Back when I was still in clinical practice, my newly pregnant patient Samantha, accompanied by her husband John, asked if I would order every medical test known to modern science in order to guarantee, beyond a shadow of a doubt, that both mother and baby would be healthy, chromosomally intact, genetically perfect, and immune to any risks of pregnancy or childbirth. Samantha was a young, healthy twenty-eight-year-old woman. Neither Samantha or John had any personal or family risk factors, and from what I could gather, Samantha’s pregnancy was likely to be as low risk as they come.
I warned them that ordering unnecessary tests increases the risk of false positives, putting Samantha and the baby at risk of overtreatment. I also warned them that insurance would not cover unindicated testing, and they’d wind up with a whopping bill if I did order these tests. They didn’t care. Samantha was an heiress, and they were willing to spend anything to ensure that Samantha and the baby would be healthy.
Because I’m well acquainted with the dangers of overdiagnosis and overtreatment, and because, like all good doctors, I took the Hippocratic Oath that made me promise to “first, do no harm,” I didn’t feel comfortable ordering tests that were likely to cause more harm than good. Instead, I initiated a conversation with Samantha and John about how, as a mother and recovering control freak myself, I understand how much anxiety can spring forth during a pregnancy. We’d all love to think that we can test our way to certainty, eliminate risk, and guarantee a positive outcome. But as any experienced OB/GYN or midwife knows, the only thing certain about pregnancy and childbirth is uncertainty.
The Struggle for Control
When it comes to health, many people manage the fear, uncertainty, and vulnerability of the body’s fragility by going from doctor to doctor, begging for more tests. Surely, more tests are better, right? If we test for everything, we won’t miss anything, right?
It’s a known fact that patients are getting too many tests these days. And it’s not just patients who are guilty of requesting too many tests. Doctors are just as responsible for the epidemic of overtesting.
A recent New York Times article points out the harmful toll overdiagnosis and overtreatment may take on your health. What many don’t realize is that every time a test is performed, you run the risk of either falsely diagnosing, misdiagnosing, or overdiagnosing a disease.
What Is Overdiagnosis?
A false positive test result means the test comes back positive, even when the disease doesn’t really exist. It’s a function of the test itself, and every test has a specified false positive rate. Misdiagnosis, on the other hand, means somebody made a boo boo. Overdiagnosis means making a real diagnosis that needn’t be diagnosed.
Nowhere is the problem of overtesting more painfully obvious than in the quest for early detection and prevention of cancer, the disease Americans fear as their number one health concern (second is Alzheimer’s disease for those who are curious.)
A study published in the Journal of the National Cancer Institute estimates that twenty-five percent of breast cancers detected on mammogram, fifty percent of lung cancers diagnosed by chest X-ray and sputum analysis, and sixty percent of prostate cancers diagnosed by prostate specific antigen (PSA) are “overdiagnosed.” The authors of the study define “overdiagnosis” as “the diagnosis of a ‘cancer’ that would otherwise not go on to cause symptoms or death.”
Overdiagnosis is not the same as a misdiagnosis, which implies that the pathologist made a mistake looking at the specimen under a microscope. Overdiagnosis of cancer suggests that the cancer exists, but that it could be argued that it is clinically irrelevant. That, if left untreated, it would either regress spontaneously (we know this happens), or the patient would die of something else before the cancer caused death.
The authors describe how these overdiagnoses can harm patients and reduce quality of life, leading to medically unnecessary procedures, such as radical surgery and treatments known to predispose to future cancers, such as chemotherapy and radiation. The authors conclude, “Whereas early detection may well help some, it undoubtedly hurts others. In general, there is no right answer for the resulting trade-off between the potential to avert a cancer death and the risk of overdiagnosis. Instead, the particular situation and personal choice have to be considered.”
What Should We Do?
So what’s a health conscious, cancer-fearing patient to do? I’ll be sharing my answer to this question in Part Two of this blog series.
Until then, tell me what you think about all this. Have you or anyone you know been overdiagnosed or overtreated? Tell us your stories here.
Committed to your health,
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