Is Preventive Medicine Actually Overtreatment?
IRA FLATOW, host:
Up next, for decades, one of the routine treatments for women with breast cancer has been not only to remove breast tissue but to cut out a large number of cancerous lymph nodes around the armpit also. But a new study out this week in the Journal of the American Medical Association suggests that sort of extensive surgery may actually offer no benefit for some women with the early stage breast cancer.
For women in this study with and without the operation but undergoing chemo and radiation, survival rates were very high, both of them, around 90 percent over five years. In this case, at least for about 20 percent of breast cancer patients, it appears that less is more, and they can do without the painful surgery, an example of overtreatment.
But overtreatment isn't just a problem for patients diagnosed with cancer. It could sometimes be a problem for healthy people, as my next guest writes in his book "Overdiagnosed: Making People Sick in the Pursuit of Health," because even healthy people are subject to more and more tests every time they visit the doctor.
Think about it, what do you do? You get the normal tests. You get your cholesterol level, maybe your liver test if you're doing statins, you have a PSA, you have a body scan, tests that are often they often result in treatment. And because the traditional dogma is, as my next guest writes, more early diagnosis means better medical care, which means more treatment; and more treatment means better health.
But is that traditional view true? Is it accurate? Should we still be thinking about it that way? Are all these tests and treatments actually improving our health or are we looking too hard for disease?
Dr. H. Gilbert Welch is the author of "Overdiagnosed: Making People Sick in the Pursuit of Health." He is professor of medicine at Dartmouth Medical School in Hanover, New Hampshire. He joins us from Vermont Public Radio. Welcome to SCIENCE FRIDAY, Dr. Welch.
Dr. H. GILBERT WELCH (Author, "Overdiagnose: Making People Sick in the Pursuit of Health): It's great to be with you, Ira.
FLATOW: Why is it because doctors can do all these diagnoses, all these tests that they do, do them?
Dr. WELCH: Well, certainly, part of it is what's possible, and what's possible is, of course, changed dramatically over the last year. But it's also part of our ethos, if you will, that it's always a good thing to look for early forms of disease. And, of course, that message just been sent out to the public through the media and other sources that, of course, the thing you want to do is look for early forms of disease.
But the truth is there are really two sides to the story. I think patients are used to thinking of treatments as having side effects, but so does testing. And the side effect of looking for early forms of disease is that we find, virtually, all of us have some. That's because we all harbor some abnormalities. And we never know which patients are those that have abnormalities that are going to cause problems in the future. So we tend to treat everybody we find with an abnormality and that means we're just treating some patients who can't benefit from our treatment because they were never going to develop the problem at hand if they're overdiagnosed.
FLATOW: But how do you say to the person, you know, that maybe in the minority, as you say, that you may have saved that person's life by overdiagnosing them? Is that worth of maybe one in a hundred cases?
Dr. WELCH: Well, I think that's the question we all need to face. And, you know, sort of, traditionally, doctors have focused on the one out of a thousand we might help by looking for early forms of disease. But we haven't really asked the question, what happens to the other 999? And this problem was really demonstrated to us in prostate cancer screening, which is really a poster child for the problem of overdiagnosis.
20 years ago, a simple blood test was introduced. And 20 years later, over one million Americans have been treated for a cancer that was never going to bother them. That test was the PSA, or prostate specific antigen. And it turned out an awful lot of men had abnormal PSAs. Many were found to have microscopic cancers far more than whatever suffer from prostate cancer.
Now, you might say, does it matter? Yeah, sure it matters because most of these men were treated with either radical surgery or radiation. And roughly a third suffered side effects of treatment generally related to bowel, bladder or sexual function. Even a few have died from it.
So this is a problem. It's a matter of finding the balance between the question of just how hard we should be looking for problems in well patients.
FLATOW: This is SCIENCE FRIDAY from NPR. I'm Ira Flatow with H. Gilbert Welch. We're talking about overdiagnosis. He's the author of "Overdiagnosed: Making People Sick in the Pursuit of Health."
And I you know, you picked up on an interesting line there because prostate cancer is one of those things where people are now saying, you know, every man is probably going to have prostate cancer if he lives long enough sometime in his life. And maybe we should just be do watchful waiting instead of doing all that treatment for some people.
Dr. WELCH: Well, I think that the question here is - before we get to the question of watchful waiting, at which point the patients already been told they have prostate cancer, I think we need to move back a step and recognize that the really important question is how hard to be looking and what different patients want. And I'm not arguing people shouldn't have PSA test. I'm arguing they should know both sides of the story. And I think different people in the exact same circumstance can make different decisions about it.
FLATOW: And so you have opted out of the PSA test?
Dr. WELCH: I certainly have. Just - first, there's a little bit of confusion about whether the test actually does do what it says it's suppose to do, which is to lower prostate cancer mortality. I believe it does. But I think you have to screen about a thousand men for a 10-year period annually for one to avoid a prostate cancer death. Now, that might seem like, sure, let's do it, if there was no downside to the process. But there is a downside to the process. Somewhere between a hundred to 200 hundred will have to biopsied over that period.
And more concerning, somewhere between 30 and 50 will have to be treated for a cancer that was never going to bother them. Now that treatment, as I said before, you know, had some real side effects. About a third of men will have some sexual, bowel or bladder dysfunction. Now, for me, as I look at those numbers, I said, boy, that's not a very good deal. I'll stay away from it. I'll accept the fact that maybe I'm the one in a thousand that will be helped. But I don't want to make that mistake, somewhat more common side effect of being treated unnecessarily.
Dr. WELCH: But it doesn't really matter what I think. It matters what patients think. And different patients may feel differently about it. And if they want to have prostate cancer screening, I'd say, go ahead. I just think people should know both sides of the story.
FLATOW: All right. We're going to come back and talk more with Gilbert Welch, author of "Overdiagnosed: Making People Sick in the Pursuit of Health." Our number: 1-800-989-8255. What do you think? Do you think you're getting too many tests at the doctor's office? Are you willing to forego some tests and maybe take your chances, thinking that, you know, it's not quite necessary? Give us a call: 1-800-989-8255. You can tweet us @scifri. Stay with us. We'll be right back after this break.
I'm Ira Flatow. This is SCIENCE FRIDAY from NPR.
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FLATOW: You're listening to SCIENCE FRIDAY. I'm Ira Flatow.
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Right now, we're talking about overdiagnosis with my guest, Gilbert Welch. He is author of "Overdiagnosed: Making People Sick in the Pursuit of Health." Our number: 1-800-989-8255.
When I go to my doctor, he takes, you know, vials of blood and he runs dozens of tests through them. Am I being foolish having all these tests done?
Dr. WELCH: Well, it's certainly a relevant question. We've gotten much more sort of infatuated with sort of routine screening tests, and some of those tests are reasonable to consider. But one of the things you should know is that we've been consistently changing the rules about what constitutes abnormal.
I'm talking now about conditions that are defined by numbers - things like high blood pressure, high cholesterol, diabetes and osteoporosis. All those diseases are defined by a number. If you're on the wrong side of that number, you have a condition.
Dr. WELCH: If you don't - on the right side of the number, you don't. But the numbers we've used to define those diseases have changed over the last 20 years. And in each case, they've changed in the same direction, to label more Americans as abnormal. And that's happened for a number of reasons. One, it's sort of true belief that it's always good to identify more people at risk, sort of a language that people would use. But there's also a lot of money behind it because it is - the quickest way to expand a market for a drug is to expand the number of patients who are supposed to take the drug.
And so there have been a lot of problems with conflicts of interest and physicians on these consensus panels that define these diseases. And that's just another dimension of the problem of overdiagnosis. This is labeling more people as abnormal, as needing treatment. And as you move into people who have milder and milder forms of a condition, fewer and fewer of them will actually go on to develop the feared consequence of the disease. But they still suffer the harms of treatment.
FLATOW: Mm-hmm. Let's go to...
Dr. WELCH: And so this is the kind of balance we have to think about more in this country, particularly since, you know, every day we get new tests. You know, you hear about a cancer test...
FLATOW: Right. Ask your doctor.
Dr. WELCH: ...that can find a single - yeah.
FLATOW: Ask your doctor about this drug or this new test. Let's go to Dave in New York, New York. Hi, Dave.
DAVE (Caller): Hi. Thanks for taking my call.
DAVE: I just am curious as a patient whether or not physicians are guided by liability to categorize as much as they can about a particular patient. And as a patient who carries insurance, am I at risk of being dropped? Because now, all of a sudden, even though I'm asymptomatic, I've now been tagged with a potential problem.
FLATOW: Is - are doctors over-testing because of liability? Are they afraid that if they don't, there's some liability there?
Dr. WELCH: Well, David actually brings up two issues. Let's first deal with the malpractice issue, which all my colleagues would want me to mention, which is part of the problem. It's not all of the problem. We feel, as physicians, that we're punished for underdiagnosis, but there's no corresponding penalty for overdiagnosis. So that's totally a symmetric set of incentives and, of course, that pushes us to overdiagnose.
But he also brings up another problem, which may, hopefully, will be fixed with health care reform, although I think it remains to be seen. And that is - there are downsides to having diagnoses. And one of the most immediate one for patients is - in the past, at least, and probably still currently - it does threaten your insurance. It may make it a lot more expensive to get insurance or you may not be able to get it at all.
But there are other downsides for diagnosis. You know, just being given a diagnosis tends to - can affect people's self-perception of their own health. The truth is, you know, health is more than simply a physical state of being. It's more than simply the absence of all abnormality. It's also a state of mind. And it's hard to feel too well when doctors are constantly looking for things to be wrong.
But the biggest problem with overdiagnosis is that it triggers overtreatment. And all of our treatments have harms. They range from the headaches of renewing prescriptions, scheduling appointments, subsequent testing, to the physical harms of the side effects of drugs, complications from surgery and even death.
FLATOW: Thanks for calling. And some of the times, is it not the case that these treatments - you talked about overtreatment as being the real danger here - that doctors make money on those treatments? They might be happy to have that diagnosis because they've got a treatment they can give you that will make them money?
Dr. WELCH: Yes. It's true that doctors make money on it, probably even more important, institutions make money on it. And now I'm thinking both about pharmaceutical companies and device manufacturers. And I'm also thinking about hospitals who have learned that disease screenings, free disease screenings, are a great way to recruit new patients. And that raises some huge ethical issues, whether this is the right thing for health care system to do is to be going out to look to identify in new patients who will then be paying patients.
FLATOW: Let's go to David in San Antonio. Hi, David.
DAVID (CALLER): Hi. As a prostate cancer survivor, I must say I generally agree with what you're saying about overdiagnosis. But the PSA, in general, just raised my ire and desire to call, because I feel like - I'm four years out from having prostate cancer and having the organ removed by robotic-assisted surgery, and I am totally happy that I did it.
And if I had not been having the regular PSA test, which my physician recommended since age 45, established a baseline for what my normal was and saw an up-going trend. Mine had reached - it was 1.1, 1.2, 1.3, then the other year it was 2.3 and then 3.9. He said, well, you know, it's trending up. We better have you sent for a biopsy.
I went in and saw the urologist, and he did the famous DRE and felt nothing. And said, well, we better schedule a biopsy anyway just to be sure because my finger isn't 100 percent accurate. And, well, a couple of weeks later, I had the biopsies as well. Make sure my people call you back. I don't see anything abnormal in the ultrasound that guides the probe nor in what we see so far.
Well, bottom line, the following Friday, the doctor called me. And when the doctor calls you, it's not to give you good news. And basically, he said your Gleason score 3 plus 3 bilateral and (unintelligible) to remove it. And I had it removed. And I was very happy that I did. So my bottom line is I think the PSA is a very useful tool. It does not diagnose cancer. But in the long term, it - watch your trend, and it'll tell you something is going wrong in your personal case.
FLATOW: Okay. Thanks for that testimonial. Gilbert? Dr. Welch, any - how do you react to that?
Dr. WELCH: Sure. I hope David was helped by the test, and I'm glad he's doing well. That's great and that's important. The truth is most men found to have prostate cancer following a PSA are not helped by the test. Probably one out of 1,000 that have been screened for 10 years will be helped by the test. We believe that to be the case. But somewhere between 30 and 60 are treated unnecessarily. I hope he's not in that group but the chances are he is.
And that's the problem with the - with early detection of, particularly, prostate cancer, but also thyroid and breast cancer. As we look for early forms of cancer, we recognize that virtually all of us harbor some early cancers. And we don't know which ones are ultimately going to be -matter, so we end up treating all of them. And that's the problem with looking for early forms of cancer.
FLATOW: So what do you do? What kind of advice do you give to people who go in to their doctors for their checkups, their annual, their physicals? Do you say to your doctor, I don't need this test? Don't give me that test. I've done my homework. I shouldn't be having this. Are you telling your doctor what to do?
Dr. WELCH: Well, I think the first thing people need to do is develop a little bit of healthy skepticism about the value of early diagnosis. I think, as a profession and the public health community, we've sort of systematically exaggerated the benefits of it. And we've either downplayed or totally ignored the harms. And it's time to be a little bit more open about both sides of the story, and the story is a complex one. It's a little counterintuitive. And that's why my colleagues and I wrote the book is so we could put it in one place, across the series of diseases, the problem of overdiagnosis.
And then I think patients have to do a little bit of a sort of self-assessment. Where do they sit on the spectrum between wanting to pursue disease? Is that the way they want to go through life, looking for things to be wrong, always hoping that there'll be a chance that they'll be able to avoid some future outcome? Or - and they accept the fact that they maybe medicalized unnecessarily along the way. Or whether you want to go to the other extreme, which I call to pursue health, which is to live well while you're feeling well. Certainly, you see a doctor when you don't feel well. But recognize that you may miss some potential benefit of avoiding a rare cause of death, but you also avoid being medicalized prematurely.
Now, I've drawn those as pretty discrete extremes. But I think this is a question we all have to address particularly as there are more and more tests and more and more ways we can look for things to be wrong within ourselves.
FLATOW: Mm-hmm. So you're saying the treatment may be worse than not doing anything at all? It's very...
Dr. WELCH: It's not that - it's - I want to go back a step. It's before the treatment. It's the test. Because once you're tested, once you're told you're abnormal, I think you've already suffered some of the downsides of testing.
Dr. WELCH: So, again, I want to be clear to your audience. I'm a conventionally-trained physician. I teach. I do research. I see patients. And I believe American medicine can do really good things for sick patients. The question is, how much to be involved with it when you are well.
FLATOW: Mm-hmm. 1-800-989-8255. What don't we know about diagnosis? That it's heading in a right direction or new techniques? Are there new techniques that you think are welcome, that you're happy to see being developed, diagnostic techniques, or we just - we have enough already?
Dr. WELCH: Oh, no. I think we're making a lot of advances. And, you know, so take CT scanning, for example...
Dr. WELCH: ...I mean, this is a way that - you know, it's been around 20 or 30 years, an MRI. It's a way we can now see the inside of the body in exquisite detail. It's been a great advance for us to evaluate people who are acutely ill and try to decide whether they have appendicitis or whether they're bleeding in their head or something. This is - there have been wonderful advances.
The problem is, when you deploy them on a normal population, the well population, you also find a lot of abnormalities. Almost all of us harbor meniscal tears in our knee, whether or not we have knee pain. We have discs popping out of our back even - whether or not we have a back pain. So the problem is they identified so many abnormalities in normal people, you don't know what to do. But all of the pressures on us are to go ahead and to treat those people.
FLATOW: I got you. Dr. Welch, thank you for taking time to be with us today, and good luck to you.
Dr. WELCH: Well, thank you for having me.
FLATOW: You're welcome. Dr. H. Gilbert Welch, author of "Overdiagnosed: Making People Sick in the Pursuit of Health." He's also a professor of medicine at Dartmouth Medical School in Hanover, New Hampshire.
This is SCIENCE FRIDAY from NPR.
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