WE ARE FREQUENTLY TALKING ABOUT CASES WHEN PROVIDING A DIAGNOSIS TAKES A LONG TIME AND REQUIRES A Few doctors to change The opposite situation – that is, overdiagnosis – is no less problematic. Because of it, a person is diagnosed with a disease or condition, which, most likely, will not manifest itself in any way during the patient’s life, but knowledge about them will still spoil this life. This is not an “erroneous conclusion”, because the diagnosis is being made correctly – however, without it being made, in most cases, nothing would have changed. At the same time, monitoring the condition will take up the time of the patient and medical personnel, require money and exert psychological pressure. That is why overdiagnosis is spoken of in a negative way: it does more harm than good.
Too many surveys
Overdiagnosis occurs primarily due to the fact that a person is exposed to variations in the structure of the body that will never cause harm, deviations from the (conditional) norm that do not progress or progress too slowly, or anomalies that will eliminate themselves. The reason is paradoxical – the higher the technical and laboratory capabilities, the more advanced methods we use, the greater the chance of finding “something”. This in itself is good, because it helps to identify diseases in the early stages. But advanced technology can be harmful if such examinations are carried out without evidence.
It is for this reason, and not because they “feel sorry”, that doctors do not send patients for research without a real reason. The physician’s job is to decide whether a particular test is needed in a particular situation. In order to neutralize differences in education or personal opinion, these decisions must be made on the basis of research that has proven the appropriateness of research in a particular situation. So that the doctor does not look for all the research conducted on the topic every time, there are clinical recommendations – they are made up of groups of experts who have already evaluated all noteworthy publications on this topic.
In Russia, the situation with the latter is not very good: for many specialties there are no uniform modern recommendations, and outdated standards have little in common with modern evidence-based medicine. In December 2018, a clinical guidelines law was finally approved . True, some associations, for example, the endocrinological one , have been publishing such recommendations for several years – and so far the problem of their simple non-compliance remains.
There are situations when the examination was carried out according to indications, but thanks to advanced methods, an overdiagnosis occurred and a “surprise” was discovered that was not related to the reason for the test. For example, with CT of the chest or abdomen, you can accidentally find a small benign adrenal tumor that does not manifest itself in any way – it is even called an incidentaloma .
The more accessible and more diverse the diagnostic methods, the more chances of finding “something” – and the higher the temptation to use them. Commercial laboratories have appeared that do not require a referral from a doctor to contact them – and, of course, insignificant deviations have begun to be detected more often. Unfortunately, there are no statistics on this topic – it is not known how many people did not undergo certain analyzes and how many deviations from the norm were detected in this case. But if you donated blood in a paid laboratory at least once in your life and were worried about receiving a form with a highlighted red parameter, which differed from the “normal range” by one, then you may also have been a victim of overdiagnosis.
To prevent this from happening, the feasibility of the analysis should be discussed with a competent specialist. There is no need to be tempted by a full-body PET-CT scan (positron emission tomography) for a quarter of the price or buying a glucometer “for self-monitoring” if you do not have diabetes. You should not sign up for a paid ultrasound examination of the thyroid gland just because you feel a “lump in your throat.” With a high probability, it will turn out to be a manifestation of a completely different condition (possibly emotional stress), but some nodules may be found in the thyroid gland – and this is precisely the case when early detection does not improve the results of treatment.
According to a study in South Korea, the incidence of thyroid cancer increased 6.4 times from 1999 to 2008. But despite the more frequent detection, mortality from thyroid cancer during this period did not change significantly. At the same time, 95% of neoplasms were small (less than 20 mm) and were detected by ultrasound screening. That is, the disease began to be detected more often at an earlier stage, and this did not affect the prognosis in any way: if it was later diagnosed and started to be treated, nothing would have changed.
Displacement of the boundaries of the norm
The reason for overdiagnosis may be a shift in the boundaries separating the “norm” and everything outside of it. For example, most people have trouble sleeping, sadness, or difficulty concentrating from time to time. For some, these symptoms are intense and debilitating, but most often they are mild or fleeting. While the former may benefit from diagnosis and treatment (for insomnia, depression, or attention deficit hyperactivity disorder), the latter may not benefit. A shift in the norm, in which any bad mood or insomnia is portrayed as a disease, sometimes a strategy of marketing campaigns aimed at promoting a new drug or method of treatment.
What does this lead to
and what to do
Overdiagnosis is a harmful and costly problem . It often leads to over-treatment without indications, and its consequences can be physical, psychological, social and financial. It’s not just about money for paid tests. Time in the hospital and doctors’ work are also expensive, and sometimes they are wasted – or could be wasted on a person in whose life the examination and treatment would really make a difference. As for the physical and psychological consequences , they primarily concern patients. By themselves, tests and examinations are accompanied by certain risks, and if the disease is detected, the risk of anxiety and depression increases. To prevent overdiagnosis from happening, the main thing a doctor can do is to follow clinical guidelines and the principles of evidence-based medicine.
In an ideal world, it would be enough to advise patients not to self-medicate and self-diagnose and follow the advice of doctors – however, the question remains that not all doctors are guided by clinical guidelines. Therefore, at least you should not hesitate to ask questions about your health and about why this or that analysis is needed. If you cannot get information from a doctor, you can use the Internet – only by choosing the right sources. You can see the clinical guidelines yourself (they are in the public domain), read the media about evidence-based medicine (for example, “ Just ask ” or “ Topical medicine ”), ask a question on the forum, or get telemedicine advice.
When is screening needed
For healthcare organizers, the issue of overdiagnosis is different: what research should be used as a screening and how to carry out a clinical examination so as not to reveal too much? Complex algorithms are used to plan the screening, and the tests selected must be sufficiently sensitive and specific. Sensitivity is the ability to give a positive result for all people who have the disease; Specificity is, on the contrary, the ability of the test to show that all healthy people are healthy.
In addition to these parameters, it is important how the disease is spread in the population, the same screening may not be recommended for everyone. There are special calculators that help calculate the value of a test as a screening test. Taking into account all these data, recommendations are made – for example, in the United States, they were brought into a convenient table with division by age.
For all adults, US guidelines require doctors to measure blood pressure, ask about smoking, and have a blood test for HIV infection . It is highly desirable to also assess alcohol consumption, symptoms of depression and body weight. Testing for hepatitis C virus infection is recommended for anyone born between 1945 and 1965 (and for people at high risk). Colon cancer screening is required from age 50 (or 45 for African Americans).
There are recommendations for screening separately for women: it is important that it is recommended to screen all women of reproductive age for partner violence . Cytological examination to exclude cervical cancer every three years is indicated for all women 21–65 years old. Breast cancer screening should be done every two years, starting at age 50 (or more often in high-risk women). There are slightly differing data according to which annual screening is recommended for women 45–54 years old, and every two years from 55 years old. Measurement of bone density (densitometry) to exclude osteoporosis, which is more common in women, is always performed if a high risk has been identified using the FRAX calculator , and from the age of 55 this examination is desirable for all women.
Men are advised to test for PSA (prostate-specific antigen) levels at the age of 40–69 years with a high risk of prostate cancer – but over the age of 70, this test is not advisable. Everyone – both children and adults – is recommended to regularly (once every 1-4 years) have visual acuity checked. There are similar tables for children and adolescents too . All other screening tests are performed only if risk factors are present. And no matter how terrible this or that disease may seem, you should not check for it yourself. It is better to discuss with your doctor when it is appropriate to do this (and whether it will be necessary at all).
How are things in Russia?
Screening newborns for congenital diseases is a good example of important screening. Since 2018, their list in Russia has expanded from five to eleven items. Early detection of these diseases helps to avoid serious health problems and even death. With adults, everything is much more complicated: our healthcare system does not maintain registers, thanks to which you, for example, will be called to the hospital for a CT scan to exclude lung cancer , knowing that you are from 55 to 77 years old, your smoker index is at least 30 pack-years and you continue to smoke (or quit no more than fifteen years ago). The system simply does not have such data. Therefore, it is necessary to communicate important information to the attending physician and remain within the limits of common sense: the fact that overdiagnosis exists does not mean that one should refuse examinations altogether.
Most likely, the future belongs to electronic medical records, preventive questionnaires for risk factors and the automation of these processes. Perhaps it will look like this: from your home computer, you enter your personal account on the website of the unified healthcare system and answer a number of questions. The system is loaded with a database of clinical recommendations and approved screening programs – and after filling out the questionnaire, information is displayed on the screen which examinations need to be signed up for this year. If the situation is more complicated than usual, then you will be offered a remote consultation to clarify the data.