Is early detection of disease always an advantage?
Most people think that detecting and treating illness as early as possible is a good thing and gives you the greatest chance of getting well again. That isn’t necessarily the case.
DIAGNOSIS: Ever improving medical technology allows doctors to also discover conditions and precursors of disease that may never progress. To be on the safe side, most people still want to receive treatment.
However, the treatment itself can cause serious side effects and result in damage and trauma patients could do without.
“There needs to be a better balance in the information provided about the pros and cons of discovering such conditions and being treated for them,” say NTNU professors Bjørn Hofmann and John-Arne Skolbekken.
The two professors recently published an article in the medical journal The BMJ on their review of research literature dealing with early detection of diseases from the 19th century to the present. Their findings are disturbing.
“We have uncovered a surge of attention being given to early detection of disease, be it cancer, cardiovascular disease or mental illness,” Hofmann says.
He reports that 30 times as many articles about early detection of disease are published today as in the 1950s, taking into account that the total number of publications has increased.
“The increased interest in this topic would be fine if the literature had balanced the focus on benefits and harms. Unfortunately, we find that a lot of research articles are just looking at the beneficial aspects. Twice as many of them mention the benefits of early detection as mention the harms,” Hofmann adds.
For each article that looks at both pros and cons, 76 articles deal with only one side of the issue or do not discuss it at all.
Unilateral focus on the positive aspects of early detection may lead to the conclusion that early detection is always a good thing. This is problematic.
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Using resources on false alarms
With the increased focus on biomarkers to detect disease, topics such as overdiagnosis and overtreatment are becoming increasingly relevant. With a simple blood test, urine test or even breath test, you can easily check for diseases – even home tests and apps are being developed for this purpose.
“The idea that disease should and must be detected early has almost become a movement. We’re concerned that this trend will gain even more momentum and worry people unnecessarily, given the new biomarkers. It also means we’re using our resources on false alarms, rather than focusing on treating those who really need it,” Hofmann said.
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Professor and social therapist Steinar Westin supports the views of Hofmann and Skolbekken.
“As soon as something is labelled, many people will jump on treatment just to be on the safe side. We have to be critical of where to set the limit for what we call disease,” said Westin.
One example of the need for such a limit is the Norwegian Directorate of Health, which has recently decided that all pregnant women should be tested for gestational diabetes using a comprehensive and resource-intensive glucose tolerance test.
Gestational diabetes has previously been screened for with a simple urine dipstick. Westin notes that the new method will label a lot more women as being at risk for diabetes – including many who perhaps don’t even have gestational diabetes – and it will be up to doctors to clarify things afterwards.
“Does this decision result in better health for more people? Do we know that the individuals we capture really gain anything from it? These are questions we need to ask ourselves initially,” says Westin.
He believes that increased awareness of all possible risk factors and indications can make people more self-absorbed and increase patients’ health anxiety unnecessarily.
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A necessary price
There is a difference between diseases and disease severity. Hofmann doesn’t question that early detection and treatment are critical for certain conditions to avoid illness. The pressure is great especially when it comes to cancers.
Solveig Hofvind, Head of section for the Breast Cancer Screening Program at the Cancer Registry of Norway, believes the problems Hofmann and Skolbekken point out are challenging because we don’t know enough about how many patients are treated for conditions that would not progress into a very serious cancer disease.
“We’re constantly developing new diagnostic methods for all types of diseases, and that’s part of the future. Maybe we do treat some individuals who don’t need it, but that may be the price we have to pay to save more people from serious illness and death,” Hofvind says.
Breast cancer screening reduces mortality
It is always tough to be diagnosed with cancer, but Hofvind doesn’t doubt that it is better to remove a small breast tumour with local anaesthesia than to wait and see if it grows bigger, when it might require more extensive and stressful treatment.
The introduction of breast cancer screening and improved treatment methods has reduced the mortality rate of the disease. Whereas screening previously detected breast tumours down to 2.5 cm on average, tumours are now detected when they are average of 1 cm and can be detected down to a millimetre in size.
“We can’t tell if the tumour will just stay put and we don’t know enough about the trigger factors that can cause tumours to begin to grow, making this a challenging ethical issue. We don’t know who and how many people get treated unnecessarily. But we want patients to be able to make informed choices and don’t want to misinform them about the consequences,” Hofvind says.
Hofmann and Skolbakken believe that it is essential for ethically sound patient treatment that the benefits and harms of early detection and treatment be communicated better.
For people to be able to make informed choices in the future, Hofmann emphasizes that we mustn’t only give patients a rosy picture about the benefits of early treatment. Patients also need to know the likelihood of being treated unnecessarily.
In cases where early detection results in treating conditions that otherwise would regress or stagnate, the person would die with the condition and not of it. Treatment can in this case become a greater burden than the original disease would be.
“As an ethicist, I’m concerned with balance and that people know what they are getting into. How can we make sure that detecting diseases early actually results in better health? Many people accept overdiagnosis and overtreatment because they’re afraid of getting the disease. That’s okay, but then they need to be well informed – and we can’t be the ones who’ve made them fear the illness,” says Hofmann.
Surge in publications on early detection, Bjørn Hofmann, John-Arne Skolbekken, BMJ 2017;357:j2102 http://www.bmj.com/content/357/bmj.j2102.full?ijkey=nOoQmxesLSX1mDk&keytype=ref