Overdiagnosed: Making People Sick in the Pursuit of Health [Hardcover]

Conventional wisdom is that more diagnosis, especially early diagnosis, means better medical care. Reality, says Dr. Gilbert Welch - author of "Overdiagnosed," is that more diagnosis leads to excessive treatment that can harm patients, make healthy people feel less so and even cause depression, and add to escalating health care costs. In fact, physician Welch believes overdiagnosis is the biggest problem for modern medicine, and relevant to almost all medical conditions. Welch devotes most of his book to documenting his concerns via examples of early diagnosis efforts for hypertension, prostate cancer, breast cancer, etc. that caused patient problems.

Welch provides readers with four important and generalizable points. The first is that, while target guidelines are set by panels of experts, those experts bring with them biases and sometimes even monetary incentives from drug-makers, etc. Over the past decades many target levels have been changed (eg. blood pressure, cholesterol levels, PSA levels), dramatically increasing the number classified as having a particular condition. (Welch adds that prostate cancer can be found at any PSA level - about 8% for those with a PSA level of 1 or less, over 30% for those with a level exceeding 4; most are benign.)

The second is that treating those with eg. severe hypertension benefits those patients much more than treating those with very mild hypertension or 'prehypertension;' the result is treating those with lesser 'symptoms' can easily cause new problems that outweigh the value of the hypertension treatment.

The third is that Welch believes it is usually more important to treat those with disease symptoms (eg. pain) than those without. For example, almost 70% of men 60-69 have prostate cancer, as well as about 10% of those aged 20-29 - a large number are better left untreated because their particular cases involve a very slow-growing form and the side-effects of treatment outweigh the benefits. Welch also reports that a study of over 1,000 symptom-free people that underwent total-body CT screens found 86% had at least one detected abnormality, with an average of 2.8. Many of these abnormalities later disappear (some cancers disappear), while others grow very slowly, if at all. Providing unneeded treatment subjects patients to unneeded pain, risk of adverse outcomes (including death), and unneeded expense.

Examples: Welch cites the example of a mildly hypertensive older man that he treated; unfortunately, while shoveling snow the individual passed out from a combination of sweating and the diuretic prescribed for his high blood pressure. Welch discontinued the man's medication. Similarly, Dr. Welch treated a patient with mild diabetes - the result was she fainted from low blood sugar (the level fluctuates around a mean) while driving just after a meal and was severely injured in an accident. Dr. Welch discontinued her medication as well.

Meanwhile, at the same time that a number of target guidelines have been tightened, the availability and capability of scanning and other detection devices to find abnormalities has also increased. For example, since the early 1990s, Welch tells us that the Medicare per capita use of head scans has doubled, the rates of abdominal scans have tripled, chest scans quintupled, brain MRI rates quadrupled, etc. New biopsy methods for detecting prostate cancer (eg. sampling from 18 points rather than 12 or fewer) also increase the number of benign 'false-positive' diagnoses, probably much more so than true positives.

Why is there so much testing? Dr. Welch attributes it to well-meaning disease advocacy groups, testimonials (eg. ex-Senator Dole regarding his prostate cancer), quality-improvement efforts that include testing as one of their criteria, malpractice awards, hospital/specialist/drug company marketing (beware of these, says Welch), and honest disagreement over its value. He's also concerned about what lower-cost DNA testing will add to the overdiagnosis problem, contending that everyone's genes will reveal heightened susceptibility to some ailments and diseases, with little that can be done despite the knowledge. The author would probably also be concerned about new Medicare requirements to provide a battery of up to 45 medical tests ("The Wall Street Journal" - 1/18/2011). That article also reports that a "New England Journal of Medicine" review of hundreds of preventive-care studies showed that fewer than 20% saved money.

Bottom-Line: Dr. Welch raises an important topic for improving health care while reducing costs. His main recommendation, more data from clinical trials showing the outcomes of choosing one diagnosing standard/method over another, is important and appropriate.

Dr. Welch's book is important and a good read. He explains concepts clearly and thoroughly, and the topic is timely and important for Americans, both from a public health (and personal misery) standpoint, as well as a skyrocketing national medical costs standpoint.

I have worked in the medical field off and on over the years, and even worked on a prostate cancer project, so I already knew a fair bit about the prostate cancer screening/treatment debate. I learned even more from Dr. Welch.

One question that I have had for years, and that has never been answered to my satisfaction is:

If a person is being treated for cancer, and they die from the treatment (on the operating table, from the drugs/radiation, etc.), do they count in the "deaths from cancer" statistic? I personally have known many more people who died from the treatment itself than who died from the cancer, and yet that particular topic does not get addressed. Are death rates from prostate cancer (for instance) holding steady because the treatments don't work, or because men are dying from unnecessary treatment and that offsets the successful treatments? (I did notice that the death rates for prostate cancer went *up* with an increase in detection in the figure on page 56.)

Statistics are smoky, and it really helps to know more about the study design. Dr. Welch does a very good job of describing the various studies, and their flaws and strengths. I'm sure it is a huge hot potato to discuss death rates from treatment, but I would be very interested in seeing those numbers broken out.

I read Overdiagnosed this morning, and I strongly urge you to read it, too. If you've ever wondered why our country's healthcare costs are skyrocketing even though our health outcomes lag behind the rest of the industrialized world, this book has the answers. We are overtested, overdiagnosed and overtreated. But sadly and paradoxically, this intensive use of "preventive" medicine has not improved our physical health or sense of well being -- it has diminished it.

Dr. Welch builds a strong case that Americans are overdiagnosed in a clear, concise and compelling way. He provides anecdotal accounts of people who were seriously harmed by the overzealous use of modern, high tech testing. And he backs these stories up with findings from landmark medical research studies. As we move from chapter to chapter and disease to disease, we see the same patterns emerge: thresholds for "illness" are lowered and suddenly tens of millions of people are diagnosed and treated for mild or nonexistent "diseases" that never would have harmed them.

Dr. Welch identifies the key players who brought American medicine to this sorry state -- big pharma and medical products manufacturers hungry to increase profits, doctors who order unnecessary tests to avoid malpractice lawsuits, and overzealous patient advocacy groups who press for action in the absence of any scientific evidence of improved outcomes.

Dr. Welch explains key concepts like "lag time bias" and "overtreatment bias" that enable you to see why the benefits of aggressive preventive medicine are far less than you have been led to believe. Once you understand terms like these, you will never again be swayed by misleading advertising or public health campaigns. Instead, you will be able to make decisions about your own health care in a rational, intelligent, and informed way.

In short, if you read one health related book this year, it should be "Overdiagnosed." Buy one copy for yourself and another for your doctor.

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