Reducing Overdiagnosis With Multilevel Approach

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There have been long-standing fears of false positives and excessive out-of-pocket payments.
There have been long-standing fears of false positives and excessive out-of-pocket payments.

The medical establishment needs to take responsibility for the rate of overdiagnoses resulting from screening practices that are sometimes unnecessary, an epidemiologist argued in The New England Journal of Medicine.

“No single approach will adequately address the issue,” writes Joann Elmore, MD, MPH, who is professor of medicine and adjunct professor of epidemiology at the University of Washington School of Medicine in Seattle, WA. 

“Instead, a multilevel approach ranging from research and education at the population level to intensified focus at the patient level is needed.”

The potential “collateral damage” of screening practices is not new. There have been long-standing fears of false positives and excessive out-of-pocket payments. More recently, multiple studies have pointed to the risk of overdiagnoses of cancer, explains Dr Elmore.

She says that although researchers and experts can get caught up in the minutiae of “statistical issues and study design, we should move forward by agreeing that overdiagnosis does occur, even though the exact percentage of overdiagnosed cases remains unknown.”

Dr Elmore suggests several strategies to tackle the problem, using breast cancer as an example to illustrate her proposed approach.

At the patient and population level, she says, patients should know about the potential for overdiagnosis before providing consent for a screening examination. Additionally, rather than screening large populations who are at low risk, high-risk individuals could be targeted, explains Dr Elmore.

At the provider level, better tools could be implemented to improve diagnostic processes, she argues.

“We are using archaic disease-classification systems with inadequate vetting and defective nosologic boundaries,” Dr Elmore writes. “Diagnostic thresholds for ‘abnormality' need to be revised, because the middle and lower boundaries of these classification systems have expanded without a clear benefit to patients.”

Finally, at the health-system level, providers should be given less credit for curing possibly benign diseases, she argues.

“The mantras, ‘All cancers are life-threatening' and ‘When in doubt, cut it out' requires revision,” advises Dr Elmore.

She concludes by pointing to arguably the most important quality of any patient-doctor relationship—trust.

“Building trust in science and medicine starts by taking ownership of all aspects of the screening cascade, including the collateral damage of our well-intentioned efforts,” she emphasizes.

 

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Reference

  1. Elmore JG. Solving the Problem of Overdiagnosis. N Engl J Med. 2016;375(15):1483-1486. doi: 10.1056/NEJMe1608683

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