OVERDIAGNOSIS: Making People Sick in the Pursuit of Health
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1 OVERDIAGNOSIS: Making People Sick in the Pursuit of Health H. Gilbert Welch MD, MPH A Fundamental Medical Paradigm: The best way to keep people healthy is to find and treat disease early. Underlying assumption: Without intervention, early forms of cancer invariably progress to advanced cancer. DNA damage Failure to repair Atypical cell Carcinoma in situ Deterministic model Invasive cancer Cancer death Inconsistent observations: Whenever we look for early cancer, we find a lot more people have cancer than we would ever expect to go on to develop advanced cancer. (i.e. not all early cancers progress to become advanced cancer) DNA damage Failure to repair Atypical cell Carcinoma in situ Stochastic model Invasive cancer Cancer death Implications: 1. Early diagnosis leads us to label too many people as having cancer. Those not destined to develop symptoms or death from their cancer are overdiagnosed. 2. Because we don't know who is overdiagnosed and who is not, we treat everybody. Thus some are treated who can't benefit from treatment (because their "cancer" would never bother them) and can only be harmed. Disclaimers 1. Not saying that advanced cancer is not a bad disease it is. 2. Not saying you should never be screened for cancer. Instead trying to be clear there are two-sides to the issue. While some may be helped, others are hurt.
2 There is a vast reservoir of cancer... Figure 1 - PROSTATE CANCER RESERVOIR IN MEN DYING FROM AN ACCIDENTAL DEATH Proportion found to have prostate cancer 8% 7% 6% 5% 4% 3% 2% 1% % Age Group...so as we look harder we always find more Figure 2 - HOW INCREASING THE NUMBER OF BIOPSIES (LOOKING HARDER) FINDS MORE PROSTATE CANCER 6 biopsies 11 biopsies Look Hard Look Harder 6 biopsies 12 biopsies 6 biopsies 13 biopsies 18 normal biopsies biopsies % % 1% 2% 3% 4% % of men found to have prostate cancer OVERDIAGNOSIS: Making People Sick in the Pursuit of Health - 2
3 Look Harder, Find More How many lakes in the State of Utah? Continental US View = 1 Utah View = 3 High Uinta View = 39+ (in one section) OVERDIAGNOSIS: Making People Sick in the Pursuit of Health - 3
4 National Data: Prostate Cancer New prostate cancer diagnoses (per 1, men) TURP era PSA era Risks of surgery: loss of sexual function, difficulty urinating or being able to control urine Risks of radiation: painful defecation due to radiation proctitis OVERDIAGNOSIS: Making People Sick in the Pursuit of Health - 4
5 National Data: Thyroid Cancer, Melanoma & Breast Cancer New thyroid cancer diagnoses and deaths (per 1, people) New diagnoses 4 2 Deaths Thyroid Cancer more neck exams more ultrasounds Risks of surgery - hoarseness, trouble swallowing, calcium imbalance Must take life-long replacement medication. New melanoma diagnoses and deaths (per 1, people) New diagnoses Deaths Melanoma more skin exams more biopsies Risks of surgery - generally minor, occasionally requires flaps & grafts Anxiety associated with lifelong surveillance New breast cancer diagnoses and deaths (per 1, women) New diagnoses Deaths Breast Cancer more mammography Disfiguring surgery often combined with 3 radiation treatment and/or chemotherapy (with attendant nausea, fatigue, and hair loss)...and all these diagnoses can affect the ability to obtain health insurance OVERDIAGNOSIS: Making People Sick in the Pursuit of Health - 5
6 Appendix Cancer screening is only one aspect of the "early detection" dogma There are other ways we turn people into patients We are also screening more for conditions other than cancer (coronary artery disease, carotid stenosis, abdominal aortic aneurysm, peripheral vascular disease, etc.) and whenever we look harder, we find more. We have "changed the rules" to expand the number of Americans said to have various conditions. Like what constitutes a normal cholesterol... 4% Proportion of US adult population 3% 2% New patients 1% Old patients % Cholesterol level (mg/dl)...and have done the same for diabetes, high blood pressure and osteoporosis. Finally, there's the whole issue of genetic testing for chronic diseases. We all harbor genetic variants that will show us to be at "increased risk" for some disease or other. If we continue to blindly follow this dogma, we all could be turned into patients. But is this really the road to better health? OVERDIAGNOSIS: Making People Sick in the Pursuit of Health - 6
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