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Cancer Establishment Admits We’re Getting Overtested and Overtreated

The views expressed are those of the author and are not necessarily those of Scientific American.

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I’ve complained in previous columns about excessive medical testing, which leads to unnecessary treatment and drives up health care costs. Overtesting helps explain why health-care costs for Americans are much higher than in any other nation, whereas our health ranking is low, roughly equivalent to that of Cubans.

An estimated 70,000 American women were overdiagnosed with breast cancer as a result of screening in 2008.

The medical establishment is gradually acknowledging these hard facts, as indicated by a recent article in the Journal of the American Medical Association: “Overdiagnosis and Overtreatment in Cancer: An Opportunity for Improvement.” The article was written by a working group formed by the American Cancer Institute last year “to develop a strategy to improve the current approach to cancer screening and prevention.”

The three authors state: “Over the past 30 years, awareness and screening have led to an emphasis on early diagnosis of cancer. Although the goals of these efforts were to reduce the rate of late-stage disease and decrease cancer mortality, secular trends and clinical trials suggest that these goals have not been met; national data demonstrate significant increases in early-stage disease, without a proportional decline in later-stage disease.”

In other words, increased screening has led to increased diagnosis of cancer but has not significantly decreased mortality. The problem with screening, the authors note, is that “cancers are heterogeneous and can follow multiple paths, not all of which progress to metastases and death, and include indolent disease that causes no harm during the patient’s lifetime.”

That is, screening often detects growths that represent no significant threat and yet are nonetheless often treated with surgery, chemotherapy and radiation, all of which degrade health. The authors state: “Physicians, patients, and the general public must recognize that overdiagnosis is common and occurs more frequently with cancer screening.” [Italics in original.]

“Policies that prevent or reduce the chance of overdiagnosis and avoid overtreatment are needed,” the authors assert, “while maintaining those gains by which early detection is a major contributor to decreasing mortality and locally advanced disease.”

One policy change that the authors recommend would be to avoid using the term “cancer” to describe tumors or other abnormalities that are not life-threatening. When patients hear the word “cancer,” they often demand further tests and treatment, even when medically unjustified, and physicians are too often eager to comply.

The JAMA article, if anything, downplays the problems with cancer testing. For example, the authors state that “colon and cervical cancer are examples of effective screening programs in which early detection and removal of precancerous lesions have reduced incidence as well as late-stage disease.” As I stated in a column last year, “Why I Won’t Get a Colonoscopy,” the value of colonoscopies has not been clearly demonstrated.

In that same column, I quoted Gilbert Welch, a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice Welch, writing in The New York Times that screening healthy people leads to “needless appointments, needless tests, needless drugs and needless operations (not to mention all the accompanying needless insurance forms).”

Welch, author of the excellent book Overdiagnosed: Making People Sick in the Pursuit of Health (Beacon Press, 2011), added, “This process doesn’t promote health; it promotes disease. People suffer from more anxiety about their health, from drug side effects, from complications of surgery. A few die. And remember: these people felt fine when they entered the health care system.”

Welch and a colleague estimate in The New England Journal Of Medicine that 70,000 American women were overdiagnosed with breast cancer in 2008. As I have reported previously, men who take a prostate-specific antigen test and receive a cancer diagnosis have been estimated to be 47 times more likely to get unnecessary, harmful treatments—biopsies, surgery, radiation, chemotherapy—than they are to have their lives extended.

The Affordable Health Care Act represented a reasonable step toward reforming over-priced, under-performing American medicine. But true reform will require ending the epidemic of overtesting and over treatment, which is bankrupting us without improving our health.

Photo by Rhoda Baer, National Cancer Institute, courtesy Wikimedia Commons.

John Horgan About the Author: Every week, hockey-playing science writer John Horgan takes a puckish, provocative look at breaking science. A teacher at Stevens Institute of Technology, Horgan is the author of four books, including The End of Science (Addison Wesley, 1996) and The End of War (McSweeney's, 2012). Follow on Twitter @Horganism.

The views expressed are those of the author and are not necessarily those of Scientific American.

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  1. 1. k banco 7:59 pm 08/5/2013

    Good points. If you think all this is bad though, what about all the terrible overuse of narcotics, anxyolytics, antipsychotics, antidepressants. I’m a pharmacist and these classes (and several more) are terribly overused and abused and often serve little more than being expensive placebo pills. I see hundreds (literally) of patients a day and I can often tell from a mile away (or at least as they wander down the isle to the pharmacy) what drug they’ll be asking for.

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  2. 2. M Tucker 2:27 pm 08/6/2013

    Yeah, we have a problem with our “preventative medicine” AND we are actually losing the war on cancer.

    “increased screening has led to increased diagnosis of cancer but has not significantly decreased mortality.”

    “The U.S. Congress declared a “war on cancer” with the 1971 National Cancer Act and poured money into fighting the disease. Yet ever since, new cancer cases have risen three times faster than the U.S. population.” (from the book review of the latest issue of SA) and I am assuming those “new cases” are actual cancer cases and not non-life threatening tumors or abnormalities. But that quote does go along with my personal view of the widening gap between the bloom of cancer cases and the medical communities inability to cure it.

    From the CDC:
    In 2010, a total of 2,468,435 deaths occurred in the United States. The first two leading causes of death, heart disease (597,689 deaths) and cancer (574,743).

    Cancer deaths, way more (more than 8 times) than diabetes but we hear so much more about the risk of diabetes.

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  3. 3. jonhuie 4:31 pm 08/6/2013

    Scientific American does its readers a disservice by promoting the views of a self-described “anti-testing nut.” (his own words in his Colonoscopy article)

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  4. 4. Scientifik 12:08 pm 08/7/2013

    “Policies that prevent or reduce the chance of overdiagnosis and avoid overtreatment are needed,” the authors assert

    ^Policies or more accurate diagnostic tests that leave no room for misinterpretation?

    BTW this 16-year old puts the entire big pharma industry to shame with his groundbreaking research in cancer diagnosis.

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  5. 5. MaritzaG 12:12 pm 08/7/2013

    I take exception to your comparison with Cubans. Cuban doctors and health care has been usually considered outstanding. Perhaps in recent past, care is not up to par due to lack of meds due to embargo, but certainly not due to expertise in the field.

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  6. 6. Scientifik 12:48 pm 08/7/2013

    “Overtesting helps explain why health-care costs for Americans are much higher than in any other nation”

    Testing doesn’t have to be expensive (see the BBC story I linked above).

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  7. 7. Scientifik 4:48 am 08/8/2013

    “Yeah, we have a problem with our ‘preventative medicine’ AND we are actually losing the war on cancer.”

    We have a problem with preventive medicine because preventing cancer is counter to the financial interest of pharmaceutical companies. They simply don’t have any incentive to invest in cancer prevention research. The less people develop cancer, the lower their profits.

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  8. 8. zeplinair 8:04 pm 08/14/2013

    Scientifik, that drive is indeed true, but I think just as important is that cancer prevention so far has been so complex and variable (as are the causes of cancer), and our knowledge of the genetics that make one group of people more vulnerable than another to certain instigators, is so sparse, that it is difficult for pharma to target than to target qualities in common that cancers seem to have after they develop. The other ways to stack the deck against cancer tends to be behaviorally based, which unfortunately attempts to promote offer limited success. The old drivers of human behavior, not to mention the opportunistic food products that target them, that in mass favor immediate gratification vs planning and motivation that to most are too abstract and far off in their minds to intuitively jump the hurdle to positive behavior change, sees to that. We know (imperfect) ways to prevent cancer, but if this knowledge was logistically extendable to the population, we would have alot less smokers, obese and/or sedentary people than we do. Frankly, if pharma could find targets to prevent cancer, that would be far more profitable, because far more people don’t have cancer than do, but for the same reason we immunize (also from pharma), more people could be motivated to fear getting cancer than actually do. So…thinking this much about it, actually you are wrong.

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  9. 9. zeplinair 8:58 pm 08/14/2013

    Also, do the humanities have a version of the IgNobel; the given annually at Harvard by the editors of the Annals of Improbable Research in which the endeavor of science pokes fun at itself, as counter to the Nobel (though one of its winners did go on to win a Nobel)? The Annals of Inprobable Research yearly awards research that is seemingly so inane that it makes you laugh, but when though of more deeply may make you think (the grad student who tasted tadpoles-back in the days you could still get away with that-actually revealed very important principles of natural selection). One of the categories in the IgNobels is research that “cannot or should not be replicated.” Those seriously doing science are very well aware of the foibles of those attempting science and the frustrating and contaminating social processes and hierarchies(as the dubiously ‘winning’ scientists led onto stage by a rope, or the paper airplanes thrown by the crowd at a truly respected laureate wearing a target, largely missing him as analogy for publication and citation, and the paper airplanes swept off the stage by a traditional elderly Nobel laureate) can bear a true jester with self-effacing humor.

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  10. 10. zeplinair 9:14 pm 08/14/2013

    Scientik, thanks for the link. It is a very intriguing story that also shows that those too deep in the way things are done can be stifled so much in imagination that some whipper-snapper can show them something that should be obvious, but wasn’t in their professional scenery to notice-a big problem with overspecialization coupled with Balkanisation (thankfully many are showing the enormous benefits of crosstalk). However, it is the research and not the age of the researcher that is important in science. The age is only provocative for the public. The article is short on detail for meaningful critique of the scientific and actual medical value of the work. I wish they would have a link to the actual study or first source communication (which should also link to the original work) so the public can have a direct path to ascertain whether the enthusiasm for this is justified, or if it is overblown through the common sins of science journalism.

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