How to diagnose overdiagnosis

In a BMJ editorial, within the framework of the campaign "Too much medicine," Professor Paul Glasziou and editor Fiona Godlee, among others, spoke of the phenomenon of overdiagnosis and analysing their characteristics, and since this is a trending concept, I think it's a good idea to pay attention to it.

In a medicine previous to cancer screening programs as we know them today, people were diagnosed according to the appearance of the first symptoms. It was the visible tip of the iceberg. But as it was suspected that when the symptoms appeared, the illness simmered below the clinical perception for long time, it was believed it was necessary to develop diagnostic techniques to allow seeing the iceberg below the water, with the assumption that the sooner the pathological process in motion is detected the sooner is possible to act, therefore obtaining a better prognosis.

But now we can see that things did not fully go as intended. In general, we can affirm that thanks to screening programs forecasts have improved, but unfortunately the mortality rates are the same, and voices criticizing this rummaging through the invisible parts of the iceberg, have enough arguments to defend that while early diagnosis may detect many cases that perhaps wouldn’t have emerged at all, this is done at the expense of improving survival rates in an artificial way.

The parsimonious medicine

I started the last Mondays’ post with the "Too much medicine" campaign from the British Medical Journal but in this one I want to talk about the "Less is more" article from "JAMA Internal Medicine" that began in April 2010 with the aim of bringing to our attention the side effects of diagnostic tests and treatments that from the outset are not expected to add any value.

Parsimonious medicine versus spending cuts

Dr. Jon Tilburt, an internist and researcher in biomedical ethics at the Mayo Clinic, and Dr. Christine Cassel, president of ABIM Foundation (see the Video that presents the "Choosing Wisely” campaign), in an article published in JAMA, attempt to differentiate between the ethics of "no budget and therefore I can’t request a test" and those of "this test does not suit you, it will not contribute anything new to what we already know, and additionally, the test itself carries risks that do not outweigh the expected benefits". According to the authors, as at the moment the two ethics are competing on the same stage, an effort must be made to explain them better from a professional point of view. 

Less is more: "Overtreated" by Shannon Brownlee

The campaign "Too much medicine" by the British Medical Journal wants to highlight the threat of over diagnosis to the health of individuals, and also expose the inherent waste of resources involved in inappropriate clinical practice. According to the BMJ, there is evidence that more and more people suffer from over diagnosis and overtreatment for a wide range of clinical circumstances such as cases of asthma, chronic renal failure or prostate and thyroid cancer. Through this campaign, the magazine plans to improve awareness among physicians of both the benefits and side effects of treatments and technologies, and thus find out how excesses can be reduced safely and properly.

The editor of the BMJ, Fiona Godlee, gives much attention to the campaign: “As medicine based on evidence, or clinical safety, were the movements of the previous decades, combating excess is a contemporary manifestation of an ancient desire: no harm when we want to heal".

To start talking about this campaign, I thought it would be appropriate to review the book “Overtreated" whose author, Shannon Brownlee is a science journalist who has published in Atlantic Monthly, New York Times, New Republic and Time.

Too much medicine

This is the title of the first chapter of the book, where she writes: “As most clinical practices have never been scientifically proven, when someone was faced with them, it turned out that many of them did not offer a good balance between damage and benefits, they only believed it and let’s review some clinical activities that, having had their base in the moment that have been evaluated, had to be rethought seriously such as tonsillectomies, hysterectomies, frontal lobotomies, radical mastectomies, arthroscopies knee arthritis, radiological screening for lung cancer, inhibitors of proton pump for stomach ulcers, menopause hormone therapy, high-dose chemotherapy for breast cancer, etc."