Catherine Riva of Re-Check was selected by the organizers of the Conference to present the results of her investigation on the “mammo-business”, an extensive system of business models and careers building grown in Switzerland around mammography screening. Her long-form investigative piece was honored in 2014 with a Media Award of the Swiss Academies of Medical Sciences. Catherine participation to the Conference was supported by the Foundation for Research in Clinical Pharmacology and by the Center for Evidence-Based Medicine in Oxford.
What is overdiagnosis? It mainly occurs when a test leads to the diagnosis of a “histological disease”, a “disease” that would have neither caused symptoms during the patient’s lifetime, nor killed him. In other words, the patient will be diagnosed, labelled “sick” and unnecessarily treated. He will suffer the consequences induced by the medicalization of his condition: anxiety, possible mutilating surgery and sometimes highly toxic treatments.
A major problem is that no one can say if a diagnosis is an overdiagnosis. As Bernard Duperray pointed out as for the case of breast cancer screening, overdiagnosis is a “totally counter-intuitive concept”, because “neither the caregiver, nor the pathologist, nor the patient can identify it. For them, there are only diagnoses.” Overdiagnosis can only be demonstrated by epidemiological studies.
Overdiagnosis is a particularly disturbing phenomenon and a substantial aspect of the Too Much Medicine tendency that affects modern societies. The growing number of tests and screenings developed in the last 30 years, particularly in the field of cancer, as well as the casualness with which they are introduced and recommended, are of increasing concern to a growing number of specialists, observers and caregivers. Specially worrying: the reservoir of dormant diseases is enormous and it sharpens the appetites of the industry, but also of NGOs, researchers and politicians eager to profile themselves.
The situation is so alarming that some researchers decided to organize a conference to bring together scholars and practitioners. Objective of the event is to alert, acquire instruments for defining and documenting the problem, and ultimately develop solutions. The first Preventing Overdiagnosis Conference was held in 2013 in New Hampshire.
Once upon a time, overdiagnosis and too much medicine were fringe ideas
Among its organizers Steven Woloshin and Lisa Schwartz, both professors at the Dartmouth Institute for Health Policy and Clinical Practice. They were also the ones who opened the 5th edition of Preventing Overdiagnosis, held from August 17th to 19th in Québec City, the first to be dellivered in both French and English.
Steven Woloshin opened his speech with a joke: “Once upon a time, overdiagnosis and too much medicine were fringe ideas,” he noted, alluding to fringe science, a “field of study which departs significantly from mainstream theories and is considered to be questionable by the mainstream.”
“That is no longer the case,” he argued. ”Thanks to the efforts of a small but growing international community of researchers, medical journal editors, policy makers, and consumers these ideas have moved into the mainstream. Three major medical journals—The BMJ (Too Much Medicine), JAMA Internal Medicine (Less is More) and The Lancet (Right Care)—have run series dedicated to establishing a rigorous evidence base, stimulating debate and promoting practice and policy changes to address overdiagnosis and overtreatment.”
“It’s so rewarding to see this evolution,” said Lisa Schwartz. “There are more and more professionals and patients involved. There is also a shift: from a description of the problem, to a more active phase with the development of guidelines, with a communication effort to reach out to the public and with initiatives like Choosing Wisely. ”
The 5th edition of Preventing Overdiagnosis was held under the motto “Towards Responsible Global Solutions” and illustrated this evolution. On one hand with presentations and workshops dedicated to case studies to document extent and complexity of the problem. On the other hand with sessions devoted to possible actions to counter and stop it. Organized by the Quebec Medical Association (QMA), the Université Laval Faculté de médecine and the Canadian Medical Association (CMA), the event attracted about 400 participants who had to choose among 130 presentations, workshops, seminars and debates.
The program was very broad: from setting a framework to determine when screening interventions should be de-intensified or de-implemented, to the development of shared decision-making tools, to sometimes intense discussions on the role of health policies and the responsibility of medical scientific journals, to projects like “Too Much Medicine Day” (#TMMDay), launched by the excellent initiative Show More Spine. This action, which Re-Check is an official partner of, aims to counter the flood of hundreds of official “days” alerting on all possible diseases, because this awareness has the perverse effect of nourishing overmedicalisation. The idea had emerged during the 4th Preventing Overdiagnosis conference in Barcelona and the meetings in Quebec City were the occasion for fruitful brainstorming to sketch how “Too Much Medicine Day” shall look like. Its modalities should be finalized in August 2018 at the next Conference that will take place in Copenhagen.
Overdiagnosis and Too Much Medicine had rarely such a favorable environment as today
At the end of three dense and stimulating days, Re-Check take home message: Overdiagnosis and Too Much Medicine, as well as the extent of their deleterious effects are today way better documented. Moreover, the fringe ideas have earned their stripes and are considered by the most lucid as a major public health problem. The initiatives presented at this Conference edition are a step in the right direction and some of them are already well established internationally or are being implemented. But given the inevitably limited influence of the actors who carry this movement, it continues to lag behind the extraordinary power of the big players in the system, especially the industry.
In this context the reflection on “global solutions” that the organizers have called for will sooner or later explicitly incorporate a more fundamental level that has been only sporadically addressed in Quebec City: the determinants of the current system and the necessity to reform the institutions. This will not go without fights. Just think about fast-track approvals, mandatory vaccines or the ambivalence of medical journals: Overdiagnosis and Too Much Medicine had rarely such a favorable environment as today.
Some presentations and workshops tackled these structural issues. Re-Check specially enjoyed the interventions of Vinay Prasad, the Biojest collective, Geneviève Rail and Marc-André Gagnon. Starting from a wide range of perspectives, they all suggested ways in which this reflection could be structured: with the consistent elimination of conflicts of interest in research, a critical review of the medical journals economic model and the come back of a greater methodological diligence.
Save the date! The next Preventing Overdiagnosis Conference will take place in August 2018 in Copenhagen – Re-Check will be there.
Pour aller plus loin:
BMJ podcasts during the Conference:
1. Vinay Prasad, Oregon Health and Sciences University, brilliant co-author of “Ending Medical Reversal”
2. “From theory to practice” – with Jessica Otte (Family physician from Canada), David Warriner (Cardiologist from the UK), Jack O’Sullivan (Junior doctor from Australia), Imran Sajid (GP from the UK)
3. Stacy Carter, University of Sidney
4. Rita Redberg, JAMA
Trailer of Thomas Lemke’s documentary (DK) “Sygdom søges” (“Blissful Ignorance”)
What is overdiagnosis? A video of informedhealth.org
Ending Medical Reversal: Doc-to-Doc with Vinay Prasad, MD
Center for Evidence-Based Medicine @CebmOxford, AMQ Québec @amqquebec, France Legaré @SMD_ULAVAL, Vinay Prasad @VinayPrasad82, Stacy Carter @stacymcarter, Rita Redberg @RFRedberg, Less Is More/Dr Otte @LessIsMoreMed, Imran Sajid @imransajid, Patrick Archambault@patarchambault, Maude Dionne WikiCISSSCA