Overdiagnosed: Should I have more tests or treatments?

One Computerized tomography (CT) scan of the abdomen and pelvis will expose you to more radiation than the residents of Fukushima, Japan absorbed after the Fukushima Daiichi nuclear power plant accident in 2011. –Consumer Reports, March 2015, Vol.80 No.3, 39.

High-risk patients with heart failure and cardiac arrest hospitalized in teaching hospitals had a significantly lower 30-day mortality when admitted during dates of national cardiology meetings (70% survival when doctors attended meeting as compared to 60% survival when doctors did not attend the meetings). –-Jena et al, 2014.

There are so many questions

I feel healthy but worry that cancer could be lurking in the background, should I do a preventative body scan?

I sometimes have slightly higher blood pressure especially when the doctor measures it. It is probably borderline, should I go on medication?

Should I have my PSA tested?

I am a healthy fifty year old, should I have a mammogram?

Should I have an annual physical?

In the quest to stay healthy or prevent disease, we are bombarded by information that preventative testing would save lives and improve health. Only in the United States and New Zealand allow direct to consumer medical advertising which tends to increase excessive drug use and medical testing (Liang & Mackey, 2011). The messages imply that medical screening and testing (e.g., body scan or stress tests) can identify early stages of a disease and implying that earlier treatment will improve quality of life and survival. Similar messages encourage basically healthy people to take drugs for borderline conditions (e.g., borderline hypertension, osteopenia, increased cholesterol levels. What is not shared is the possible risk of unnecessary medical interventions or  the harm caused by drug or treatment side effects especially when they are used for a long time period.  When unbiased research such as the Cochran Reviews are done,  even the annual physical exam appears to offer no benefits (Krogsbøll et al, 2013). Similarly,  mammograms and PSA testing  for a healthy population appears to offer no benefits and may increase risks. It is truly difficult to accept that an annual health check up is worthless or that a routine mammogram or PSA test may do more harm than good since for many years the public message has been the opposite:  to get more screening and testing. There are many reasons for this approach such as:

1. Genuine belief, although not evidence based,  that an early intervention and more testing would reduce suffering.
2. Financial incentives for the parties that perform testing and preventative screening or encourage increased drugs sales for borderline conditions for which the risk and benefits are not well documented.
3. Fear of lawsuits by medical providers.  If a patient develops an illness which possibly could have been diagnosed by screening, even though the screening may not have affected the actual outcome, the health professional could be sued.

Become an informed consumer

When you have a symptom and do not feel well, see your doctor and get diagnosed, it may safe your life.  At the same time be an educated consumer and when unexpected findings are discovered and not related to your specific symptom/complaint, ask questions before agreeing to have more tests or treatments. Ask your provider some of the following questions which were initially outlined by Dr. Eugene Robins (1984):

1. Why are you doing this test or procedure?
2. What are the risks and what are the benefits?
3. What are the risks of treatment and what are the benefits of treatment?
4. How accurate is the test?
5. How will the test results change the treatment strategy?
6. Are there less invasive strategies that could be used? Be very careful of exposing yourself and especially children to CT scans. It is estimated that for every 1000 children who have an abdominal CT scan, one will develop cancer as a result (2015, Consumer Report, March 16).

To be able to navigate the complexities of diagnosis and to understand the risks and benefits of treatment and testing, read the recent two articles in the New York Times, Can this treatment help me? There is a statistic for that, How to Measure a Medical Treatment’s Potential for Harm and the superb book, Over-diagnosed-Making people sick in the pursuit of health,  by Drs. H. Gilbert Welch, Lisa M Schwartz, and Steven Woloshin who are professors at Darthmouth Institute for Health Policy and Clinical Practice. This book is a must read for every patient and health care provider.

References:

(2015). Overexposed. Consumer Reports, 80(3), 37-41. http://www.consumerreports.org/cro/2015/01/when-to-skip-ct-scans-and-x-rays/index.htm

Carroll, A.E. & Frakt, A. (2015). How to Measure a Medical Treatment’s Potential for Harm. New York Times, February 2.

Frakt, A. & Carroll, A.T. (2015). Can This Treatment Help Me? There’s a Statistic for That, New York Times, January 26.

Jena, A. B., Prasad, V., Goldman, D. P., & Romley, J. (2014). Mortality and Treatment Patterns Among Patients Hospitalized With Acute Cardiovascular Conditions During Dates of National Cardiology Meetings. JAMA internal medicine. doi:10.1001/jamainternmed.2014.6781 http://www.drperlmutter.com/wp-content/uploads/2015/01/Cardiac-outcome.pdf

Krogsbøll, L. T., Jørgensen, K. J., & Gøtzsche, P. C. (2013). General health checks in adults for reducing morbidity and mortality from disease. JAMA, 309(23), 2489-2490. http://drkney.com/pdfs/WAC_A_061913.pdf

Liang, B. A., & Mackey, T. (2011). Direct-to-consumer advertising with interactive internet media: global regulation and public health issues. JAMA, 305(8), 824-825. http://jama.jamanetwork.com/article.aspx?articleid=645713

Robins, E. D. (1984). Matter of Life & Death: Risks vs. Benefits of Medical Care. New York: W.H. Freeman and Company

Welch, H.G., Schwartz, L.M., & Woloshin, S. (2011). Over-diagnosed-Making people sick in the pursuit of health. Boston: Beacon Press.