3 ms·

Scans don’t cause overdiagnosis. Eager checklist-driven doctors cause overdiagnosis. You will see incidentalomas, how you use that information is not preordaine

Scans don’t cause overdiagnosis. Eager checklist-driven doctors cause overdiagnosis. You will see incidentalomas, how you use that information is not preordained.

astura 9y ago
Scans directly cause overdiagnosis. It's very non-intuitive but scans and tests have the potential to cause more harm than good. From TFA: >Overtesting has also created a new, unanticipated problem: overdiagnosis. This isn’t misdiagnosis—the erroneous diagnosis of a disease. This is the correct diagnosis of a disease that is never going to bother you in your lifetime. We’ve long assumed that if we screen a healthy population for diseases like cancer or coronary-artery disease, and catch those diseases early, we’ll be able to treat them before they get dangerously advanced, and save lives in large numbers. But it hasn’t turned out that way. For instance, cancer screening with mammography, ultrasound, and blood testing has dramatically increased the detection of breast, thyroid, and prostate cancer during the past quarter century. We’re treating hundreds of thousands more people each year for these diseases than we ever have. Yet only a tiny reduction in death, if any, has resulted. >H. Gilbert Welch, a Dartmouth Medical School professor, is an expert on overdiagnosis, and in his excellent new book, “Less Medicine, More Health,” he explains the phenomenon this way: we’ve assumed, he says, that cancers are all like rabbits that you want to catch before they escape the barnyard pen. But some are more like birds—the most aggressive cancers have already taken flight before you can discover them, which is why some people still die from cancer, despite early detection. And lots are more like turtles. They aren’t going anywhere. Removing them won’t make any difference. >Over the past two decades, we’ve tripled the number of thyroid cancers we detect and remove in the United States, but we haven’t reduced the death rate at all. In South Korea, widespread ultrasound screening has led to a fifteen-fold increase in detection of small thyroid cancers. Thyroid cancer is now the No. 1 cancer diagnosed and treated in that country. But, as Welch points out, the death rate hasn’t dropped one iota there, either. (Meanwhile, the number of people with permanent complications from thyroid surgery has skyrocketed.) It’s all over-diagnosis. We’re just catching turtles.
- paulsutter 9y ago
  Solution -> never show a scan to a doctor who will over-react to an incidentaloma
  - astura 9y ago
    It's not "overreacting." If you do a scan in someone asymptomatic and see a tumor it's oftentimes completely impossible to know if it's a "turtle" or a "bird." They can look exactly the same and we don't have a crystal ball.
    - paulsutter 9y ago
      Just wait and see how it develops. My doctor agrees, you could check with yours. By your argument, if there's no need to scan, there's no need to treat it right away either. Of course, if you are the sort of person who is prone to panic, you probably don't want to get a scan
  - emiliobumachar 9y ago
    That doctor needs to be somehow shielded from lawsuits, or they'll be incentivised to give undue weight to the risk of leaving something real untreated.
    - paulsutter 9y ago
      Good point. Of course, the overdiagnosis is then caused by the legal environment (not the scan). As an individual of course you can always sign a release for your doctor. If he seems uneasy about nontreatment, just write a letter to release him from liability for nontreatment so he knows he can relax and actually consider your wellbeing rather than liability.
      - emiliobumachar 9y ago
        Interesting. But you also don't want to bias them toward nontreatment (do you?). I wonder if one would get better outcomes in lawsuit-heavy countries by just starting all interactions with health professionals by handing out unsolicited full liability releases like candy. "I want you to do what you think can work, not what is easy to justify if it fails." Maybe only if one has a particularly difficult health condition.

Scans don’t cause overdiagnosis. Eager checklist-driven doctors cause overdiagnosis. You will see incidentalomas, how you use that information is not preordained.

astura 9y ago

Scans directly cause overdiagnosis. It's very non-intuitive but scans and tests have the potential to cause more harm than good. From TFA: >Overtesting has also created a new, unanticipated problem: overdiagnosis. This isn’t misdiagnosis—the erroneous diagnosis of a disease. This is the correct diagnosis of a disease that is never going to bother you in your lifetime. We’ve long assumed that if we screen a healthy population for diseases like cancer or coronary-artery disease, and catch those diseases early, we’ll be able to treat them before they get dangerously advanced, and save lives in large numbers. But it hasn’t turned out that way. For instance, cancer screening with mammography, ultrasound, and blood testing has dramatically increased the detection of breast, thyroid, and prostate cancer during the past quarter century. We’re treating hundreds of thousands more people each year for these diseases than we ever have. Yet only a tiny reduction in death, if any, has resulted. >H. Gilbert Welch, a Dartmouth Medical School professor, is an expert on overdiagnosis, and in his excellent new book, “Less Medicine, More Health,” he explains the phenomenon this way: we’ve assumed, he says, that cancers are all like rabbits that you want to catch before they escape the barnyard pen. But some are more like birds—the most aggressive cancers have already taken flight before you can discover them, which is why some people still die from cancer, despite early detection. And lots are more like turtles. They aren’t going anywhere. Removing them won’t make any difference. >Over the past two decades, we’ve tripled the number of thyroid cancers we detect and remove in the United States, but we haven’t reduced the death rate at all. In South Korea, widespread ultrasound screening has led to a fifteen-fold increase in detection of small thyroid cancers. Thyroid cancer is now the No. 1 cancer diagnosed and treated in that country. But, as Welch points out, the death rate hasn’t dropped one iota there, either. (Meanwhile, the number of people with permanent complications from thyroid surgery has skyrocketed.) It’s all over-diagnosis. We’re just catching turtles.

paulsutter 9y ago
Solution -> never show a scan to a doctor who will over-react to an incidentaloma
- astura 9y ago
  It's not "overreacting." If you do a scan in someone asymptomatic and see a tumor it's oftentimes completely impossible to know if it's a "turtle" or a "bird." They can look exactly the same and we don't have a crystal ball.
  - paulsutter 9y ago
    Just wait and see how it develops. My doctor agrees, you could check with yours. By your argument, if there's no need to scan, there's no need to treat it right away either. Of course, if you are the sort of person who is prone to panic, you probably don't want to get a scan
- emiliobumachar 9y ago
  That doctor needs to be somehow shielded from lawsuits, or they'll be incentivised to give undue weight to the risk of leaving something real untreated.
  - paulsutter 9y ago
    Good point. Of course, the overdiagnosis is then caused by the legal environment (not the scan). As an individual of course you can always sign a release for your doctor. If he seems uneasy about nontreatment, just write a letter to release him from liability for nontreatment so he knows he can relax and actually consider your wellbeing rather than liability.
    - emiliobumachar 9y ago
      Interesting. But you also don't want to bias them toward nontreatment (do you?). I wonder if one would get better outcomes in lawsuit-heavy countries by just starting all interactions with health professionals by handing out unsolicited full liability releases like candy. "I want you to do what you think can work, not what is easy to justify if it fails." Maybe only if one has a particularly difficult health condition.