The first steps in reducing overdiagnosis are to acknowledge that overdiagnosis exists and to appreciate that overdiagnosis is a problem worth reducing. If one accepts the former but disagrees with the latter, which is to say that overdiagnosis exists but is a price worth paying to avoid underdiagnosis and undertreatment, then overdiagnosis will not be mitigated. Conversely, if one does not admit the inherent trade-off between overdiagnosis and underdiagnosis and acknowledge that reducing overdiagnosis will increase underdiagnosis or undertreatment, then no solution is possible.
Radiologists are in the midst of overdiagnosis, whether we like it or not . We are firefighters or arsonists, or both. Overdiagnosis is a vexing problem. Reducing overdiagnosis is challenging at multiple levels. The most challenging part is the culture ingrained in us.
The ingrained culture can create a dichotomy between overdiagnosis and overtreatment. The dichotomy says that the problem is not overdiagnosis but overtreatment . The argument is appealing but only superficially.
Let us consider pulmonary embolus (PE). Radiologists may say that the problem lies not in their detection of subsegmental PE but in the treatment of isolated small PEs. If clinicians chose to, they could forfeit treating the PE, but that they treat it despite the statistical futility of the treatment places the responsibility on them, not on us.
Then we must ask of what purpose is the diagnosis, if treatment instead of altering outcomes, causes net harm? Why do we urgently call the clinicians about a tension pneumothorax and not a simple renal cyst? Is it not because the treatment, its urgency, its success, and the natural path of tension pneumothorax in the absence of treatment, is markedly different from a simple cyst? Are we not responding to outcomes, then? Our reporting is not value neutral. We discern what is clinically important, not list alphabetically what we see.
To separate overdiagnosis from overtreatment, as a matter of philosophy or ontology, has troubling implications for radiologists. It implies our job is to list imaging findings, nonjudgmentally, that is, devoid of clinical judgment. It means that it is up to the clinicians to interpret the significance of the finding. This dichotomy is all the more disconcerting at a time when radiologists must assert themselves as clinicians more urgently than ever before.
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
References
1. Jha S.: Overdiagnosis and the information problem. Acad Radiol 2015; 22: pp. 947-948.
2. Jha S.: Overdiagnosis versus overtreatment: a false dichotomy. Radiology 2014; 270: pp. 628.
3. Gur D., Sumkin J.H.: Screening for early detection of breast cancer: overdiagnosis versus suboptimal patient management. Radiology 2013; 268: pp. 327-328.
4. Patel T.: It’s overtreatment, not overdiagnosis. Acad Radiol 2015; 22: pp. 1044-1045.
5. Sakr W.A., Grignon D.J., Haas G.P., et. al.: Age and racial distribution of prostatic intraepithelial neoplasia. Eur Urol 1996; 30: pp. 138-144.
6. Harach H.R., Fransilla K.O., Wasenius V.M.: Occult papillary carcinoma of the thyroid: a “normal” finding in Finland: a systematic autopsy study. Cancer 1985; 56: pp. 531-538.
7. Hoang J.K., Langer J.E., Middleton W.D., et. al.: Managing incidental thyroid nodules detected on imaging: white paper of the ACR Incidental Thyroid Findings Committee. 2015; 12: pp. 143-150.
8. ACR white paper aims to cut thyroid-nodule workups. Medscape Medical News. November 12th, 2014. http://www.medscape.com/viewarticle/834792?src=rss?src=sttwit (accessed June 9, 2015)
9. Koh H.K., Sebelius K.G.: Promoting Prevention through the Affordable Care Act. NEJM 2010; 363: pp. 1296-1299.
10. Jha S.: Screening and insurance. JACR 2013; 10: pp. 949-952.
11. http://www.hrsa.gov/quality/toolbox/measures/breastcancer/ (accessed June 9, 2015)