Overtreatment : When Medicine Does More Harm Than Good

Why do millions of people a year get tests and procedures that they don’t really need ?

Researchers estimate that 21% of medical care is unnecessary.

Kaiser Health News senior correspondent Liz Szabo moderated a discussion a panel of experts to explore overtreatment.

KHN panelists were:

  • Dr. Louise Davies, An associate professor of otolaryngology – head and neck surgery in The Dartmouth Institute for Health Policy & Clinical Practice
  • Dr. Saurabh Jha, an associate professor of radiology at the University of Pennsylvania
  • Dr. Barry Kramer, director of the division of cancer prevention at the National Cancer Institute
  • Dr. Jacqueline Kruser, a pulmonologist and critical care physician at Northwestern University Feinberg School of Medicine
  • Dr. Ranit Mishori, professor of family medicine at the Georgetown University School of Medicine.
  • Reference.
  • Video source : KHN was live.

Screening for Cervical Cancer – US Preventive Services Task Force Recommendation Statement

New Cervical Cancer Screening Guidelines: What You Need to Know

Some women have a new option for cervical cancer screening — and it doesn’t necessarily involve a Pap test — according to updated guidelines from a government-appointed panel of experts, livescience reports.

Key Points

  • Women under age 21 should not be screened for cervical cancer.
  • Women ages 21 to 29 should undergo screening every three years using a Pap test, also called “cervical cytology.” (HPV testing isn’t recommended for women ages 21 to 29 because, in this age group, HPV infection is common and is often cleared by the immune system.)
  • Women over age 65 do not need to be screened for cervical cancer if they are up to date on their screening, their tests in the previous 10 years were negative and they don’t have other risk factors for cervical cancer.

Abstract

Importance
The number of deaths from cervical cancer in the United States has decreased substantially since the implementation of widespread cervical cancer screening and has declined from 2.8 to 2.3 deaths per 100 000 women from 2000 to 2015.

Objective
To update the US Preventive Services Task Force (USPSTF) 2012 recommendation on screening for cervical cancer.

Evidence Review
The USPSTF reviewed the evidence on screening for cervical cancer, with a focus on clinical trials and cohort studies that evaluated screening with high-risk human papillomavirus (hrHPV) testing alone or hrHPV and cytology together (cotesting) compared with cervical cytology alone. The USPSTF also commissioned a decision analysis model to evaluate the age at which to begin and end screening, the optimal interval for screening, the effectiveness of different screening strategies, and related benefits and harms of different screening strategies.

Findings
Screening with cervical cytology alone, primary hrHPV testing alone, or cotesting can detect high-grade precancerous cervical lesions and cervical cancer. Screening women aged 21 to 65 years substantially reduces cervical cancer incidence and mortality. The harms of screening for cervical cancer in women aged 30 to 65 years are moderate. The USPSTF concludes with high certainty that the benefits of screening every 3 years with cytology alone in women aged 21 to 29 years substantially outweigh the harms. The USPSTF concludes with high certainty that the benefits of screening every 3 years with cytology alone, every 5 years with hrHPV testing alone, or every 5 years with both tests (cotesting) in women aged 30 to 65 years outweigh the harms. Screening women older than 65 years who have had adequate prior screening and women younger than 21 years does not provide significant benefit. Screening women who have had a hysterectomy with removal of the cervix for indications other than a high-grade precancerous lesion or cervical cancer provides no benefit. The USPSTF concludes with moderate to high certainty that screening women older than 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer, screening women younger than 21 years, and screening women who have had a hysterectomy with removal of the cervix for indications other than a high-grade precancerous lesion or cervical cancer does not result in a positive net benefit.

Conclusions and Recommendation
The USPSTF recommends screening for cervical cancer every 3 years with cervical cytology alone in women aged 21 to 29 years. (A recommendation) The USPSTF recommends screening every 3 years with cervical cytology alone, every 5 years with hrHPV testing alone, or every 5 years with hrHPV testing in combination with cytology (cotesting) in women aged 30 to 65 years. (A recommendation) The USPSTF recommends against screening for cervical cancer in women younger than 21 years. (D recommendation) The USPSTF recommends against screening for cervical cancer in women older than 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer. (D recommendation) The USPSTF recommends against screening for cervical cancer in women who have had a hysterectomy with removal of the cervix and do not have a history of a high-grade precancerous lesion or cervical cancer.

Recommendations of Others

… “Women at increased risk of cervical cancer (ie, women with a history of cervical cancer, a compromised immune system, or diethylstilbestrol exposure) may need to be screened more often.” …

Reference. US Preventive Services Task Force, August 21, 2018.

Is early detection always the best medicine ?

The Recommended Dose, with Alexandra Barratt

Hosted by acclaimed journalist and health researcher Dr Ray Moynihan, The Recommended Dose tackles the big questions in health and explores the insights, evidence and ideas of extraordinary researchers, thinkers, writers and health professionals from around the globe. The series is produced by Cochrane Australia and co-published with the BMJ.

Press Play > to listen to the recording.

Dr Ray Moynihan’s guest has led something of a double life, using both medicine and the media to explore and promote the critical role of evidence in healthcare. Now based at the University of Sydney, Alexandra Barratt‘s journey from clinician to journalist to global advocate for evidence based medicine and shared decision-making is a fascinating one.

Here Alexandra talks with Ray about her varied career and the reasons she’s ended up challenging conventional wisdom. She also talks about her research into the pros and cons of breast cancer screening and questions the widely-accepted idea that early detection is always the best medicine.

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USPSTF Draft Recommendation Statement Cervical Cancer : Screening

The US Preventive Services Task Force has New Draft Guidance for Cervical Cancer Screening

These recommendations do NOT apply to women with in utero exposure to diethylstilbestrol or women who have a compromised immune system (e.g., women living with HIV).

The major change from the US Preventive Services Task Force (USPSTF) 2012 recommendation is that testing for high-risk strains of human papillomavirus (hrHPV) alone is now recommended as an alternative to cytology or Papanicolaou (Pap) screening alone beginning at age 30 years; cotesting is no longer recommended.

As in the 2012 recommendation, the USPSTF continues to recommend that women aged 21 to 29 years undergo Pap screening every 3 years.

The USPSTF recommend against screening in women younger than age 21 years because there is adequate evidence that regardless of sexual history, screening younger women does not reduce cervical cancer incidence or mortality.

The USPSTF also continues to give a thumbs down to screening in women older than age 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer, as well as in women who have had a hysterectomy and their cervix removed and do not have a history of a high-grade precancerous lesions or cervical cancer.

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The Little Known Truth About Mammograms

Adam Ruins The Hospital – Season 2 | Ep 203, 2017

Mammograms might be able to detect cancer but they can’t tell the difference between different types. Turns out, mammograms can harm and save much fewer lives than you think.

Diagnostic tests : how to minimise harm

We must develop new diagnostic tests to tackle real health problems, not to generate them

New diagnostic tests: more harm than good, BMJ 2017;358:j3314,
06 January 2016.

Defenders against overdiagnosis, BMJ 2017;358:j3487, 20 July 2017.

Although new diagnostics may advance the time of diagnoses in selected patients, they will increase the frequency of false alarms, overdiagnosis, and overtreatment in others.

Bjorn Hofmann, professor of medical ethics at Norwegian University of Science and Technology, explains how to minimise harm. Press Play > to listen to the recording.

Key messages

  • Innovative technologies and ample venture capital are combining to produce new disease biomarkers and mobile monitoring devices
  • These new diagnostics are technologically advanced but do not automatically provide improvements in clinical care and population health
  • They have the potential to help some but also to increase the frequency of false alarms, overdiagnosis, and overtreatment in others
  • Excessive testing and false alarms may increase healthcare workload and shift clinicians’ focus towards the healthy
  • Misleading feedback at both the population and individual levels tends to favour further market growth
  • Clinicians must provide a strong counterbalance: educating patients, respecting baseline risk, thinking downstream, and expecting misleading feedback

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The New War on Cancer

50-Year War on Cancer: Can We Win?

The signing of the National Cancer Act by President Richard M. Nixon on December 23, 1971, was considered a declaration of war on cancer.

In a multi-part series, the National Post explores why we need a new war on cancer.

Cancer nation

Where you live could affect your odds of getting cancer or dying from it.

Interactive map: Cancer is an indiscriminate disease, affecting rich and poor, old and young. Still, Canadians’ odds of getting sick depend surprisingly on where they live.

Why we need a new war on cancer

Over-treating and over-screening is doing patients more harm than good

The issue: Advances in screening and diagnosis are sending some cancer patients down aggressive treatment paths that they shouldn’t be on.
The solution: A new war on cancer and a rethinking of resources.

Drug money

Some cancer treatments cost as much as $33,000 a month, but fall well short of being wonder cures

A Post analysis of 17 cancer drugs that cost between $4,700 and $33,000 a month reveals only three had evidence that they extended lives when approved by Health Canada.

Bankrupt by cancer

Cancer is not just a life-threatening disease ― but a financial disaster.

In Canada, a country that prides itself on looking after the sick, no matter their ability to pay, Canadians are declaring bankruptcy because of cancer.

The fundraising complex

Of the $2.7 billion that cancer charities spent in 2013, only 45 per cent went towards fighting cancer.

The Post’s analysis of cancer funding reveals the depth of inefficiencies in the sector. In 2013, more than half of total funds went to salaries and overhead.

Learning to live with cancer

As science gets better at controlling cancer for longer periods of time, it might be best to kill the battle rhetoric

Nowhere else in medicine is the battle rhetoric more entrenched than in cancer. And its defeating people. Who wants to go war with their own bodies?

Prevention as the ultimate cure

Prevention saves more lives than any cancer drug

However, in the multi-billion-dollar cancer business, efforts to stop people from contracting the illness account for as little as five per cent of what’s spent.

How to reduce your risk of becoming a breast cancer patient by one third

Dr Peter Gøtzsche’s views on breast cancer screening

Video published on 1 April 2015 by John McDougall.

Peter C. Gøtzsche, MD is a Danish medical researcher, and leader of the Nordic Cochrane Center at Rigshospitalet in Copenhagen, Denmark. He has written numerous reviews within the Cochrane collaboration.

Dr.Gøtzsche has been critical of screening for breast cancer using mammography, arguing that it cannot be justified; His critique stems from a meta-analysis he did on mammography screening studies and published as Is screening for breast cancer with mammography justifiable? in The Lancet in 2000. In it he discarded 6 out of 8 studies arguing their randomization was inadequate.

In 2006 a paper by Gøtzsche on mammography screening was electronically published in the European Journal of Cancer ahead of print. The journal later removed the paper completely from the journal website without any formal retraction. The paper was later published in Danish Medical Bulletin with a short note from the editor, and Gøtzsche and his coauthors commented on the unilateral retraction that the authors were not involved in.

In 2012 his book Mammography Screening: Truth, Lies and Controversy was published. In 2013 his book Deadly Medicines and Organized Crime: How Big Pharma has Corrupted Healthcare was published.

Breast cancer screening not associated with a reduction in the incidence of advanced cancer

Mammograms tied to overdiagnosis of breast cancer

The current study offers fresh evidence linking routine screening to over-diagnosis of non-aggressive tumors because it compares outcomes over a single time period in two regions of Denmark – one that offered biennial mammography for women aged 50 to 69 and one that didn’t.

January 2017 Study Abstract

Background
Effective breast cancer screening should detect early-stage cancer and prevent advanced disease.

Objective
To assess the association between screening and the size of detected tumors and to estimate overdiagnosis (detection of tumors that would not become clinically relevant).

Design
Cohort study.

Breast Cancer Screening in Denmark: A Cohort Study of Tumor Size and Overdiagnosis, Annals of Internal Medicine, DOI: 10.7326/M16-0270, 10 JANUARY 2017.

Philips Mammography Truck, Brazil via philips_newscenter.

Setting
Denmark from 1980 to 2010.

Participants
Women aged 35 to 84 years.

Intervention
Screening programs offering biennial mammography for women aged 50 to 69 years beginning in different regions at different times.

Measurements
Trends in the incidence of advanced (>20 mm) and nonadvanced (≤20 mm) breast cancer tumors in screened and nonscreened women were measured. Two approaches were used to estimate the amount of overdiagnosis: comparing the incidence of advance and nonadvanced tumors among women aged 50 to 84 years in screening and nonscreening areas; and comparing the incidence for nonadvanced tumors among women aged 35 to 49, 50 to 69, and 70 to 84 years in screening and nonscreening areas.

Results
Screening was not associated with lower incidence of advanced tumors. The incidence of nonadvanced tumors increased in the screening versus prescreening periods (incidence rate ratio, 1.49 [95% CI, 1.43 to 1.54]). The first estimation approach found that 271 invasive breast cancer tumors and 179 ductal carcinoma in situ (DCIS) lesions were overdiagnosed in 2010 (overdiagnosis rate of 24.4% [including DCIS] and 14.7% [excluding DCIS]). The second approach, which accounted for regional differences in women younger than the screening age, found that 711 invasive tumors and 180 cases of DCIS were overdiagnosed in 2010 (overdiagnosis rate of 48.3% [including DCIS] and 38.6% [excluding DCIS]).

Limitation
Regional differences complicate interpretation.

Conclusion
Breast cancer screening was not associated with a reduction in the incidence of advanced cancer. It is likely that 1 in every 3 invasive tumors and cases of DCIS diagnosed in women offered screening represent overdiagnosis (incidence increase of 48.3%).

Regular Mammograms Risk-Benefit Characterization Theater

Breast-Cancer and Mammography : Consider the Pros and Cons

How Tiny Are Benefits From Many Tests And Pills? Researchers Paint A Picture

Mammograms are said to cut the risk of dying from breast cancer by as much as 20 percent ; some researchers want people to question that kind of thinking.

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