Overdiagnosed: Making People Sick in the Pursuit of Health

This book will probably appeal to people like me, who have already been questioning the value of endless screening tests, but I hope others will read it as well. It is a large dose of sanity in the face of all the pressure from doctors, advocacy groups for various diseases, public service ads and commercials from companies offering screening tests who tell us we need to be screened because "early detection saves lives." Usually they throw in some stories of people who got screened, got treated and are still alive. They are all quoted saying "Early detection saved my life."But did it? Or did it just turn them into patients years before their "disease" would have manifested itself? Worse yet, maybe that tiny growth detected on the X-ray would NEVER have turned into actual disease. In that case, they did not need any treatment and may have been harmed by the treatment they received. Dr. Welch calls this "overdiagnosis."Dr. Welch points out that these "success" stories lead to more screening which leads to more useless treatment. Proponents often cite the increased "cure" rate of those who are screened versus those who are not. Logically, the time between diagnosis and the time when the patient is considered "cured" (say, five years with no recurrence) will be greater if a tumor was found several years before it would have manifested as symptoms. With or without screening, a tumor would grow (or not grow) at the same rate. Without screening, a tumor that grows will be discovered when the patient has symptoms. That's a later diagnosis, but the course of the disease is the same and early treatment might make no difference at all.MY MAMMOGRAM STORYI am in my middle 60s and had always resisted getting a mammogram until recently. I had changed doctors and my new doctor gave me a referral and I decided to do it this time. I think it was mostly out of curiosity and because Medicare would pay for it (a wrong reason, I know!). The screening was done at a huge hospital complex (Beaumont Hospital in Royal Oak Michigan). The procedure was fast and not too unpleasant, but I was surprised to get a phone call a few days later telling me I needed to make another appointment for more views. I asked why and got no real answer, other than the Radiologist wants more views. I said I needed more information before I would come back and they said to call my doctor. I did that, and his staff person had to search for any information about my mammogram, but finally found what the hospital had sent and it merely said that the results were inconclusive for the left breast. This does not tell me what was inconclusive. I then received a letter from the hospital, which said the initial findings showed "a need for additional imaging studies, such as additional mammographic views, ultrasound or MRI for a complete evaluation." This sounded to me like the start of a cascade of expensive and possibly invasive and dangerous services which I did not want. I got several more calls from the hospital urging me to make another appointment, but I was not satisfied with the lack of real information as to why I should do that. Finally another woman called me who would only say she was "Sharon," so I don't know her position, but she must have been a supervisor because she did tell me more (there was an "asymmetrical density " in the left breast), but would not name the Radiologist (I later got her name from my Medicare payment info online). Sharon said (in effect) I was likely called back because this was my first and only mammogram and they had nothing to compare it with. I subsequently received a certified letter from the hospital, which I take to be their "CYA" letter in case I turn up with cancer and sue them. I finally sent them my own certified letter explaining why I was not returning and asking for access to the images and notes from my mammogram. They have never responded.I do breast self-exam and there are no lumps or any abnormality. I have no symptoms and I feel fine. I am more willing to trust my own instincts that I do not have brest cancer than I am willing to trust the people at the hospital. My only regret is getting the mammogram in the first place.To hear all the hype about mammograms, you'd think they somehow PREVENTED cancer, whereas they do no such thing. They are X-rays of the breast and the "findings" are the opinion of a Radiologist who does not see you or examine you. I find Radiology a strange kind of medical specialty. It does not involve patient contact, but is based on a person (presumably the Radiologist) studying images and coming to a conclusion. In the book, Dr. Welch has a horrific story of a pregnant lady whose imaging screening could not image one of her baby's feet. The Radiologist decided the baby probably had a club foot. The poor mother-to-be drove herself crazy learning all about club feet and imagining what life would be like for her deformed child. When the baby was born, both feet were perfect. The point is, these images are often going to find anomalies that can't be definitively said to be deformity or disease. But the findings WILL lead to a lot more medical services.I think Dr. Welch actually underestimates one of the consequences of this and that is the expense. Whether it's the patient paying (increasingly the case) or insurance or Medicare, screening leads to a lot of expensive services that are not needed and can do a lot of harm. Men treated for early signs of prostate cancer can become permanently impotent, and the worst of it is their prostate cancer may never have progressed to a point where they would have symptoms. Many men with prostate cancer eventually die of something else because the cancer is so slow growing, or may not grow at all. Particularly with prostate and breast cancers, studies involving autopsies show many people have small cancers they never knew they had and which never caused any symptoms.Dr. Welch works for the VA, which is a single-payer government-funded system in which the doctors have no financial incentive for overtreating patients, but I think lots of doctors are biased in favor of treatment when it may not be needed because of the extra income it brings. Radiologists who don't even see the patient have every incentive to say they "need more views." The hospital has every incentive to encourage women to come for mammograms, then to do more imaging if anything at all is found on the screening X-rays.Dr. Welch also barely mentions the fact that X-rays CAUSE cancer! Yes, we've all heard about how tiny and harmless those doses are in a mammogram or other X-ray, but the effect is cumulative. That is one reason I was not eager to "have more views" taken. When those dose amounts in a mammogram are mentioned, how many "views" are they based on? Why don't screening services release actual information of the dosage of each view? How do I know their machines are working properly or that their technicians are competent? Why should I trust these medical providers on this subject when they have so much incentive to encourage "more views?"Too much worrying about our health and visiting doctors when we are not sick is adding to our bloated health care bill in the US. Maybe we should just accept our own mortality and not seek ever-more information from inside our bodies via screening. People talk about the supposed benefit of finding disease early, but never about the harm of pursuing tiny ambiguous anomalies leading to treatment that could be unnecessary and surely is expensive.This book is very well-written, with clear explanations, nice graphs to help illustrate the points made, and plenty of eye-popping examples. Before you buy in to "early diagnosis" and give into the pressure to get screened, read this book and use your head. Dr. Welch makes his case.

Over Diagnosed is an interesting tale. At first I approached this with some concern as if it was just another one of those trend setting books by some physicians seeking to push the latest idea. After a few pages I was hooked and saw that Welch was in my opinion spot on. Yes there is too much diagnosis. As anyone who is in the medical area knows one of the most costly machines ever invented was the CAT scan. I recall that the second such machine went into Mass General I believe in 72 or 73, and was immediately put to use in determining if a stroke was a block or a bleed. In those days this was a real issue and the CAT scan allowed for a rapid and accurate determination and helped save lives. Then its use expanded. Today with a CAT scan, as Welch states, we can find things that we never ever suspected, and then what?Chapters 1 and 2 set the scene for what the authors intend to present. Namely that there are lots of over diagnosis out there and for lots of reasons. Part of the author's presentation is that we have defined more disease. Take the example of Diabetes, it was fasting blood sugar of 140 and now we start treatment at 100! The reality is that we should really look at the average over some period of time, using say HbA1c which is a metric measuring average blood sugar over 60-90 days. It is a good measure but still not perfect. We also should remember that HbA1c follows BMI, namely the fatter you are, the greater the chance of having Type 2 Diabetes, and then of course all the sequelae. The authors give a good overview of this idea.Chapter 3 is the one which details the issue of "if you look you shall find". I have seen many examples of this. Welch has many tales about this phenomenon. Welch may very well be understating the problem, but he is spot on!Chapter 4 is the lynchpin chapter for several reasons. It is the prostate cancer chapter and here I may differ with the authors but not by much. The rule of thumb is that 50% of men in their 50s have prostate cancer, PCa, 60% in their 60s, 70% in their 70s and so on. This is a really rough rule of thumb but the author makes the point that most PCa is indolent, slow growing and not the cause of death. The problem is we do not know how to differentiate between slow and fast growing so we tend to deal with all of them assuming the worst. In addition the author on p 59 discusses the American and European Trials and he discusses their conclusions. If one were to look deeper into the trials one would see major defects. The American used a fixed 4.0 PSA over the 10 year period even though the number was shown during that period to require substantial age related adjustments. Thus the problem with the American Trial was that they asked the wrong question. The asked did a PSA of 4.0 show significant reduction in mortality? The proper question should have been; what level of PSA at what age brackets shows a significant reduction in mortality. The European Trial was defective in that measurements were also at 4.0 but the time between was considerable or not at all. Thus I would argue with the author that these results have merit. The other problem with PSAs is that they lead to biopsies which have some morbidity. But frequently we see HGPIN, which has been assumed a precursor to PCa but we also see HGPIN and then its total regression. Why? Genetics, immunological, a result of the first biopsy, or perhaps there was a PCa stem cell and they got it the first biopsy. Or a million other things. Notwithstanding the authors phrase the issues quite well.Chapter 5 looks at several other cancers and screening. I will focus on one, melanoma. In the late 60s when we saw a melanoma we were ready to amputate a limb if that was where it was located. That generally was because it was detected late in the stage. However today with increased sensitivity to one of the deadliest cancers known, we can detect it earlier. On p 68 the authors show a curve which shows incidence and mortality versus time. Mortality is almost constant whereas incidence is increased. In the prior chapter on PCa the argument made is that we can now determine PCa at much lower levels and at levels where mortality is not changed. That is we are detecting non-lethal PCa. The author tries to make the same nexus here, not exactly, because he readily recognizes the deadly nature of melanoma, but to the casual reader it may look that way. There is a true increase in the incidence of melanoma due to lifestyles, excessive ultraviolet exposure, and the good news is mortality is slowly decreasing. That I believe is a point needing better clarity.Chapter 9 is well done and hits a significant fact. Genetics, which is expressed in your DNA, is interesting, but only in a small set of diseases is it the prime causative factor per se. Take obesity and diabetes, not discussed in detail by the author, but of significant interest since its costs are currently well over $250 Billion per year in current 2011 medical costs. There is the desire on the part of many to find the "genes" which cause this. Obesity is, however. in almost all cases, a disease where the patient violates a law of nature, input less output equals net accumulation, they just consume too much. Type 2 Diabetes, in more than a majority of cases, is driven by obesity and its related inflammatory state. The attempt to blame genes may be fruitless. The same goes regarding say cancer. Vogelstein, in a now classic demonstration, showed, twenty years ago, that colon cancer was the result of 4 genetic hits. What caused the hits was unknown but they were almost always the same and always in the same sequence. Recent work on PCa has attempted to do the same there but it appears that PCa is a multi-hit cancer but sometime they are not the same set of hits, genes for PTEN, Akt, c-Myc etc are all affected but in a yet to be determined manner.Chapters 10 and 11 speak towards facts and systems. The authors does a superb job here as well. Simply, it discusses the issues related to gathering data and looking at it systematically. This is more than just having electronic medical records and the like.The conclusion is well done. What would have been useful especially since the author states he was trained as an economist, would be some detailed discussion regarding what costs could be saved by the recommendations he makes. That would be a major contribution to the overall discussion. The new health law for Medicare patients will be issuing multiple Comparative Clinical Effectiveness guidelines and these, albeit a potential rationing mechanism, may also be a potential cost increaser. It would be very useful if the author could put dollars to his recommendations. He has set out a well structure framework for that, it would be a great follow up.

This book forms a solid foundation for the argument against excessive screening and medical intervention, arguing that in many cases of medical intervention, over-treatment results which actually degrades the life of the patient more so than suffering from the ailment or risk of the disease as it is destined to progress (or not). The presentation of the medical knowledge regarding the proliferation of small asymptomatic cancers in the general population and their subsequent likelihood of actually going on to cause symptoms or death is very interesting, and something that I was not aware of. This book forms a solid foundation against the culture (big-pharma and private medical corporations assisted) of looking too hard for disease and using media to perpetuate anxiety in the public in an effort to over-prescribe treatment without scientific basis.Yet the downside is that the author is often hypocritical, relying on sparse statistics to back up his argument when available and powerful anecdotes otherwise, often the case for over-diagnosis (particularly in the beginning) is not quantified adequately, despite his criticisms against the pro-over-diagnosis bodies using exactly the same systems to their end. He often comes across as too close to being against medical intervention regardless, such as his statement regarding the woman suffering from symptomatic thyroid cancer on p.140.Overall a well written and informative read.

A really informative book, full of evidence for what is being told. The sort of book you can dip into and read up on whatever is interesting you at the moment. I bet it is hated by some members of the medical fraternity but that is tough. We have a right to know the facts before making decisions that are right for us. Highly recommended.

Brilliant exposure of how we doctors have succeeded in making people with the greatest life expectancy in the history of mankind feel ill and at risk of health disasters. Of course the book also exposes the Big Pharma companies and politicians. Every doctor and medical student should read this book. Once finished move onto "Intelligent Kindness'

Everyone should read this though-provoking book. Members of the medical profession should read this book and ensure all patients are fully advised of any potential significant risks associated with any proposed treatment . The book should be compulsory reading for all medical students.

Confirmation bias I loved it as it confir,ed my experience of of 40 years in MedicineUnlike most of this genre does not blame big pharma, but many other tragetsincluding doctors themselves.