30% of digestive endoscopies have questionable indications

@varelalaf

In an article in the series "Less is More" by Gastroenterology, three digestiologists, Shaheen, Fennerty and Bergman, after an extensive review of the literature, conclude that 30% of digestive endoscopies have questionable indications. According to the authors, many clinical practice guidelines stimulate the exaggerated consumption of these tests in clinical situations of doubtful indication, such as recommendations for the follow-up of low-risk patients of Barrett's disease (oesophageal reflux), which they say they are "carefully misleading." On the other hand, the prevailing cancer phobia places a lot of pressure on the examination rooms, which are permanently overwhelmed, not only by inappropriate requests but by follow-up guidelines that anticipate the requirements demanded by the clinical practice guidelines themselves.

The early diagnosis of colorectal cancer, thirty years later

@varelalaf

Health systems have long-planned population programs for the early detection of certain cancers through diagnostic techniques arising from the clinical setting, such as prostate-specific antigen (PSA), mammograms, ultrasound or the study of faecal occult blood that is the case at hand. This issue is generating confusion in society because one thing is to take care of one's health and the other, quite different, is to undergo medical tests to discover tumours in their early stages. On the other hand, discomforts are also generated among professionals, because it’s not the same to treat patients who seek help for health problems, than to propose extensive tests to the healthy population.

Contradictions of today’s medicine according to Dr. McCartney

Dr. Margaret McCartney, a Scottish family doctor and regular contributor to the BMJ, is the author of "The Patient Paradox" a book with a critical scientific view written in the office. I regularly follow Dr. McCartney’s contributions and two of her tweets have already been selected as tweet of the week in this blog. "Cancer: Are military metaphors appropriate?" and "If we don’t die of cancer, what do we die of?". On June 17 I had the opportunity to listen to her at the inaugural conference for the Catalan Society of Clinical Pharmacy seminar. The thesis of her speech: "Too much medicine for the well and not enough for the sick" seemed very much to the point, therefore I decided to read her book; and I must say that I liked it so much that if I was an editor, I would order a Spanish translation right now.

What is the paradox that Dr. McCartney refers to? 

This paradox is no more or less than the thesis of her speech in Barcelona. If one is sick one must be persistent in order to receive the appropriate care (booking an appointment with the family doctor, limiting oneself to a little timeframe to explain what's wrong, putting up with long waiting lists to receive specialty care, etc). But if one is well, then the situation is reversed and the risk of overacting prevails, such as that in a screening or a health review, one is placed in the patient’s or in the pre-patient books thus occupying the position of a patient at risk and therefore, to receive preventative treatments for pathologies that may never occur or to be treated to combat a disease that one does not have.

Overscreening: new excess data

Cancer Screening Rates in Individuals With Different Life Expectancies http://t.co/Kefm8bPEiQ

— JAMAInternalMed (@JAMAInternalMed) 21 agost, 2014

JAMA Internal Medicine has just published the results of a study from the National Health Interview Survey (NHIS) - US in the period 2000 to 2010. The study included 27,404 participants aged 65 years or more, and used a NHIS specific index to assess the risk of mortality to 9 years of life.

The conclusion is that a substantial proportion of US population with limited life expectations received screenings for prostate, breast and colorectal cancer. These results show that the overscreening is standard practice in the US. These practices, the study's authors relate, rarely produce any benefits to these population groups and instead, increase health spending and induce therapeutic overbearing from with complications arise.

This American study warns us that we need more professional and social debate, not only about the advantages and disadvantages of preventive practices in healthy people, but also about the limits of such practices in geriatric patients who already have their own clinical management difficulties.


Jordi Varela

Editor

"Too much mamography" or the mirage of screenings

By Cristina Roure @crouren

The BMJ recently published the results of a randomized Canadian study which shows that annual mammography in asymptomatic women under 60 does not bring any advantage in reducing mortality from breast cancer compared with physical examination without mammography and, instead, it leads to more than 20% over diagnosis. The article is accompanied by an editorial entitled "Too much mamography" which suggests the need to rethink the breast screening policies as it has done with PSA screening in the case of prostate cancer.

It can be somewhat counterintuitive to think that a test that can detect cancer early and therefore provide the opportunity to treat it early, does not reduce mortality, but often not only the citizens but also the professionals have difficulty interpreting the benefits and risks of screenings and to communicate them clearly to patients when making the decision to participate or not in the program. Gerd Gigerenzer, Director of the Max Planck Institute for Human Development in Berlin explains it very well in his book Calculated Risks. How to know when numbers deceive you¹.