Uncommon Common Sense – January 2013

Uncommon Common Sense

By Bill Frayer

Over-Diagnosis: Treating the Healthy?


Bill-Frayer-2010Many of us have had the uncomfortable experience of going to the doctor for routine laboratory tests and discovering that we have “abnormal” results.  In other words, when we went in we felt fine and seemed well, but we discovered that we were indeed not so fine and had some alarming numbers which suggested we were, in fact, sick. Sometimes, of course, medical screening does reveal underlying conditions and saves lives.  Routine colonoscopies, for example, undeniably find precancerous polyps and save many people from developing colon cancer.   

Over the past several years, however, many doctors and medical journalists have begun to question the wisdom of routine screening for many conditions.  In many cases, the “numbers” which indicate that a person falls in an abnormal range, have been lowered, so that levels which would previously have been considered normal are now considered abnormal and require treatment.  This, of course, creates millions of new patients and, obviously, new customers for the drug companies. 

So what’s the problem with over-diagnosis?  Isn’t it always better to be safe than sorry?  Not really.  The most obvious example may be using the PSA tests to screen for prostate cancer.  Since this screening became routine, men with elevated PSA results were urged to get prostate biopsies.  Since many men tested positive for cancer cells, they often underwent surgery to remove the prostrate, which killed a few of them and left many impotent or incontinent. The reality is, most prostate cancers are not lethal and most patients die from some other cause. In other words the costly, dangerous treatments are largely unnecessary.  So, over-diagnosing patients is not harmless.  It can be expensive and dangerous.

Of course, the idea of not screening is counter-intuitive.  We have all accepted the idea that finding disease early is critical. Unfortunately, it’s not that simple.  The screening for melanoma, breast cancer, prostate cancer, thyroid cancer, and ovarian cancer have not led to decreased deaths from these diseases.  We are diagnosing more cases, of course, but many of these cancers would not have killed the patients anyway.  We are creating tremendous anxiety, increasing the cost of healthcare, and subjecting patients to needless interventions, often for no reason. 

More examples: Before 1998, normal cholesterol was considered 240.  When the number was lowered to 200, it created 42 million more patients for the drug companies. When “normal” blood pressure was lowered from 160/100 to 140/90, 13.5 million new patients were created. In terms of mammography screening for breast cancer for women under 50, 1000 women need to be screened over a ten-year period to save one life!  Yet, many women have then been exposed to the radiation of mammography unnecessarily. In the case of the new blood pressure and cholesterol limits, those with lower range “abnormal” numbers have exceedingly few bad outcomes with no treatment whatsoever. 

Much of the information I have included here came from the book, Over-diagnosed by Welch, Schwartzl, and Woloshin, published in 2011 by Beacon Press. I have read similar articles in the New York Times and other newspapers as well.  I urge readers of the Ojo to investigate this topic for yourselves. So what does this suggest?  Certainly medical screening has its place. People with dangerous diseases can be identified and treated successfully. But does our paradigm have to change? Are more numbers and aggressive treatment of disease always beneficial?  Should we be skeptical about what lower-range abnormal numbers tell us? Is this one reason why medical costs in the United States are so high, yet the outcomes are far below those countries which spend far less? You decide.     

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