Over-diagnosis and Over-treament, Less is sometimes more

There have been many books published recently by physicians concerned about over-diagnosis and over-treatment. One very emotional area that caused great controversy when new prevention guidelines were published (regarding mammograms) relates to early detection and treatment of cancer. It would seem intuitively obvious that early detection and early treatment of cancer would save lives but it turns out this is not always so straight forward. Some cancers are very slow growing and early detection and treatment can cause more harm than good. This has been argued relative to screening for breast cancer, cancer of the uterus and prostate cancer, among others. For these particular cancers the screening tests are mammograms, pap smears and PSA blood test. To understand how and why less could be better you should read  Overdiagnosed.

If a cancer is diagnosed by a screening test 3 years before symptoms would have resulted in a diagnosis, but the early treatment does not change the course of the illness compared to treatment latter, it gives the appearance that the patient lived three years longer as a result of early treatment simply because the patient carries the diagnosis for three years longer. This actually turns out to be the case in many situations. Despite this knowledge our emotional response as physicians and as patients refuses to adapt to new data and we continue to follow old habits such as annual pap smears even though the data suggests that pap smears every three years would be equally  effective in saving lives and would actually prevent unnecessary, expensive and anxiety producing follow up procedures and testing. The exception to this recommendation would be for “high risk” individuals that still benefit from more frequent screening.

It turns out that in the US we likely over-diagnose and over-treat many conditions. The benefits of treatment are sometimes not justified by the side-effects and complications of the treatment. As a result of this concern the  Choosing Wisely campaign was created by a consortium of more than 30 Medical Specialty Societies with a goal of avoiding unnecessary testing and treatment. This is similar to the   Too much medicine campaign | BMJ

Medical testing can cause harm directly (complications of the test itself) but also indirectly. False positive results can lead to further invasive testing which can have complications and create anxiety for the patient.

Beyond screening tests for patients without symptoms there are many drugs now being marketed to treat “conditions” that may not need treatment. (read my posts on statins as an example) Big money is behind over-treatment and it is hard to stem the tide. Dr. Malcolm Kendrick | Scottish doctor and author of ‘The Great Cholesterol Con’

The BMJ (formerly the British Medical Journal) has been much more active in addressing these concerns as stated below:

“Has modern medicine undermined the capacity of individuals and societies to cope with death, pain, and sickness? Has too much medicine become a threat to health? Yes, argued Ray Moynihan in a BMJ theme issue in April 2002. He accused the pharma industry of extending the boundaries of treatable disease to expand markets for new products. Barbara Mintzes http://www.bmj.com/content/324/7342 blamed direct to consumer advertising of drugs in the US for portraying a dual message of “a pill for every ill,” and “an ill for every pill.” Elsewhere in the issue, doctors were accused of colluding in and encouraging medicalisation. Leonard Leibovici and Michel Lièvre http://www.bmj.com/content/324/7342/866 wrote : “The bad things of life: old age, death, pain, and handicap are thrust on doctors to keep families and society from facing them.”

Useful links:

Treatment of GERD with prolonged use of a Proton-pump inhibitor results in increased risk of pneumonia and increased risk for vitamin B12 deficiency http://jama which can result in permanent nerve damage, anemia and other ailments. This class of drug has many other potential complications. They cause decreased intestinal absorption of minerals and other nutrients and likely alter the mix of important health-promoting bacteria in your gut. They can lead to  Small intestinal bacterial overgrowth in 35% of patients who use them. They also likely contribute to increased risk of osteoporosis,  fractures and a four-fold increase in certain heart  rhythm disturbances. These drugs are now available as non-prescription medications as well as prescription medications and they are often indiscriminately used for prolonged periods of time.

Sleeping pills are another example of over-prescribed medications. The FDA has approved the use of many of these drugs for just a few weeks at a time but I see patients frequently on these medications for years. They can  lead to addiction within a few weeks, can cause dizziness, drowsiness, memory problems, confusion , hallucinations, and other side effects, and should not be used with alcohol. Sleep walking, sleep eating, sleep driving, and other abnormal-dangerous behaviors have been reported with many sleep medications. In addition to these concerns:

“An analysis of data of clinical trials submitted to the FDA concerning the drugs zolpidem, zalepon, and eszopiclone (Ambien, Sonata, and Lunesta) found that these sedative hypnotic drugs more than doubled the risks of developing depression compared to those taking placebo pill. All studies have been funded by the drug companies without independent research.”

Examples such as this abound in the US, the only developed country that permits direct to consumer advertising of drugs on TV.

Why do we pay almost twice per capita for health care in the US compared to other developed countries while ranking between 20 and 30 on various measures of public health? Over-diagnosis and over-treatment in my opinion, are big factors.

I would encourage you to explore some of the links above to learn more about over-diagnosis and over-treatment so that you can make more informed health-care decisions.

Peace

Bob Hansen MD

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