Heads up: it may be best to do nothing

Simon Crompton

Simon Crompton

 

It’s always strange emerging from the single-mindedness of a conference to breathe the outside world’s unconcerned air. I doubt there was a person attending the British Medical Journal’s recent “Preventing Overdiagnosis” conference in Oxford who didn’t come away with the sense that overdiagnosis and its consequences is one of the biggest challenges facing health providers globally.

 

But beyond the concern of a handful of international experts – many of whom were gathered in Oxford – awareness and concern among the international cancer community seems low. Yes, most of us know that there are risks as well as benefits to breast cancer screening, and that PSA testing for prostate cancer can lead to unnecessary tests and treatment. But does that result in changes to practice? Does every one of us need to sit up and listen a bit more?

The papers presented at the conference certainly suggested “yes”. As keynote speaker Ilona Heath, a former President of the Royal College of General Practitioners, said: “Susan Sontag’s kingdom of the well is being absorbed into the kingdom of the sick, and clinicians and health services are busy ushering people across this important border in ever-increasing numbers. The costs, personal, social and economic, are enormous.”

The issue of overdiagnosis doesn’t just hover over breast cancer and prostate cancer.

The conference heard evidence that it is an issue in melanoma. An analysis of data by America’s National Cancer Institute, presented at the conference, showed that melanoma incidence has been increasing since 1975 while mortality has remained stable, strongly suggesting overdiagnosis.

Or take ovarian cancer. The conference heard about concerns that improved testing with blood tests and ultrasound are leading to increased detection of borderline ovarian tumours that might never present clinically in the lifetime of a woman.

Or thyroid cancer. A population-based study of thyroid cancer patients in Ontario, Canada between 2000 and 2008 shows that this relatively benign cancer is increasing at an “epidemic” rate. The increase seems to be confined to more affluent areas, and closely related to the availability of diagnostic ultrasound.

The suggestion is that, without sophisticated diagnostic techniques, large numbers of people with these diseases would have died of something else without even knowing they had cancer. They might have avoided distressing decisions, painful tests, potentially disabling treatments.

Such interpretations of data can prove controversial. Some evidence is strong, some is preliminary to say the least. But it undoubtedly opens up important questions for all those involved in the detection and treatment of cancers. It asks us to look up from a heads-down determination to track down and destroy cancer, and question whether sometimes – quite often – doing nothing is the best course.

It’s not an easy thing to do. Cancer World will be exploring the issues in its next three editions.

3 thoughts on “Heads up: it may be best to do nothing

  1. Nicole Guiochet

    Understanding this is very difficult for someone, healthy, reading a discussion about gain or not gain with cancer early diagnose.
    He or she cannot imagine nor understand he or she will die with another illness because cancer remains the most frightening of all, even early detected, in their mind.
    And they always will found a doctor for Psa or mammography.

    Reply
  2. Dr Damian Fogarty

    Suggesting that “overdiagnosis and its consequences is one of the biggest challenges facing health providers globally.” is such an overstatement when half of the world does not have healthcare and perhaps 2 billion are without sanitation and clean water. Furthermore there are as many problems with lack of diagnoses (rare diseases especially), wrong and delayed diagnosis ironically in the cancer arenas and other areas.
    There are a small proportion of cancer sufferers who have been over treated but I have yet to see a true population study of how this stacks up against no diagnosis and delayed diagnosis. That malignant melanoma (MM) incidence has risen but the survival stayed the same needs some scrutiny. There are other explanations beyond overdiagnosis, such as the risk factors and types of MM now cc the mid 70s. Are these cohorts really as similar as we are told? Besides there is no drug or device company behind or seeking an earlier diagnosis of MM; at least not back in the 80s when it was the public health doctors who told Australians to Slip, Slop Slap regarding protection from sun induced skin cancers. http://www.sunsmart.com.au/tools/videos/past-tv-campaigns/slip-slop-slap-original-sunsmart-campaign.html
    So all I ask for is that we have some balance and look at total populations across the world and see how many deaths are really due to over diagnosis. I will bet that mis-diagnosis and late-diagnosis is a much greater problem.

    Reply
    1. Peter McIntyre

      Clearly Damian Fogarty is correct – globally, under diagnosis and under-treatment are much greater problems. However, we can draw a parallel with malnutrition and obesity both of which today exist side by side (even in low income countries). Over diagnosis and under diagnosis are two sides of the same problem – a divided world where the wealthiest capture the resources while others go without. Overdiagnosis and over-treatment must consume resources that could be directed at those who desperately need better diagnostics and treatment. It is surely right therefore to draw attention to overdiagnosis as a waste of resources as well as being potentially damaging to the patients.

      Reply

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