The possibility of overdiagnosis first became apparent to me early in my career when I ordered a sinus film on myself. I was seeing patients in the Indian Health Service and was frustrated by how many sinus films were read as abnormal. Otherwise I felt fine; the film was just my idea of an experiment. I was rewarded with a finding: a polyp secondary to chronic maxillary sinusitis.
A few years later, soon after I joined the staff of the White River Junction VA, the possibility became more real. One of my patients called me because of persistent hoarseness. Our Ear, Nose & Throat specialist found and removed a small vocal cord tumor but also ordered a chest x-ray. The chest x-ray was read, showing a possible widening of the mediastinum, and our radiologist recommended a chest computed tomography (CT). The CT showed a normal mediastinum but also a golf ball–sized mass in the right kidney—with all the radiologic features of renal cell carcinoma. That hoarseness could produce kidney cancer was never covered in my training.
Then, virtually my entire patient panel of elderly men seemed to develop prostate cancer (and typically I was not even ordering the test responsible for the epidemic: the prostate-specific antigen).
Despite my now 25-year-old diagnosis, I have never had a problem with my sinuses. My patient’s hoarseness quickly resolved after the tumor removal, but he chose to keep his kidney and lived another decade to worry about it. (He died of pneumonia, had a 5-cm renal cell carcinoma on autopsy, but no metastatic disease.) And, a lot of prostates came out (or were radiated) for a disease that was not going to cause problems, although the treatment certainly did.
Go figure. May be this kind of stuff only happens in government-run health care, but I do not think so.
These formative experiences suggest some of the causes of overdiagnosis: indiscriminant test ordering, clinical cascades ending in incidental detection, and population-based screening. It is useful to separate the role of the radiologist from that of the ordering clinician.
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References
1. American Board of Internal Medicine Foundation. Choosing Wisely. Available at: http://www.choosingwisely.org/ . Accessed April 13, 2015.
2. Black W.C., Welch H.G.: Advances in diagnostic imaging and overestimations of disease prevalence and the benefits of therapy. N Engl J Med 1993; 328: pp. 1237-1243.
3. Pedersen J.H., Ashraf H., Dirksen A., et. al.: The Danish randomized lung cancer CT screening trial—overall design and results of the prevalence round. J Thorac Oncol 2009; 4: pp. 608-614.
4. van Klaveren R.J., Oudkerk M., Prokop M., et. al.: Management of lung nodules detected by volume CT scanning. N Engl J Med 2009; 361: pp. 2221-2229.
5. American College of Radiology. Lung CT Screening Reporting and Data System (Lung-RADS(tm)). Available at: http://www.acr.org/Quality-Safety/Resources/LungRADS . Accessed April 13, 2015.