Bob R.’s New York City doctor told him his cholesterol was high and prescribed statins. After taking the statins for two years, Bob was feeling muscle pains and had read about the possible cognitive declines tied to statins. At his next physical, Bob told his doctor he wanted to stop the statins and try exercising a little more, drop a few pounds and see if that lowered his cholesterol. The doctor agreed and noted, “You’re borderline on needing statins anyway.” Yikes! Who knew that? Bob hadn’t questioned the overdiagnosing or the treatment. He took statins and experienced the side effects, for a “borderline” benefit. Bob did lose five pounds and walked more frequently. It has now been several years since he stopped taking statins, and his cholesterol numbers have dropped and remain in a safe zone.
Overdiagnosing is, “The labeling of a person with a disease or abnormal condition that would not have caused the person harm if left undiscovered, creating new diagnoses by medicalizing ordinary life experiences, or expanding existing diagnoses by lowering thresholds or widening criteria without evidence of improved outcomes. Individuals derive no clinical benefit from overdiagnosing, although they may experience physical, psychological, or financial harm,” according to the National Library of Medicine.
Overdiagnosing often means taking meds or having procedures that are unnecessary and could cause harm. Overdiagnosing is part of the problem of “low-value care,” which include overuse of medicines, procedures or tests. Overtreatment is the use of drugs that are more powerful than needed, or used for longer times than needed. Undertreatment, not getting the diagnosis or care that you need, is the flip side of the coin to low-value care.
Here are three ways you may be under overdiagnosing.
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1. Condition Is Unlikely to Do Any Harm
In the past several decades, screening tests have become much more sensitive. They now pick up tinier tumors, more spots and subtler shadows. That sounds good, but sometimes, maybe it isn’t. Some small tumors, even cancerous tumors, would be destroyed by your own immune or hormone system if left untouched. Some small tumors can sit in a body for years and never progress into a cancer or another disease that will kill you. And shadows and spots are sometimes just that. However, once they’re found, they must be followed up on.
Cancers – According to The New England Journal of Medicine, the development of more sensitive diagnostics (MRIs, EKGs, blood levels) has ushered in a period of overdiagnosing in several cancers, including:
- thyroid cancer, the introduction of ultrasound screening
- melanoma, widespread screening for skin cancer
- lung cancer, associated with low-dose computed tomographic screening examinations
- prostate cancer, after prostate-specific antigen testing reported
What You Can Do
Before agreeing to any aggressive chemotherapies, radiation or surgery, always get a second opinion. When choosing a doctor for a second opinion, try to find one with different training from your first doctor because, for example, if you ask a surgeon, the surgeon is trained to focus on surgery. If you ask a nutritionist, the nutritionist is trained to focus on diet.
Ask about the benefits and risks of “wait and see.” If you do move ahead with drugs, make sure you are getting the lowest effective dose for the shortest amount of time.
2. Creating a New Disease By Medicalizing Normal Life Experiences
Dry Eyes
I was at my gynecologist’s office a few months ago. In casual conversation, I mentioned that I don’t wear contacts anymore because my eyes are too dry. She offered a prescription that would increase tear production. I refused so quickly and clearly, that I didn’t even learn the drug’s name. No way am I going to take a daily prescription to avoid the minor inconvenience of wearing glasses. And I totally rock glasses!
Eyes tend to feel drier as you age and using contact lenses dries eyes. Allergies and several types of common drugs also dry eyes. In all these cases over-the-counter (OTC) saline drops may be all you need. At other times, you might get more comfort by making minor adjustments, like taking breaks from looking at screens and swapping out contact lenses for glasses.
A symptom is not always a disease or a sign that you need a drug.
The drug Restasis (cyclosporine) has been approved by the Food and Drug Administration (FDA) for one specific type of dry eye. Yet the website for Restasis offers a quiz, which I took and sent to the company. It asked the following four questions:
- How often do your dry eyes bother you? (I answered “Never”)
- How frequently do you use artificial tears? (I answered “Never”)
- How helpful are artificial tears for you? (I answered “Never”)
- Are you interested in a prescription treatment for your dry eyes? (I answered “Yes”)
After submitting the quiz (which indicated no symptoms of dry eye of any kind) to the company online, I received an email from the company with a suggestion that I go to an eye doctor soon and select from a list of company-approved doctors. Clearly, that was the outcome no matter the answers.
From Health News Review: According to the FDA-approved product label, Restasis is “indicated to increase tear production in patients whose tear production is presumed to be suppressed due to ocular inflammation associated with keratoconjunctivitis sicca.” Keratoconjunctivitis sicca is caused by inflammation that decreases tears and salivary secretions, and may be associated with other autoimmune conditions such as rheumatoid arthritis.
This is not the same as chronic dry eyes, which have many causes, including decreased tear production (most commonly from aging) and contact lens use; and increased tear evaporation (from dry air, diminished oil production with aging by glands in the eyelid, prolonged screen use without blinking and other conditions). Artificial tears are the first line in treating all these conditions.
Low Testosterone
Or “LowT,” as the ads so delicately phrase it. The first thing to know is that very few men have “Low T,” and they are mostly in their 40s, 50s and 60s. Next, there is no “normal” level of testosterone. It varies among people, and age does affect it. And finally, there are several ways to measure testosterone, for example, total testosterone vs. “free” testosterone. A quiz on a website is NOT a way to measure it.
Some decrease in testosterone levels is expected with age, but if you have symptoms that concern you, don’t assume it’s Low T. There are common underlying conditions that can decrease testosterone level, such as diabetes, obesity and aging. Non-drug therapies are longer lasting and safer than drugs. They are exercising, getting enough sleep and engaging in couples therapy with your partner.
Testosterone supplements have a host of potential side effects, such as increased red blood cells (that can cause blood clots), enlarged prostate and gynecomastia (enlarged or sensitive breasts). Teh gel transdermal formulation that is usually rubbed on thighs is linked to heart disease. If women or children are exposed to testosterone (through contact with skin that has testosterone gel in it) it is dangerous. On the other hand, testosterone can treat anemia and thicken bone density in men.
ADHD
The diagnoses of attention deficit hyperactivity disorder (ADHD) have increased for years and there are probably several reasons for it. In some cases, doctors say, it may not be a pathological problem, but instead a case of a child simply being less mature than other children in class. An Isreali research team studied children ages six to 17 and discovered that the youngest third of the class were more likely to be medicated for ADHD. “Comparative maturity,” as doctors call it, will be remedied naturally as your child ages.
If your child is having difficulty focusing, pediatricians say you can teach your child how to concentrate. First, they say, cover the basics for mental preparedness by ensuring your child (and you) eat healthfully, get an age-appropriate amount of sleep, increase physical activity and and mindfulness to your child’s day. Need some guidelines on that? Read this.
ADHD is most often diagnosed in children, but adults can have ADHD, too. If your child or you have ADHD symptoms that are creating problems in your life, they should be addressed. It might be ADHD, or instead you or your child might be suffering from stress or anxiety, have sleeping problems, have undiagnosed learning disabilities or are having difficulty socially or with teachers or authority figures. Any and all of these issues can and should be addressed with your doctor.
Because of the wide range of symptoms and vast possibilities for what could be causing them, ADHD is very difficult to diagnose. No MRI, X-ray, PET scan or even a quiz on the Internet can diagnose ADHD.
Most evaluations will include a patient interview, possible interviews with or questionnaires for friends or family members and a written assessment form, such as the Adult ADHD Self-Report Scale, Barkley Adult ADHD Rating Scale-IV or the Conners‘ Adult ADHD Rating Scales (CAARS). Also, you may need a neuropsychological evaluation as part of the assessment.
A trained psychologist or other mental health professional with specific expertise in testing should conduct a comprehensive diagnostic evaluation that can include testing for a wide variety of learning disabilities. Our son went through a battery of tests, and we discovered that he had mild ADHD, but more importantly he had a slow processing speed and a lot of anxiety. All of which were effectively managed and overcome with cognitive behavioral therapy (CBT), a healthy diet, lots of exercise and time.
3. Changing the Diagnosis or Age of Screening Guidelines to Include More People and Prevent Overdiagnosing Patients
There has been a trend to expand established diagnosis guidelines to treat “pre” diseases, such as pre-diabetes or pre-osteoporosis. In some cases, this is medically called for, especially when there are pre-existing conditions or a family history of it. But the evidence for healthy people being treated with drugs to ward off disease is, in some cases, a weak course of action.
Blood pressure and Overdiagnosing
The American Heart Association and the American College of Cardiology issued a joint recommendation in 2018 that blood pressure drugs be started in patients with a reading of 130/80 mm Hg or higher. The previous accepted recommendation threshold had been 140/90 and 150/90 for those over 50.
However, patients with mild hypertension receive no benefit in terms of lowering the risk of death or cardiovascular disease from taking medication to treat high blood pressure, though taking the medicine puts them at risk of hypotension (very low blood pressure), fainting and kidney damage.
As H. Gilbert Welch noted in a New York Times OpEd piece, “So focusing on the number 130 not only will involve millions of people but also will involve millions of new prescriptions and millions of dollars. And it will further distract doctors and their patients from activities that aren’t easily measured by numbers, yet are more important to health — real food, regular movement and finding meaning in life. These matter whatever your blood pressure is.”
Colon Cancer
The American Cancer Society guidelines recommend that regular colonoscopies screening for colorectal (colon) cancer start at 45 for patients with average risk, rather than the previously recommended age of 50. The guideline update is based on studies from 2017 that found a rise in the incidence of colon cancer among people younger than 50. The guidelines of the United States Preventive Services Taskforce (USPST) stayed at 50 and older.
There are risks with colorectal screenings and the benefits of early screening are scant. In the two analyses from the USPSTF and the American Cancer Society estimated that lowering the screening to age 45 would result in saving either one or two lives out of 1,000 but result in about 815 more colonoscopies.
Complications of colonoscopies are not typical but can be severe. They include adverse reactions to anesthesia, bowel perforation, abdominal pain and bleeding. In a 2016 study from the Yale Center for Outcomes Research and Evaluation, 1.6% of patients who had a colonoscopy experienced a complication within seven days that was serious enough to send them to a hospital. That’s not a high risk, but it’s much greater than the probability of actually having colon cancer at age 45 (from Lown Institute).
Other considerations are the expense, the time and the discomfort. Consider having a conversation with your doctor about using a noninvasive at-home fecal test instead of a colonoscopy if you are at low-risk.
Being in Charge of Your Health and Prevent Overdiagnosing
Overdiagnosing leads to overtreatment, taking drugs or having surgeries that could cause harm. Protect yourself and your family by asking questions:
- What happens if I don’t take that drug, screening test or operation?
- What are the risks if I do?
- Which risk factors in my life or family history make monitoring a disease necessary?
You are the one in charge of your health. Some questions to ask your doctor before agreeing to take a prescription may be:
- Will this cure me, take away pain or prevent something from happening?
- What if I do nothing and we monitor the condition?
- Is a pill or procedure the only way? What other options, like lifestyle changes, coaching, physical therapy or mental health treatment do I have?
- How long will I need to take this drug?
- What are the side effects or the adverse-events risks of taking this drug?
- Is it safe to take with my vitamins, supplements and any other drugs?
- What foods do I need to avoid?
Answering these questions should only take a few minutes, but doing so could save you from ingesting more medicine than you might need.
