You could call it 150 shades of gray, and few radiologists would disagree. But to Jerome Hoffman, MD, some imaging studies are black and white, and even put emergency physicians in situations that can increase patient risk. And he is taking such tests to task.
Dr. Hoffman and Richelle Cooper, MD, his emergency medicine colleague at the University of California, Los Angeles, stepped into one of the more openly contentious issues currently being debated among medical specialties — when does the Hippocratic directive “do no harm” translate into “do no screening test”?
Drs. Hoffman and Cooper, in a declarative editorial this past year, surveyed the data on cancer-detection programs and other conditions more commonly screened in the emergency department, such as pulmonary embolism. The two drew a conclusion that serves as the title of their paper: “Overdiagnosis of Disease: A Modern Epidemic.” (Arch Intern Med 2012;172:1123.)
This is no longer a mere point of discussion, but constitutes a movement to bring costs under control by pinpointing which interventions and tests actually improve the quality of health care. The American College of Physicians has convened a working group to deduce by consensus common clinical situations in which such screening and diagnostic tests are not warranted. (Ann Intern Med 2012;156:147.) The college plans to publish advisories to help guide such decision-making in the near future, said Amir Qaseem, MD, PhD, the director of the clinical policy medical education division for ACP in Philadelphia.
Longer life spans and an increase in chronic disease are reasons for growth in overutilization, he said. “There is patient demand for latest developments and technology,” Dr. Qaseem pointed out, as well as a rise in the practice of defensive medicine. Preferring to call reliance on such tests “overuse” rather than overdiagnosis, Dr. Qaseem cited imaging for low back pain and colonoscopy past age 75 as two examples.
“Part of the problem, in some cases, is that you do diagnose the disease earlier, but the patient dies at the same time that they would have if you hadn't done the screening test at all,” said Dr. Hoffman, a professor of emergency medicine at UCLA.
“When that happens, it is easy to be misled and to think that the person did better because they lived seven years after the diagnosis, for example, compared to an average life span of five years with the same type of cancer when the diagnosis is made on a clinical basis,” he said. “You think you've added two years to your patient's life. But the truth is that you didn't add anything, except that they knew they were sick two years earlier, so you've actually only added two years to the time that they had the worry about cancer, and that they had to go undergo all the morbidity of our aggressive interventions.”
In fact, the matter has become such a focus of discussion that conferences are being held this year to present and assess appropriate use of screening tools. One of them, scheduled for February, is rather ominously titled “Selling Sickness,” and promises to examine everything from misleading marketing to conflict-of-interest issues in using diagnostics. Meanwhile, a book on the subject, “Overdiagnosed: Making People Sick in the Pursuit of Health,” has won favorable reviews.
The book, written by three medical professors at the Dartmouth Institute for Health Policy and Clinical Practice, has been cited frequently in the press but not without backlash. When two of its authors published a critique of a charity that advocates mammography (BMJ 2012;345:e5132), they were later castigated in an online editorial for the same journal from a physician who accused them of offering “scientifically unsupportable misinformation” aimed at denying women access to screening. (See FastLinks.)
If all this sounds new, well, it isn't, said H. Gilbert Welch, MD, the book's lead author. “I first remember hearing about this and getting interested in it after a colleague in radiology many years ago observed he kept finding anomalies on what was then the new technology — CT scans — that could not have been seen using the old technology of chest x-rays,” he recalled. “So this became an intriguing problem.”
Since then, the potential for overdiagnosis has become a “big public health issue,” but it actually has been growing since the 1960s and 1970s, said Dr. Welch, a professor of medicine at Dartmouth. That began five decades ago, a period in which advances in screening technology first began providing opportunities for early-disease detection with the advent of mammography, computed tomography, and ways to gauge risk of hypertension, he said.
But, now just as then, abnormal results don't provide much clarity about underlying etiology. “Our detection of abnormalities far exceeds our ability to know what to do about them,” Dr. Welch said.
Nor has screening become the public health imperative that it has been touted to be, he affirmed. Instead, it is a choice. “And the truth is that it typically harms more people than it helps. But the few it helps arguably win big,” he added. “So it is a gamble [with] no single right answer.”
Dr. Hoffman, who called Dr. Welch's book a must-read for emergency physicians grappling with these issues, characterized early detection as often not representing clinical usefulness. He cited the lack of definitive answers on diagnostic imaging and the high number of false-positives from some serologic markers. “Unfortunately, [there are] only a few circumstances where a screening test catches something just at the right time,” Dr. Hoffman said. “In many cases, it turns out that it is already too late by the time the screening test turns positive, while in many other circumstances, it is still eminently treatable even if you waited for a clinical diagnosis,” he said.
And that, he asserted, is the crux of overdiagnosis — finding a disease identifiable by a screening test, but one in which the outcome of such testing might be the creation of a problem rather than the solution. These include many cases of prostate cancer in older men, who are far more likely to die with the disease than from it, he observed.
Nowhere has this been more vexing than the hunt for potentially fatal pulmonary emboli. One recent evaluation, funded by the National Institutes of Health, called on physicians to carry out the most feasible risk stratification, but noted that there is not yet the technical refinement to know just what tool is best capable of doing that. (F1000 Med Rep 2012;4:9.) Other institutions have tried to come up with ways to reduce the number of CT angiograms for ED patients suspected of pulmonary embolism by statistical modeling. (World J Emerg Med 2012;3:172.) One center suggests using a mortality-benefit threshold for determining when patients should be referred for testing and when such testing can be eschewed. (Acad Emerg Med 2012;19:e1109.)
“Knowledge is not power when it is misleading, or when we don't know how to interpret what we have just learned,” Dr. Hoffman said, pointing to imaging for pulmonary embolism as fitting into that unfortunate category. As one radiologist describing scintigraphy for diagnosing pulmonary embolism pointed out, “The deck has always been stacked against us, and our specialty [has been] frequently maligned by the referring physician as practicing ‘unclear’ and not nuclear medicine.” (J Nucl Med 2007;48:1405.)
A good rule to follow, according to Dr. Welch, is that the patients generally best positioned to benefit from screening are those at the highest risk of disease and at the lowest risk to die from something else. “My point is that this is a choice,” he said. “But to make it, everyone needs to understand the benefit and harm of looking for things to be wrong. We have not been as clear as we should be about all the uncertainty, worry, and unnecessary procedures our tests can lead to, and that the benefit of looking early has been vastly overstated.”
This is the essence of overdiagnosis, Dr. Hoffman explained, “finding something that is there but which means something different than it did in the other circumstances where we used to look for it because of clinical concern.” Now, such findings are made “in the absence of clear-cut clinical concerns” because of the liberal use of advanced technology, he said.
PSA testing has played out as a cautionary tale in many cases of a cancer marker that led to too much intervention too soon. Two years ago, Richard Ablin, MD, the self-described discoverer of the prostate-specific antigen, called the test “hardly more effective than a coin toss.” (“The Great Prostate Mistake.” New York Times March 9, 2010; see FastLinks.) He proclaimed the PSA test a “public health disaster,” and noted that it still cannot distinguish between two types of prostate cancer, “the one that will kill you and the one that won't.”
What about the Pap smear, often the first sign of cervical carcinoma? It can be life-saving but also extraordinarily worry-inducing. “So if it turns out ‘no cancer,’ you may be told you have atypia or dysplasia, and now you see yourself as having something abnormal,” Dr. Hoffman said, adding that this often means much higher patient concern about future cervical testing. The same problem exists for mammography. “You may be told you do not have cancer,” but “you are not normal either,” he said.
The tide may be turning, however, Dr. Hoffman pointed out. Flurries of studies have heightened awareness of the potential for overdiagnosis, and physicians seem far more interested in exploring the topic, compared with even a few years ago. “A lot of good doctors are concerned about this now,” he said.
But it will take time, more discussion, additional debate, and perhaps even a higher level of acrimony. Technologic advances that result in state-of-the-art tests are like a large, seagoing vessel steaming ahead, fueled for a safer, faster journey. “It is tough to turn a tanker in the ocean,” Dr. Hoffman said.
Click and Connect! Access the links in EMN by reading this issue on our website or in our iPad app, both available on www.EM-News.com.
- Read “How a Charity Oversells Mammography” at http://bit.ly/U0bvVU.
- “The Great Prostate Mistake” is available at http://nyti.ms/UDQNgI.
- Watch a video of Dr. George Lundberg, editor-in-chief of Medscape General Medicine, discussing what happens when well people seek medical care at http://bit.ly/XIN4ig.
- Comments about this article? Write to EMN at email@example.com.
Cyberchondria: A New Term for a New Age
Doctors in Great Britain have coined a catchy label for a condition that seems to be surfacing a lot in emergency medicine: cyberchondria (ISME 2012;5:71.)
This 13-letter term refers to a state of mind among patients that technologic advances in screening and intervention are the way to reduce health risks. The problem, as it has been reported in the United Kingdom, stems from reliance — make that alleged over-reliance — on tests for everything from assessing the threat of stroke to the likelihood of occult malignancy. A movement there to curtail screening apparently sprang up after a highly regarded physician who had spent decades in stroke research presented himself for stroke-risk screening at his local church where a throng of health-minded residents had shown up for the same thing. The results, not to mention the scene itself, caused him to pronounce the whole thing “nonsense,” and his story was carried across England.
U.S. physicians are challenged by the same situation. Internet-trolling people not only suspect they have a diagnosis found online, they seek the test they think will prove or disprove their findings. In fact, patients frequently express strong preferences for medical tests or treatments of their own choosing, even when physicians believe those interventions are not beneficial, two doctors observed recently in the Journal of the American Medical Association. (2012;307:149.)
And physicians often grant such requests, according to the researchers. “One compelling reason is to avoid confrontation: patient-physician relationships flourish in an atmosphere of trust and goodwill, and physicians rightly worry that disagreement will threaten those relationships,” they stated. Not surprisingly, the pair recommend against going along with “the diagnostic or therapeutic intervention … unless a modicum of potential benefit, viewed from a conventional medical perspective, is present.” — AS