Overdiagnosis Of Breast Cancer
Overdiagnosis and Overtreatment of Breast Cancer: Is Overdiagnosis an Issue for Radiologists?
Reference-Breast Cancer Res. 2006;8(2)
Complete article here at Medscape
"Overdiagnosis is diagnosis of cancers that would not present within the life of the patient and is one of the downsides of screening. This applies to low-grade ductal carcinoma in situ and some small grade 1 invasive cancers. Radiologists are responsible for cancer diagnosis, but at the time of diagnosis they cannot determine whether a particular low-grade diagnosis is one to which the definition of overdiagnosis applies. Overdiagnosis is likely to be driven by technological developments, including digital mammography, computer-aided detection and improved biopsy techniques. It is also driven by the patient's fear that cancer will be missed and the doctor's fear of litigation. It is therefore an issue of importance for radiologists, presenting them with difficult fine-tuned decisions in every assessment clinic that are ultimately counted later by those who evaluate their screening."
Overdiagnosis Of Breast Cancer
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Reviewed by Sumer Sethi
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Thursday, July 06, 2006
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Sumer Sethi
Unique blend of academic excellence and entrepreneurship, heading leading firms in India- Teleradiology Providers, pioneering company providing teleradiology services and DAMS (Delhi Academy of Medical Sciences) Premier test preparation institute in India for MD/MS/MCI preparation. He has also been an invited faculty member at various conferences, including Teleradiology in IRIA 2008 and 2011, Hospital Build Middle East, Congress of the Brain Tumor Radiology in Neuro-oncology Society. Dr. Sethi is Editor-in-Chief of Internet Journal of Radiology. He has a keen interest in Web 2.0 technologies and in maintaining his famous radiology blog, which has been featured in multiple international journals.
11 comments:
Breast cancer diagnosis is missed enough so why play around with the question, and it is a question, without any back up. It appears that what is wanted by those diagnosing breast cancer is a guess as to whether the cancer will present itself with significant symptoms or if the approach of "waiting" would be the thing to do. Physician's that have never heard "you have cancer" will never understand what that means to a patient. Mammograms, that have been touted as being so wonderful in identifying "most" breast cancers certainly have missed many. You only get more testing if you have a family history of breast cancer or for some other reason, you have a higher than average risk. This type of article is a waste of time and whoever believes it, should be doing something worthwhile to help find diagnosis, treatment and cure of breast cancer. Cancer diagnostic centers let many of their patients "fall through the cracks" when it is well known that breast cancers are MISSED a good deal of the time and due to "cost" do not suggest that women have a more diagnostic test.
I couldn't agree more with the above comment.
This business of "overdiagnosis" is a crock.. what an embarrassing concept.
Obviously the author of that article never had a close family member diagnosed with breast cancer!
I don't think either a crock or embarassing. I think the only reason you think it is a crock is because you don't really understand what overdiagnosis is and you overestimate the benefit of early detection. Another thing that you don't understand is the woman who is "overdiagnosed" is not the same as the one whose life is saved. Even if she might think her life was saved. You also don't understand that there are more women who get an unnecessary diagnosis of breast cancer than there are women whose life is saved. And that early detection doesn't always make a difference - sometimes woman may die inspite of early diagnosis and sometimes she would've survived even without it.
Overdiagnosis means that some women who would have NEVER have gotten diagnosis of breast cancer in their lives without screening (and maybe lived to an old age without ever knowing they had it) instead became cancer patients and suffered side effects of treatment that may have shortened their lives. Not to mention all the stress that came with the diagnosis of breast cancer - the diagnosis these women wouldn't have received in their lifetime. These women are not the same women as those whose lives were saved, but nobody can tell which is which. These women are really hurt. They pay the price for those women whose lives are saved.
Does saving a life of one woman worth shortening the life of another one? What about saving a life of one woman vs shortening lives of several women? How many? Is life of one woman worth unnecessary mastectomy for another? What about life of one woman vs unnecessary surgery and radiation for 10 others? For if some of these 10 get sarcoma as a result of radiation some years down the line? A heart attack? I think the number of women who are hurt is just as important as the number of women whose lives are saved.
Incidentally the article estimates overdiagnosis at 10%, but some epidemiologists who looked at the same data estimated it at 25% or even 30%. I find their arguments pretty convincing, but do your own math.
Talking about "more diagnostic tests...". How accurate do you want this test to be? Autopsies done on women who died of other causes show that quite a lot of them had DCIS. Which means that if testing becomes really really accurate, maybe as many as 30% of all women will get breast cancer diagnosis without any additional benefit of saved lives (since these women died of other causes -> their cancer was non-progressive). There is no test right now to say which cancer will progress, maybe there should be one. Maybe learning more about identifying cancers that matter is more important than simply finding more cancers.
What first two posters don't seem to understand is that not all cancers are the same. Some are indolent and would have never threatened your life even if they remained undetected, some spread so slow that even if they are detected when they become visible they can still be cured, but some are so aggressive that no matter how early you detect them, you'll die because they spread microscopically right from the start. These very agressive cancers are those that "fall through the cracks" so earlier detection would likely not have made any difference. Except for extending time one lives with the desease (and shortening the time one lives as a healthy person).
Early detection only helps with certain cancers - those that spread sufficiently slow that they can be detected and yet are destined to kill you. Provided you catch them in the right time. There are still questions about how big this subgroup is.
A simple example for first two posters.
Say a woman is diagnosed with breast cancer, goes through surgery and radiation, suffer side effects of the treatment, maybe long lasting, maybe for lifetime. Than a doctor comes up and says - "sorry we made a mistake, you've never had cancer at all". I think you'd agree this woman was harmed by the diagnosis.
In some sense overdiagnosis is such a mistake except for there is nobody to blame but the lack of a test that could say for sure which bunch of cells that looks like a cancer under the microscope is really a cancer - i.e. it is going to spread - and which is harmless and non-progressive or simply progresses so slowly that it'd only be apparent if you live till you are 200.
You say it is question without any back up, but it is well-known that since the screening started, the incidence of early breast cancer increased while there was no corresponding decrease in cases of advanced breast cancer.
More screened women are diagnosed with breast cancer than unscreened women. Yes some of it may be due to early diagnosis, but unscreened women never seem to catch up. A diagnose of cancer is devastating, so nobody wants to get it unless it means her life will be saved.
You may say that missed cancers are more important, but only if in a particular missed cancer a earlier diagnosis would've made a difference. And this also depends on the type of cancer one has. Also while missed cancer may mean missed chance to save one's life to one woman, an extra cancer mistakenly diagnosed in another woman means unnecessary treatment and maybe even early death because of this treatment. You may say the chance of the latter is low, but so is the chance that screening saves one's life.
For every woman whose life is saved there may be several who are harmed. Surely minimizing the number of the latter is important.
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What about women who are falsely diagnosed and the doctor never admits it?can you tell me if the woman has had a mastectomy ,how could she prove a wrongful breast cancer diagnosis?e mail the answer to carolinayellowhorse@yahoo.com A>S>A>P I think I was wrongfully diagnosed.
I just received a call that the radiologist wants more images after my mammogram. I am terrified, not because I fear cancer (odds are against it), but because I fear the intervention that has previously lead to multiple biopsies (all benign). At this point I am concerned about limiting my exposure to radiation-- I have literally had 100s of images done (due to stereotactic biopsy). I am not even 50. Any concerns about x-ray exposure? I noticed my doctor's office now has a release that states the effects are unknown.
I'd just like to thank the 3:24 am poster for explaining the perils of over-diagnosis so succinctly. Unnecessary cancer treatment is nothing to scoff at. Lives can be shortened, possibly permanently damaged, and sometimes lost as a result of aggressive cancer treatments. The thought that so many women are going through such treatments unnecessarily (and some studies suggest the over diagnosis rate is closer to 50%) should fill us with horror, not disdain. Women throughout the world have brainwashed into believing the misleading (not to mention highly illogical) mantra that "early detection is the best prevention".
Detection by definition is not prevention and early detection is not necessarily better for the individual than later or no detection. Instead of spending all of our time and money worshiping the mammography machine, much more effort needs to go into determining the nature of breast cancers, when to treat them, and how best to treat them. Unfortunately, however, I fear the fact that the mammography and cancer industries are so profitable will prevent this from happening for a vey long time.
I also applaud the poster who so beautifully stated the downsides of overtreatment and overdiagnosis. I am currently in the same bind - a few microcalcs found, recommendation: biopsy. I will get a second outside radiological opinion, not that it will do any good but I intend to double and triple check this situation all along the way. And of course, I will be prepared to be "fired" by my doctor ((i.e. dropped) for having the backbone, knowledge and temerity to insist on more answers. btw, I have never met or spoken to the faceless radiologist who is the frontline diagnostician in this scenario. Disconnect much? Yep. Be careful ladies,...it's your life on the line, no matter which way you look at it. Radiologists should be demanded BY LAW to sit down with each and every patient and show them the microcalcs, masses or whatever it is and discuss it thoroughly, not hide behind a door. Maybe then there'd be more accountability.
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