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Over-diagnosis is making our health system, and us, sick

Date

Joe Kosterich

30-40 per cent of breast cancers detected on screening mammography are over-diagnosed, prompting women to have surgery.

30-40 per cent of breast cancers detected on screening mammography are over-diagnosed, prompting women to have surgery.

One of the great misnomers of our time is the term “health system”.

What we have is in fact a disease system. Virtually all the money spent on “health” is actually spent on disease.

In all the arguments about budgets each year, two questions never get asked. The first is how much of the money we spend on “health” actually benefits people. The second is how much harm is done in the name of “health.”

Scientists say we regularly test blood pressure, but does that help us diagnose disease?

Scientists say we regularly test blood pressure, but does that help us diagnose disease?

Over the last 30 years there have been three major trends, which have been accepted unquestioningly up until very recently. First is the introduction of screening tests where healthy people are tested for the possible presence of early disease. Second is our increasing ability to diagnose and treat “conditions” with no symptoms such as high blood pressure. The third is a relentless lowering of thresholds at which we classify people as having a disease.

All three have led to the over-diagnosis and needless treatment of many healthy people.

The concept of over diagnosis can be difficult to get your head around. It happens when people are “diagnosed” with a condition that would never manifest into a disease or illness during their lifetime. It would never cause any symptoms and would not shorten life expectancy.

Unless it is detected on a screening test, you would never know it was there and the fact that you did not know would not matter. It may seem incredible that such a problem can exist.

But it does exist and the cost in human and economic terms is considerable even though often hidden. Some 30-40% of breast cancers detected on screening mammography are over diagnosed leading women to have surgery and other treatments.

Of course, they are eternally grateful for having their lives saved.  Yet what these women don’t know and are not told is that they would have lived anyway.

A Canadian study published in the BMJ followed 89,835 women over a 25-year period. It found no difference in deaths from breast cancer (505 versus 500 in 25 years) in women who did or did not have regular mammograms.

It also showed that one in every five cancers found on screening were not going to be a threat to health and did not need treatment. Some previous reviews have put the over diagnosis rate as high as 40% or four out of every ten.

The situation is similar with prostate cancer. For every 3000 men having a screening PSA (prostate specific antigen) blood test done, three men will live longer. One will die due to complications of treatment he didn’t need. Some 129 will suffer harm from surgery and complications of treatment. Not great odds really.

This has come about because our understanding of cancer has not matched our ability to detect it. Not all cancers grow and develop. The American Cancer Council is looking at reclassification of early stage “harmless” growths using a term other than cancer, as they are not cancers in the way we think about cancer.

In heart health, it has been shown that there is no basis for current blood pressure recommendations. They seem like a good idea but there is no evidence to support them. You would hope that lifelong treatment with medication was based on more than a good idea.

Especially as treatment “targets” have been steadily lowered over the years and side effects are not always insignificant. The elderly, in particular, can faint and fall if their pressure is too low.

And there is the lowering of thresholds for “treating” raised cholesterol with statin medications. Again, major reviews have shown no benefit in people who do not have existing heart disease.

The cost to individuals and the system of tests, medications and other treatments, which do not improve health, is massive. Reducing this would free up plenty of money to be applied where it would actually provide benefit.

Is it that simple? Of course it is not. But unless we actually ask questions about usefulness we will never get answers. Overseas, interest among doctors and others in the health system is growing and this year the second international conference on over diagnosis will be held in the UK.

We have been sold the notion that early detection and treatment is all good. If we fully understand the benefits and risks, we can make an informed decision. When we are told simple tests will save our lives we are being told only a part of the story. In no other industry are unbalanced claims like this allowed.

As a society we need to be more questioning of how money is spent in the “health system.” As individuals we need to be much more questioning about claims of benefits from tests and treatments for problems, which probably won’t affect our health or longevity especially when the tests and treatments can cause us harm.

Dr Joe Kosterich is a GP and a health industry consultant

8 comments

  • Well my mother was given lithium to treat depression after my father died... she became a completely different person.. alienated all her lifetime friends and even me. She would sometimes stop taking these pills which made her even worse.

    One day she woke up, put her house up for sale and moved to the other side of the country, what person does that on the spur of the moment??

    It was a disgrace what doctors did to her. If some one dies your supposed to be depressed, you dont need drugs.

    The doctor who prescribed her those drugs should have his license revoked IMO. Disgusts me to this day.

    Commenter
    Enron
    Date and time
    June 04, 2014, 9:50AM
    • The medical profession take themselves far too seriously and despite much good they do, also can be a menace. I was once advised that I would probably need a back fusion, but luckily decided that it was more in the doctor's interest than mine. That was 30 years ago. Although it isn't perfect, my back is better than the people I know who have had back fusions.

      The other issue is the vehement opposition to homoeopathy. I laughed it off until I tried it. Perhaps the theory is a bit strange and possibly even primitive, but in the end it is up to the scientists to explain why things work, not to decide whether they work based on current theory. Imagine where Einstein would have been if he followed that line of reasoning.

      The medical profession does need to be held to account, but we also have to accept that we are somewhere between bleeding people for their ailments and something more sophisticated. It is questionable whether it is worth the money that the big medical companies make from it though.

      The one thing that is certain though is that lack of accountability is not limited to the medical profession. Just about all of them have similar issues.

      Commenter
      PR
      Date and time
      June 04, 2014, 11:09AM
      • Scientists have plenty of theories on why homeopathy "works". Firstly, there's the placebo effect (if you expect something to work, it will a bit). Then there's the body's own immune and repair system (drinking stuff that is pure water won't stop this from working, regardless of what the water "remembers"), There's also regression towards the mean (if you see a "health practitioner" when your allergies are at their worst, then there's a fair chance that they won't be so bad the next week...even if the practitioner cancels your meeting). And, last, but not least, talking to someone about your issues can help you feel better.

        Drug companies do clinical trials to check that their products have effects beyond those explained by these factors. All such trials on homeopathy have shown no difference from drinking pure water...probably because that's all they sell...

        Einstein was doubted for years, until experiments confirmed his theories. His theories were "a bit strange" but were proved to work; homeopathy's theories are completely wacky, and have been proven not to work.

        Commenter
        Phil
        Location
        Sydney
        Date and time
        June 04, 2014, 1:51PM
      • I can vouch for some homoeopathic remedies (regardless of the theory), having tried several so called "modern" alternatives that did not work as well. There were no different expectations as to their efficacy, so there is no reason the placebo effect would have any credibility.

        Homoeopathic theory might be completely wrong, but some (not all) of the medicines do work. Of course there are vested interests on both sides of the debate, so the best is to try it for yourself.

        Commenter
        PR
        Date and time
        June 04, 2014, 6:12PM
    • There is no health system, there is a medical services system. If you want to be healthy you have to give up sugar at a young age, milk at middle age and cut back on red meat, alcohol, coffee, greasy fries etc to about once a week. You need to ride a bike or walk every day instead of being glued to a chair. That would be a health system.

      Commenter
      bg
      Date and time
      June 04, 2014, 11:24AM
      • Homoeopathy- I have been treated by a homoeopath for 24 years and still I wonder each time,will it work? I have found it often does.Employers and a much younger flatmate had a severe flu for one week,I was off work for one day,employers and me were amazed.I visited an open day at a cherry farm established by a young Tasmanian farmer and he was asked how,without netting,did he protect the fruit from attacks by birds.he told the assembly he sprayed the trees with a homoeopathic solution and the fruit had suffered no attacks since.Explain that.I have been told many stories by people who swear by its efficacy.Doctors and drug companies discredit it because it poses a threat to their incomes,ie remedies are inexpensive.Patients are not given a remedy for the flu,they are assessed to determine why their immune systems have become weakened thus allowing disease to form.Many veterinarians utilise remedies to treat animals, with remarkable results.Do animals think it will work?

        Commenter
        winston
        Location
        Tasmania
        Date and time
        June 04, 2014, 7:40PM
        • Late 1970s I completed a course with a Japanese healing/spiritual organisation where you radiate white healing/purifying light to people.Young conservative woman had her young baby in a cot by her desk every Friday afternoon and I noticed the baby's forearm was heavily bandaged.The mother said she was running the bath with hot water,the telephone rang and when she returned the baby had put one arm in the hot bath.The doctor said it was a severe burn and the arm would be scarred for life.I asked if I could hold my hand 12 inches above the arm and it may or may not help.She declined,then agreed.Monday morn she rushed to my desk and said her baby got the bandage wet so it was removed and no scar evident.The doctor could not believe what had happened and how.The arm was the same condition as prior to the burn.Doctors generally perform worthy tasks but in the future I believe other healing modalities will also become more mainstream.Many doctors now possess qualifications in Reiki,homoeopathy and other forms of healing.

          Commenter
          winston
          Location
          Tasmania
          Date and time
          June 04, 2014, 8:08PM
          • Early treatment and standardized testing are great, but prevention is better. Spend the money on health promotion, if people lived healthy lifestyles, with correct knowledge (which would come from health promotion) there would be much less money wasted on tests and treatments, when it may be too late anyway.

            Commenter
            Lily Askins
            Location
            Brisbane
            Date and time
            June 04, 2014, 11:50PM
            Comments are now closed
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