Jack O’Sullivan (@JackOSullivan3) recounts highlights from the third Preventing Overdiagnosis Conference, hosted last week by U.S. National Cancer Institute.
Fifteen hundred years BC, the Ancient Egyptians recognised the potential harms of overtreatment – ‘tumor against the god Xenus, do thou nothing there against’. Millennia later, at the National Institutes of Health, the third Preventing Overdiagnosis Conference again provided much debate around medicine’s fundamental paradox: the harms of too much medicine.
Hosted by the National Cancer Institute (US), Oxford University’s Centre for Evidence-Based Medicine, Bond University, The Dartmouth Institute, Consumer Reports and the British Medical Journal (BMJ) clinicians, patients, academics and policy makers enjoyed a full three days of academic reflection.
Cancer, and the difficulty in delivering the appropriate diagnosis and treatment at the appropriate time, was extensively covered. Cancer screening is perhaps the most contentious example, with breast, cervical, prostate and thyroid discussed in detail. Fundamentally, where a significant increase in cancer incidence with no change in mortality is observed over time, there is a strong suspicion that the increased incidence represents cancer of no clinical significance. This argument is particularly compelling where the introduction of a new screening test coincides with a rapid increase in incidence. South Korea’s thyroid cancer ‘epidemic’(paywall), presented by Hyeong Sik Ahn of the Korea University School of Medicine, was perhaps the most striking example of this.
Aside the attempts to quantify overdiagnosis within cancer screening programs, basic flaws in current medical care were discussed. Steve Woloshin and Lisa Schwartz, both from the Dartmouth Institute, explained how pharmaceutical companies use disease awareness campaigns to sell sickness. These campaigns consist of the following steps:
- ‘Lowering the disease threshold’, such as introducing pre-disease (e.g. pre-diabetes) and changing diagnostic definitions.
- ‘Raising the stakes’, a marketing campaign highlighting the dangers of a disease.
- ‘Spin the evidence’, mainly playing down side effects and highlighting benefits.
On a similar note, Cindy Pearson, Executive Director of the National Women’s Health Network, discussed her disappointment with the FDA’s approval of flibanserin (Addyi), the new medication to treat female hypoactive sexual desire disorder. She noted that the medication had previously been rejected twice and accepted on a third attempt, only after new evidence (with altered outcome measurements) emerged. Regardless, given the paucity of proven benefit and clear risks, Pearson emphasised that the approval of this medication was a marketing success, rather than one of science or equality.
An interesting and unresolved debate surrounds the future of diagnostics. On one side, Laura Esserman of the University of California, San Francisco and others discussed the need for better identification of low risk disease. They argued that, once identified, appropriate monitoring of these diseases could help mitigate risk. The most fitting example is Ductal Carcinoma in situ (DCIS), with the suggested follow up a combination of clinical, biochemical and radiological tests. The converse argument claims that where evidence suggests no treatment benefit in early detection, then early identification can only induce harm. This argument stems from the belief that a diagnosis, particularly one of cancer, has human costs (psychological, financial, opportunity costs) as well as health care costs (profligate use of resources). The monitoring approach may also lead to potentially unnecessary invasive intervention (diagnostic or therapeutic).
Importantly, amongst detailed discussion of identification and consequences of overdiagnosis, solutions were suggested and their importance emphasised. The notion of embracing uncertainty is essential. An honest conversation between clinicians and patients, based on evidence, but acknowledging the unknown is ideal and would surely prompt a truly shared decision. To engage clinicians and patients, public campaigns were suggested as well as cooperation with other like-minded organisations (Lown Institute’s RightCare for example). The formal dedication of teaching overdiagnosis in medical education was also put forward.
The third Preventing Overdiagnosis conference provided a wonderful insight into world-class research exploring the issues of overdiagnosis. In spite of its strengths, there is room for improvement. There is a notable lack of allied health professionals. A stronger presence from patients and politicians would also be advantageous. Pertinent issues such as appropriate location of care (e.g. the ever-increasing burden on emergency departments) and conflicts of interest amongst panels of experts that define disease were not covered. Finally, discussions around too much medicine in the developing world are long overdue.
The obstreperous voice calling for more parsimonious medicine grew stronger at this meeting. Most significantly, the conference highlighted the upmost importance of being solution focused, a vital point as we look towards the 2016 conference, to be held in Barcelona.
Jack O’Sullivan recounts highlights from the third Preventing Overdiagnosis Conference, hosted last week by U.S. National Cancer Institute. @JackOSullivan3