Published on Sep 26, 2013
Preventing Overdiagnosis: Winding back the harms of too much medicine
Dartmouth College – September 10-12, 2013
Overdiagnosis is the diagnosis of “disease” that will never cause symptoms or death during a patient‘s lifetime. Overdiagnosis is a side effect of screening for early forms of disease. Although screening saves lives in some cases, in others it may turn people into patients unnecessarily and may lead to treatments that do no good and perhaps do harm. Given the tremendous variability that is normal in biology, it is inherent that the more one screens, the more incidental findings will be found. For a large percentage of them, the most appropriate medical response is to recognize them as something that does not require intervention; but determining which action a particular finding warrants (“ignoring”, watchful waiting, or intervention) can be very difficult, whether because the differential diagnosis is uncertain or because the risk ratio is uncertain (risks posed by intervention, namely, adverse events, versus risks posed by not intervening).
Overdiagnosis occurs when a disease is diagnosed correctly, but the diagnosis is irrelevant. A correct diagnosis may be irrelevant because treatment for the disease is not available, not needed, or not wanted. Some people contend that the term “overdiagnosis” is inappropriate, and that “overtreatment” is more representative of the phenomenon.
Because most people who are diagnosed are also treated, it is difficult to assess whether overdiagnosis has occurred in an individual. Overdiagnosis in an individual cannot be determined during life. Overdiagnosis is only certain when an individual remains untreated, never develops symptoms of the disease and dies of something else. Thus most of the inferences about overdiagnosis comes from the study of populations. Rapidly rising rates of testing and disease diagnosis in the setting of stable rates of the feared outcome of the disease (e.g. death) are highly suggestive of overdiagnosis. Most compelling, however, is evidence from a randomized trial of a screening test intended to detect pre-clinical disease. A persistent excess of detected disease in the tested group years after the trial is completed constitutes the best evidence that overdiagnosis has occurred.
Although overdiagnosis is potentially applicable to the diagnosis of any disease, its origin is in cancer screening – the systematic evaluation of asymptomatic patients to detect early forms of cancer. The central harm of cancer screening is overdiagnosis – the detection of abnormalities that meet the pathologic definition of cancer (under the microscope) but will never progress to cause symptoms or death during a patient’s lifetime.
- 1 Overdiagnosis and the variability of cancer progression
- 2 Evidence for overdiagnosis in cancer
- 3 Harms of overdiagnosis
- 4 Distinction between overdiagnosis and false positive results
- 5 Overdiagnosis bias in survival statistics
- 6 Solutions to overdiagnosis
- 7 See also
- 8 References
- 9 Further reading