Opinion: Overdiagnosis – Dr Joe Kosterich

Cracking open overdiagnosis

Treating symptomless conditions can be a slippery slope. Dr Joe Kosterich reports some of the discussion from a recent conference.

Ultimately it comes back to physicians and patients seizing back control from public health academics… We need to return to treating people, not populations.

Sometimes the most obvious gets forgotten. Medicine’s goal is to alleviate suffering. To quote Arturo Catiglioni “[Medicine was] born with the first expression of suffering and the first desire to alleviate this suffering”.

Today we focus more on what does not cause suffering – certainly not in the immediate sense. The problems that mass screening, population health programs, commercial drivers and litigation have caused were considered at the seventh annual Preventing Overdiagnosis Conference held at Sydney University in December.

Professor Jin-Ling Tan from China deftly contrasted how medicine has changed in the past generation. Previously, we saw people with symptoms. The patient could indicate whether they were getting benefit from treatment and “had a say in what was done”.

Today we treat symptomless conditions such as raised cholesterol or blood pressure. The patient cannot tell whether they are getting benefit – only we can do that through measurements. The patient may give informed consent but arguably has less of a say in what goes on.

Prof Tan gave the example of treating moderate hypertension. The estimate is that 7% of the average Chinese hypertensive population will develop a CVD event over 10 years. Hence only 7% can potentially benefit from interventions for preventing CVD events and 93% will be treated for no net benefit to themselves. Furthermore, of the 7%, only 30% will benefit from anti-hypertensive drugs.

Only two out of 100 people treated for moderate hypertension will actually benefit from the treatment! This is astounding. Now, I am sure others have different statistics which come to different conclusions. As doctors we don’t think much about the harms (personal and economic) of treating people who will not benefit from treatment.

A Danish paper estimated that 43% of frail older people had no reason to be on one or more of their medications.

Of course, treatment follows diagnosis. Lowering of thresholds and commercial drivers of increased testing and treating were examined. Again, the common view that there is little or no downside. The problems of tainted guidelines and how they are often not applicable to real world patients was discussed.

Some sessions examined the overdiagnosis of cancer. Paul Glasziou et. al. presented a paper estimating that each year in Australia more than 11,000 women and 18,000 men are over diagnosed. This means they are found to have and be treated for something which would never have manifested clinically, nor affected life expectancy.

Necessarily such a conference cannot come up with all the answers. However, it can get us thinking. Both patients and doctors need to better understand that testing and treatments have downsides and that more is not always better.

Ultimately it comes back to physicians and patients seizing back control from public health academics. It is about individualised care not ‘best practice’ when such practice may be irrelevant to the individual. We need to return to treating people, not populations.

– References available on request