Over- and Under-Diagnosis and Treatment of Breast Cancer

I found this interesting discussion on over and under diagnosis of breast cancer and how to avoid it. Its definitely worth the read.

The big take away I found in the article is that the best way to avoid overdiagnosis is to get screening done at a breast center where the radiologists read mammograms daily. Through their jobs, they see many more breast images than other radiologists who are not as specialized and much more apt to correctly diagnose breast cancer.

Also, better education of patients and oncologists will also help with preventing over-treatment. Often the first reaction at a cancer diagnosis is 'get rid of it now and make sure it doesn't come back!' Fear takes over and the reaction of a patient goes instantly to get rid of it.

But maybe if the patient takes time to educate themselves on treatment possibilities the fear can be controlled. And the doctor is educated enough to provide the support to help the patient make the best choices and not the impulsive choices. Then the chance of over treatment can be reduced.

I think that this issue of over treatment and over diagnosis for many ailments needs more awareness and focus. We need better trained medical personnel who are able to better read screening images and provide better diagnoses. We also need additional training for medical personnel to help patients make better decisions. Finally we need more information available for patients to reduce the fear at diagnosis so they are able to make better decisions.

That's a lot of money

There is a lot of talk about breast cancer over diagnosis and false positive mammograms. A new report looked at the costs involved. They are big numbers:

How much does each false positive  mammogram, or IDC or DCIS over diagnosis cost?

• Mammogram - $852
• IDC - $51,837
• DCIS - $12,369

The total is around $4 billion (with a b) each year. That is a lot of money! The breakdown is $2.8 billion resulting from false-positive mammograms and another $1.2 billion attributed to breast cancer overdiagnosis. But its not just the financial cost but the emotional toll on the patient.

"Apart from the financial cost of screening tests and treatment, false positives and overdiagnosis expose women to risks from additional medical procedures, not to mention psychological distress. It's not uncommon for mammograms to turn up some apparent abnormality that has to be resolved with more imaging tests or a biopsy.

"We're hoping that the financial cost of this problem will help cast into greater relief the human cost," said co-author Mandl. "The two messages together are powerful. The fact that this is not only a problem, but a very costly problem, we hope will accelerate the attempts to try to fix the screening practices."

But another expert defended those practices, and called the study one-sided.

"There was no attempt to balance the costs with the benefits," said Richard Wender, who heads prevention, detection and patient-support efforts at the American Cancer Society. "I strongly feel that every study that looks at the downsides of any screening test has to be balanced with the benefits.""

But the benefits? Are those lives saved by screenings? I would hope so. But that is so much money. Maybe we need better diagnostics as well as a cure.  And yesterday's post on mortality vs survivorship numbers - think of how skewed they could be as a result of these errors.

Cancer mortality vs survival rates

Overdiagnosis of cancer greatly impacts the survival rates. Overdiagnosis occurs when people are told they need treatment for a cancer which will never progress or isn't even cancer (but we really hope that it really is cancer). If your cancer is never going to kill you, you don't need the treatment. And the treatment can cause you harm.

"Overdiagnosis can have a powerful effect on survival rates, even if no one has their life prolonged.
To understand why, imagine a country in which 1,000 people are found to have Cancer X because of symptoms (they all have progressive cancer). Five years after diagnosis, 500 are alive — producing a five-year survival rate of 500/1000 or 50 percent — and 500 have died.

Now imagine the same country with lots of cancer screening and/or incidental cancer detection.  Perhaps 2,000 would be given a diagnosis of Cancer X, although 1,000 would actually have indolent forms and not be destined to die from their cancer.  Five-year survival will increase dramatically, to 75 percent, because the 1,000 people with indolent cancer appear in both parts of the fraction: 1,500/2,000.  But what has changed?  Some people have been unnecessarily told they have cancer (and may have experienced the harms of therapy), and the same number of people (500) still died from Cancer X."

Got it? Good. And this over diagnosis costs billions. And the stress is horrible on the people. And unnecessary cancer treatment, which is pretty harsh, can cause people long term health concerns.

So when people run around saying "all these advances from research your donations helped fund have helped reduce the survival rates from this cancer", don't accept them at face value. Real research is needed to help prevent overdiagnosis and mortality rates are what need the real review.

Overdiagnosed and overtested

You are diagnosed with cancer after some tests. Then you are sent for more tests to figure out the best course of treatment. You feel tested to death - too many injections, IVs, scans, and time in waiting rooms. Finally you get a course of treatment. Did you really need all those tests?

New diagnostic tests keep being developed to help determine the best course of treatment for a patient. But how much of their results are really helping doctors and patients? A recent study confirmed that the doctors see the tests as confirmation of their recommendations. And that patients do not really understand the results.

I have been on numerous breast cancer boards where women question the significance of the results of their Oncotype DX and other tests. "My results were this and my doctor said this, what should I do?"

"Fourteen oncologists were surveyed at teaching and community hospitals in Toronto. Most said the tests enhanced their confidence in deciding whether to recommend chemotherapy in cases where the best course of action was unclear to both the physician and the patient - especially when they were truly undecided. While most said the test supported their assessment rather than altering their practice, one oncologist described the test as a "tie-breaker."

But they raised concerns about overuse and inappropriate use of the test; over-reliance on the test relative to other, more established pathological indicators; the fact that testing takes places in only one lab in California; aggressive marketing of the test and its high cost, about $4,000.

Dr. Bombard said these reservations were consistent with general concerns about overuse of laboratory testing, which has increased rapidly, contributing to the financial strain on health care systems. Estimates suggest that 10 to 50 per cent of lab tests in Canada might be unnecessary and one-third of U.S. health-care spending results from overuse or misuse of tests, procedures and therapies."

This last sentence sums it up for me. Do we need all these damn tests? Just because we can test for something do we really need to?