future?

      • Patrick on 10.26.2011 at 10:55 pm

        Excellent points Lee. I want to make it clear that when it comes to cancer, I would like as much information as possible. I was merely summarizing the viewpoint presented in the article, as it appeared that the poster above me read the headline, skimmed the introduction paragraph, and then posted a comment.

    • Jenna on 10.27.2011 at 8:04 am

      Patrick, just to let you know I have an undergraduate degree in Chemistry and working on a dual masters in chemistry and biomedical engineering. I have done research in neuroscience and orthopaedics, and currently pulmonology. I have a rare condition, allergy to exercise. When the doctors failed to diagnose me and could not understand why I was not responding to asthma medication. Took me years to diagnose myself. Also I know many people who suffer from back pain. Doctors have often told my friends “must be in their head”. Many doctors today are idiots and without compassion. In medicine being too proud to admit you don’t know is a TERRIBLE TRAIT. And FYI if the doctors told me I had microscopic pieces of cancer I would change my lifestyle. I would eat healthier, exercise more, ect. It would be a wake up call for the patient to change.

      • Aaron L'Heureux on 10.31.2011 at 9:57 am

        Exercise urticaria? I’d never heard of that before and am curious if this is what you’re talking about.

  • Alan D. Cato MD on 10.27.2011 at 12:53 pm

    All physicians were taught in medical school that testing should
    be ordered only for confirming a condition or diagnosis—that the
    physician’s clinical history and exam has already led him to be
    reasonably certain exists. Use of testing in any other manner is simply
    screening for the condition. Unlike diagnosing, screening for a
    condition is always expensive and can result in false-positive findings
    and unexpected abnormalities, of undetermined significance, that then
    need to be explained to the patient’s satisfaction, and, thus, leads to
    further testing for doing so. Because of this, medical science protocols
    have very strict qualifications defining illnesses for which it is
    appropriate and cost efficient to screen for. The protocols are based on
    in-depth statistical analysis and are in place to prevent the patient from
    undergoing expensive tests that are not likely to find anything and to
    prevent the finding of false-positive results which lead to further
    unnecessary testing, expense, and the always-present possibility of
    injury or illness caused by the test itself. Today, unfortunately, clinical
    diagnosing by physicians has taken a back seat to expensive high-tech
    screening throughout the health care system. Sometimes this is the fault
    of the physician’s engaging in self-serving clinical decision making—as
    in ordering a test for convenience/expedience, or, as in ordering a test in
    the interest of practicing defensively. Equally frequently, however,
    doctors are ordering high-tech testing—for deep-pocket patients—because
    the patients are demanding a test that they heard of through direct advertising,
    or via the media’s daily smorgasbords of “latest medical breakthroughs.” In
    today’s medical-economic environment, even the most clinically righteous
    physicians have little stomach for losing a patient, with the ability to pay, thru violation of the customer-is-always-right policy—even if the customer is definitely wrong. —Alan D. Cato MD, F.A.A.F.P. (past), and author of The Medical Profession Is Dead and the Doctor Is “Critically ill!” (Oct., 2010)

    • Nathan on 10.27.2011 at 2:22 pm

      Alan, Let me add one more reason for physician over-testing.

      Doctors sometimes order MRIs and Blood Tests when the local MRI and blood lab are partially owned by, surprise, the doctor ordering the test.

      I don’t know the prevallence. Anecdotally, it happened to my ex-wife and my brother.

      • Jenna on 10.28.2011 at 5:30 am

        In my personal experience most people are not stupid. We want to be treated like human beings and can usually pick up on a doctor who is in it for the money. I say knowledge is power. I want to know everything that is going on with my body. Yes statistically there is probably nothing seriously wrong with most people. But Dr. Cato, we are not statistics. If that screening can save 1 person then it’s worth it to at least screen for. Doctors are obligated to tell their patients the risks and doctors can also explain that performing the biopsy or whatever may not be necessary. People are not just going to rush into a surgery that can cause more harm than good. It is that person’s choice.

        Overall, I believe today too many doctors lack compassion. To the doctors, their patients are statistics. As such, people want to make sure the doctor is not overlooking something and order these “latest medical breakthroughs”. Maybe medical schools should start accepting more real human beings instead of arrogant, egotistical jerks. Ultimately, I think the reason for overdiagnosing is all on the doctor for either want to do it for self serving purposes or because the patient does not have faith in the doctor that he or she is doing the best they can.

  • LEE SMITH on 10.27.2011 at 5:22 pm

    Alas, what are we lay persons (even with PHDs as Jenna and I have) to do. I’ve observed the education of MDs — we had to remove our PHD students from medical school basic science courses because the courses were so off base and the med students and faculty didn’t want to be told they were wrong — and the faculty were afraid of being sued by the students. I’ve seen so many premed students fixated on getting in to med school at all costs. Knowledge for it’s own sake was never on their agenda. So is it surprising that MDs either want to make $$ using equipment or selling books or making the government and/or insurance companies happy. We can’t trust ANY MDs, that’s a given starting point as we can tell from all that each group of MDs says about a different group, and it’s up to each MD to prove he or she is for real. However MDs are a resource for us (and indeed there are some who are honest knowledgable and committed to humanity). Sooo — the bottom line is get the data including screening, read the literature, get multiple opinions find some of the minority of honest Drs (very few since each “side” is very clear how dishonest their opponents are)and play an important role in charting your own future as best you and your honest MD (we all have found a few) can. And most of all, don’t let the panels and committees treat you as a statistic — all statistical distributions have tails and why should anyone settle for being average when one can strive to be above average be it decisions about how to deal with a PSA reading or any component of live. After all what is life about but trying for the best, not settling for the worst— the worst who form the data for many of these so called statistical studies. My hypothesis is that they don’t show that on average screening is useless, but rather that an average medical practice is useless when it comes to interpreting screening

  • bruce f smith on 11.24.2013 at 11:54 am

    I am 66 years old. I have come to the conclusion that not many of us over 60 don’t have some minor ailment to contend with. When I go to my doctor we discuss any issues I have with a goal of striking a balance between testing, and learning to live with some things. Recently I started to feel a very slight popping in one knee. We discussed it and my Dr. recommended not testing unless it presented a real problem to me because he was confident that the solution would be worse than living with the issue. 6 months later the problem has virtually disappeared. My Dr. never makes me feel that he is rushed. Clearly he considers these conversations important.

    My wife’s new Dr on the other hand tests for everything. Her Fasting blood sugar count was a ‘little high’ so she has just finished her third test. She feels great other than the stress of having the tests. Based on what she learned in reading the info on this site she has decided to ask what her count is (re the 130 # mentioned). She is confident these tests were not necessary.

    I guess I can count myself lucky regarding my Doctors perspective.

    A laymen

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