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The issue of overdiagnosis and overtreatment has recently been in the news, especially when discussing breast cancer, prostate cancer, and thyroid cancer. Meaning too much unnecessary treatment with harms, when the best approach would have been to do nothing, as studies have suggested or actually shown. Now here is an article in Medscape suggesting that rather than be quick to operate or treat, the best approach for nearly 70% of prostate cancers may be just "watching".

The U.S. Preventive Task Force, which analyzes the value of screening tests, in May 2012 recommended AGAINST routine prostate-specific antigen (PSA)-based screening for prostate cancer for all age groups. According to them, studies do not show that benefits of routine screening of asymptomatic prostate cancer and the resulting treatment outweigh the harms of treatment (e.g., surgical complications including death from surgery, erectile dysfunction, urinary incontinence, bowel dysfunction, and bladder dysfunction), or that prostate cancer treatment even reduces mortality (deaths).

They point out that: "There is convincing evidence that PSA-based screening programs result in the detection of many cases of asymptomatic prostate cancer. There is also convincing evidence that a substantial percentage of men who have asymptomatic cancer detected by PSA screening have a tumor that either will not progress or will progress so slowly that it would have remained asymptomatic for the man's lifetime. The terms "overdiagnosis" or "pseudo-disease" are used to describe both situations." (NOTE: others have argued against this recommendation)

When reading the full Medscape article, it was pointed out that in the study being discussed, one person who was offered active surveillance but declined and was treated with an immediate radical prostatectomy, still died of metastatic prostate cancer. This was an example of a case where when the disease is truly aggressive, it may have spread "like a bird" throughout the body (in Dr. H. Gilbert Welch's terms in his books Overdiagnosed and Less Medicine, More Health) from the very beginning, and may be unstoppable no matter what is done.

I have also noticed reading other prostate cancer studies that a certain percentage of prostate cancers regress from the point of diagnosis (the PSA test and biopsy). In other words, researchers are finding that cancer can have different paths: regresses, stays the same, grows slowly (and can be treated when symptoms appear), or grows very quickly and is so aggressive and unstoppable that it goes through the body "like a bird". And we don't know which will be the aggressive ones when we first find them, thus the controversies over what to do: screen or not?, and treat or not?  ...continue reading "Nearly 70% of Prostate Cancers Can Just Be Watched?"

 The following article supported what I have been reading over the past few years: that medical tests and treatments also have downsides, that it is possible to "know too much", that more harm than benefits can occur from certain tests, procedures, and medicines, and lifestyle changes (eat a less processed more plant-based diet, move more, and don't smoke) can be better than some medicines or certain procedures. The doctor mentioned in this article (Dr. H. Gilbert Welch) recently published a book aimed at the general public which I just read and highly recommend: Less Medicine, More Health. Dr. Welch is an academic physician, a professor at Dartmouth Medical School, and a nationally recognized expert on the effects of medical testing. In 2012 he published the well regarded and more technical and in-depth book on this issue: Overdiagnosed: Making People Sick in the Pursuit of Health. From The Atlantic:

The Downside of Medical Screening

If you had a disease, and you could find out sooner rather than later, why wouldn’t you?Medicine has long focused on early detection of diseases as part of a move toward preventive care. But imperfect tests, false positives, and overdiagnosis mean that sometimes the tests do more harm than good, and in recent years, there have been more recommendations to reduce some kinds of screening, including pap smears, colonoscopies, mammograms, and even annual pelvic exams.

“This is something we all need to understand, the two sides of early detection. It does help people, but it’s almost guaranteed to harm others,” said H. Gilbert Welch, a professor of medicine, public policy, and business administration at Dartmouth College, and author of the book Should I Be Tested for Cancer? (He reveals his answer in the book’s subtitle: “Maybe not.”)

The more you look for disease, the more you find it. And in the case of cancer, it’s hard for doctors to know if what they find is dangerous and needs to be addressed, or if it’s just a small tumor that won’t grow and poses no threat. “We can’t be sure which is which, so we treat everybody,” Welch explained at the Aspen Ideas Festival’s Spotlight Health session. “That means we’re treating people who will never experience problems from their disease.”

But they may experience problems from the treatment.The panel gave the example of prostate cancer, which is very common in men—one in seven American men will be diagnosed with it in their lifetimes. “But it turns out a lot of these cancers are very indolent,” said Jessica Herzstein, a preventive-medicine consultant and member of the U.S. Preventive Services Task Force. Around 30 to 40 percent of men who’ve been treated for prostate cancer likely had “slow-growing tumors that would never have become a threat to the man’s lifespan or health,” according to the Prostate Cancer Foundation.

In other words, “you’re going to die with them, not of them,” Herzstein said, “and the treatments are very very harmful.” Radiation therapy, for example, can cause incontinence and erectile dysfunction, and hormone therapy can cause osteoporosis and depression.

The possibility of a false positive is another downside. Not only could it lead to more invasive follow-up tests or treatments that aren’t needed, but it can also give patients unnecessary anxiety.“If we resolve the test by saying ‘The test was wrong, you’re fine!’, that’s one thing,” Welch said. “But most false alarms aren’t resolved that way. [It’s more like] ‘You don’t have cancer, but you have some abnormality that possibly puts you at a higher risk for cancer, but we’re not going to do anything about it. I think that’s where there can be [mental] harm.”

Ultimately, it comes down to a weighing of the benefits and the harms, and, in the absence of clear evidence, the preferences of the patient. The U.S. Preventive Services Task Force helps identify which tests are beneficial by evaluating and grading them. It gives tests an A if there’s a high certainty of substantial benefit, a B if there’s moderate certainty of substantial benefit, a C if there’s moderate certainty of a small benefit, a D if there’s moderate or high certainty of no benefit, and an I if the evidence is just too insufficient to say.

The task force gave prostate cancer screening a D. HIV screening got an A. For breast cancer screening, an always-controversial topic, the results vary. Breast self-exams got a D. Mammograms got a B, but only for women between 50 and 74 years old. For women in their 40s, the grade is a C, meaning the task force recommends patients and physicians discuss and decide together.

Before getting a screening test, patients should think about what would happen if they get a positive result, and if they’d be ready for it, Welch advised. “If I were to go through this, and have this diagnosis, would I want to have this surgery?” Herzstein asked, posing a hypothetical. Would you want to undergo the biopsy, the chemo, whatever treatments come next? “Maybe you don’t even want to go there if there is no treatment for the disease,” she added. Welch gives an example. “With Alzheimer’s disease that’s a fundamental question: What are you going to do with a positive result?” he asked.