When health services harm more than help
The dangers of overdiagnosis
A version of this commentary appeared in the Globe and Mail, the Medical Post and KevinMD
“First, do no harm,” as suggested by Hippocrates, is a vitalprinciple that should always guide physicians, but they are alsowell aware that in modern health care, whether in the form of drugs, operations, radiotherapy or any other form of treatment,there is always the possibility of causing harm to their patients. All drugs have potential adverse side effects and all surgerycarries risk. Doctors and patients need to be reasonably satisfiedthat the likely balance of benefit and harm with any interventionis favorable.Unfortunately, our ability now to test for and find insignificantabnormalities in people often leads to medical interventions thatoffer little or no benefit but still carry all the potential harms.Harm as a consequence of necessary treatment can be accepted, but exposing healthy people to harm fromtreatment that they should not have had in the first place is unacceptable. An international effort is now underway to identify the specifics of this “overdiagnosis” problem, to raise professionaland public awareness about it, and to attempt to bring it under control.Many features of our societal culture conspire to cause overdiagnosis and overtreatment, including the enormouspublic appetite for medical services, the erroneous notion that earlier diagnosis always causes a better result, thefear and denial of death, the huge advances in technology bringing an ever-widening range of sensitive diagnostictests, and the inevitable vested interests of drug and technology firms and of health care professions.The public are bombarded with messages on what disease they don’t know they have yet, what drug they should betaking, and what they must urgently talk to their doctor about.There are abundant examples in current medical practice. When enthusiastic specialty groups keep lowering thethreshold level for calling a test for diabetes, kidney failure or high blood pressure abnormal, many more people arelabeled with a disease. Drug firm advertising has convinced the public that cholesterol is a disease rather than anormal component of the blood. Normal human experiences, like grief, sadness, shyness, anxiety or hyperactivityrisk getting you a diagnosis of a psychiatric “disorder” accompanied, of course, by a drug prescription. The dangers
of sleeping pills and of antibiotics for viral infections do not seem to be understood by huge numbers of patients
and, unfortunately, many physicians also.Overdiagnosis is a serious problem in screening for cancer, especially of the prostate, breast and thyroid. This hasbeen a very hard lesson to learn in view of the high hopes and the resources that we have invested in screeningprograms as the way to reduce mortality from cancer. The initial hope for the benefit of breast (mammography) andprostate (PSA) screening has been tempered by the more recent evidence on the very small size of the potentialbenefit in relation to the substantial harm caused by false positive tests. For decades these screening tests have ledto biopsies revealing microscopic cells that are currently labeled as “cancer” by the pathologist, but with uncertainpotential to cause any significant problem for the patient in the future.