Could test cascades be avoided after an incidental finding?

Jordi Varela
Editor

 

Incidental findings resulting from a diagnostic test or screening are being a headache for modern medicine, a problem that is only growing hand in hand with the refinement of imaging technology and genomics. In some cases, the investigations that follow the incidental findings indicate the existence of silent pathologies, or in the initial phase, and timely clinical intervention is effective, although in often, the cascades of tests that are derived end up being unproductive, as well as potentially dangerous, for patients. It’s a phenomenon that generates anguish in hypothetical patients and burnout in professionals, who don’t know how to stop it, since once there is a probability that what is found is dangerous, the pressure to reach the end is unstoppable. Unfortunately, the evidence shows that there is no evidence that compliance with clinical practice guidelines is capable of ending these cascades once they have started and, on the other hand, it has not been possible to demonstrate that the establishment of economic penalties or co-payments can stop the phenomenon.

A survey by the American College of Physicians of almost a thousand internists concludes that where we must emphasize to prevent excess tests is precisely in the practice of shared decisions before prescribing the initial test. That is, according to the internists surveyed, people, before accepting a diagnostic test or an imaging test, should be aware of the dilemmas that may be encountered later. To illustrate this approach, nothing better than an example.

Screening for lung cancer

Despite the environmental pressure, the Spanish public health system considers that there is still not enough evidence to approve the selective screening of lung cancer in smokers, between 55 and 80 years of age, through the annual performance of a low-dose CT scan. In the United States, on the other hand, the advice is current, with the condition imposed on Medicare and Medicaid beneficiaries of attending a prior visit of a shared decision where the interested party, once it's confirmed that they meet the inclusion criteria, is informed that, as a consequence of the screening for which he or she is a candidate, out of every 1,000 people like him or her, 3 will avoid dying of lung cancer, but 18 will not, 365 will receive some type of false alarm in any of the tests, which will cause 25 people to end up having a negative biopsy, 3 of which will suffer complications. The graph also informs that 4 of the people screened will suffer overdiagnosis, so they will be treated unnecessarily for lung cancer, having to suffer the risks inherent to the treatment.

The researchers claim that after receiving the information, some candidates decide not to enter the program (they don’t say how many), anyway it seems that at least those who do, have a more realistic view of the benefits and risks and, therefore, they are more prepared to feel responsible for a likely and risky battery of tests.

Today, the impact of involving people in prescribing the test that triggers the cascades of subsequent investigations is not known, but this seems the only way to ensure more positive results is more sharing among the parts.