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What if millions of medical diagnoses, procedures, and treatments were based on, at best, questionable scientific evidence, but still performed daily, the world over, in the name of saving patients lives or reducing their suffering? A new JAMA review indicates this may be exactly what is happening.
A concerning new review published in the Journal of the American Medical Association online ahead of print on the topic of overuse of medical care, i.e., health care for which "risk of harm exceeds its potential for benefit," finds that many commonly employed medical procedures, to which millions are subjected to each year, are based on questionable if not also, in some cases, non-existent evidence.
According to the review, which was co-authored by researchers from some of the country's most esteemed medical institutions, medical overuse can also be defined as a health care practice that patients would forego consenting to if fully informed. They elaborate further on the definition of medical overuse:
[Medical] Overuse encompasses overdiagnosis, which occurs when "individuals are diagnosed with conditions that will never cause symptoms," and overtreatment, which is treatment targeting overdiagnosed disease or from which there is minimal or no benefit."
Clearly, when information is lacking or withheld concerning the true risks and benefits of a medical procedure, the principle of informed consent is violated. And this is, no doubt, a far too common occurrence in today's medical landscape where market forces rather than scientific evidence drive the medical consensus that determines the standard of care. In fact, there is reason to believe that the published biomedical literature is so corrupted by industry influence, and publication bias, that the entire ivory tower of 'Evidence-Based Medicine,' which Kelly Brogan, MD, recently described as a House of Cards, is actually based on nothing more than a coin's flip worth of certainty.
But there is also the far more insidious problem of the misclassification and/or misunderstanding of disease which can mislead researchers, health care professionals, and their patients into performing and undergoing harmful procedures without anyone realizing the harmful and sometimes deadly consequences they have wrought.
For example, over the past eight years, we have identified what is essentially a vast, submerged iceberg of overdiagnosed and overtreated medical conditions, with the worst examples being common forms of breast, prostate, thyroid, and ovarian cancer. It was not until 2013 that the issue broke wide open, when a National Cancer Institute commissioned expert panel acknowledged that early-stage or 'stage zero' breast (DCIS) and prostate (HGPIN) "cancers" are actually benign or indolent lesions of epithelial origin and should never have been, and should never be, termed "carcinomas." Essentially, the NCI report revealed that millions have been wrongly diagnosed and treated for breast and prostate cancers over the past few decades that they never had. In the case of DCIS, about 1.3 million U.S. women were subjected to some combination of either mastectomy, lumpectomy, radiation, and chemotherapy over the past 30 years, even though their screen-detected condition had no symptoms, and left untreated would likely never have caused them any harm. And this does not even account for the radiobiological harms caused by x-ray mammography, which may have planted the seeds of malignancy into the healthy breasts of millions of women in the name of "prevention through early detection."
The new study, titled "Update on Medical Practices That Should Be Questioned in 2015," reviewed 910 articles published in 2014, of which 440 directly addressed medical overuse. 104 of these were selected as "most relevant," with the 10 most influential articles selected by author consensus, and forming the basis for their 10-topic critique, which is divided into three sections: overdiagnosis, overtreatment, and methods to avoid medical overuse.
Asymptomatic Carotid Stenosis: Colloquially known as "blocked or restricted arteries in the neck," carotid artery stenosis often presents with no symptoms (asymptomatic), and yet is routinely treated with carotid angioplasty and stenting (placing a balloon or stent within the artery to open it) or surgical endarterectomy (removal of the inner lining of the artery and obstructive deposits found there) as "precautionary measures." The review referenced a systematic review and meta-analysis by the US Preventive Services Task Force that found no studies providing data on whether screening for carotid stenosis reduced stroke. What was found is that carotid ultrasonography screening leads to many false-positives; a finding that I believe, contributes to increased morbidity and mortality in screened populations.
Screening Pelvic Examinations Are Inaccurate in Asymptomatic Women and Are Associated With Harms That Exceed Clinical Benefits. Pelvic examination is often included in annual preventive visits for women and usually consists of both visual examination and the insertion of the hand and instruments like a speculum in the vagina. This soft-tissue evaluation includes the upper genital tracts, as well as urethra, bladder, and rectum. Amazingly, a cited review found no studies assessing the effect of pelvic examinations on morbidity or mortality from cancers (including ovarian cancers) or benign gynecological conditions. Moreover, it was found that the harms of screening include "discomfort, anxiety, psychological effects, embarrassment, and unnecessary procedures, including surgery (1.4% [29 of 2000] of women in one study)." The review opined strongly about the study implications: "Do not perform screening pelvic examinations. Clinicians should educate female patients about the low value of the examination. This review informed a new guideline from the American College of Physicians recommending against routine pelvic examinations for screening asymptomatic women." Given the lack of evidence supporting pelvic examinations, could the practice be considered just another form of the violation of women by medical care providers, not unlike unnecessary C-sections?
Head Computed Tomography Is Often Ordered but Is Rarely Helpful: Computer tomography uses ionizing radiation and sometimes a contrasting agent in diagnosis, both of which have significant potential to cause adverse health effects. Often CT scans produce incidental, and clinically unimportant findings, and will lead to additional CT scans being ordered. The review concluded, "A second head CT scan rarely affects patient management. Clinicians should be judicious in ordering multiple CT scans in the same patient." Consider also, that a study published in the NEJM in 2007 estimated that .4% of all cancers in the US may be attributable to CT scans!
Thyroid Cancer Is Massively Overdiagnosed, Leading to Concrete Harms: In the past 30 years, there has been a global increase in the implementation of thyroid cancer screening programs which have lead to dramatically increased rates of diagnosis of "thyroid cancer," mostly due to papillary carcinomas, which are non-fatal. Thyroid cancer mortality rates remained the same throughout this period, a clear indication of overdiagnosis, i.e. the thyroid lesions were non-cancerous insofar as they would have never caused harm if left untreated. The review cited a new study that reviewed the 15-fold increase in thyroid cancer in South Korean, from 1993 to 2011, concluding that, "Overdiagnosis of thyroid cancer is extremely common. The harms associated with this overtreatment include lifelong thyroid replacement, hypoparathyroidism, and vocal cord paralysis." Learn more by reading my article, "Thyroid Cancer Epidemic Caused by Misinformation, Not Cancer."
There Is No Benefit to Paracetamol or Acetaminophen for Acute Low Back Pain: Low back pain is one of the most common reasons why people seek medical attention, and acetaminophen/paracetamol (Tylenol) one of the most common treatments, but the study pointed out that in the first large double-blind RCT of Tylenol for back pain in patients without serious spinal pathology, the drug was not observed to be more beneficial the placebo group. The review concluded: "There is no benefit to acetaminophen or paracetamol use for acute back pain. Reassurance with advice on likely resolution may be the primary treatment for acute low back pain." Also, consider that Tylenol has recently been found to have psychiatric adverse effects, such as the dulling of emotions, and is one of the most toxic chemicals to the liver known.
Postoperative Opioid Use Continues Past the Postoperative Period: Opioid drugs are often used for post-operative pain control. The review referenced a study that found 3% of patients continue to take opioid prescriptions beyond 90 days after the procedure. The review opined: "Clinicians should diligently reassess patients receiving postoperative opioids to ensure that these medications are used safely and appropriately because opioid overuse is associated with obvious psychological and physical harm. Given the millions of patients undergoing surgery each year, it is essential that postoperative opioid use does not become a gateway to long-term opioid use."
The Harms of Perioperative Aspirin Outweigh the Benefits in Patients Undergoing Noncardiac Surgery: Aspirin use is common in the period before and after non-cardiac surgeries, even though its role in cardiovascular complications is not fully understood. According to a randomized, blinded trial comparing 200 mg/d of aspirin with a placebo during the 30-day periooperative peroid in 10,010 patients undergoing noncardiac surgery, one third of whom had vascular disease, that when the primary outcome of death or nonfatal heart attack were evaluated, there was no difference between groups (although the frequency of major bleeding was higher in the aspirin group). The study's implications were described: "Do not treat patients undergoing noncardiac surgery with aspirin during the perioperative period unless they have had stent implantation in the past year because harms may occur and there is no benefit. In patients with an indication for aspirin independent of surgery, restart aspirin use after the perioperative period, although optimal timing is not clear." Learn more about aspirin's harmful nature by reading, "The Evidence Against Aspirin and For Natural Alternatives."
Renal Artery Revascularization for Renal Artery Stenosis (RAS) Has No Clinical Benefit: a common occurrence in aging population are vascular disease including stenosis of the renal artery. A meta-analysis of 8 studies on the topic found renal artery stenting in combination with medical therapy was not superior to medical therapy alone in reducing mortality, congestive heart failure, stroke, or worsening renal function. The implications of this research were summarized as follows: "Do not perform renal artery revascularization in patients with clinically relevant RAS. Furthermore, testing for RAS has little benefit. Consistent randomized evidence shows that optimizing medical therapy is the best approach to management of hypertension and chronic kidney disease, with or without RAS."
Medications to Raise High-Density Lipoprotein Cholesterol Level Do Not Improve Cardiovascular Outcomes: There is some evidence that low HDL-C levels are associated with an increase risk of cardiovascular events. A meta-analysis of drug interventions for raising HDL< which included niacin, fibrates, and cholesteryl ester transfer protein inhibitors, found none of these drug classes improved cardiovascular morltaity, all-cause mortality, or stroke compared with controls. The study's implications were summarized as follows: "In patients with low HDL-C levels who are treated with statins, there is no clinical benefit to HDL-C–targeted therapies."
Methods to Avoid Overuse
Most Diagnoses Are Based on History and Physical Examination, and Conservative Management Is Valuable: There are 400 million annual office visits in the U.S. alone. At least 50% of the time, people go to see their doctor for physical symptoms (a symptom-based paradigm). In juxtaposition, the era of screening has lead many physicians to take a disease-based view, diagnosing patients without symptoms with problems because of suspicious laboratory findings or lesions (a disease-based paradigm). The review discovered that about one-third of patient symptoms don't match up with identifiable disease, and that "Approximately 73% (range, 56%-94%) of diagnoses are based on the history and an additional 4% to 17% on the physical examination. There is considerable overlap between physical and psychological symptoms, and approximately 75% (range, 71%-79%) of symptoms improved in weeks to months." They stated their finding's implications as follows: "Be cautious in using diagnostic tests to identify disease without high pretest probability because most disease can be diagnosed with a thoughtful history and skillful physical examination. Clinicians managing patient symptoms without obvious cause should be aware that physical and psychological symptoms co-occur, should recognize that most symptoms resolve within a few weeks to months, and should consider that serious causes of symptoms rarely emerge during long-term follow-up."
The review concluded that based on research emerging in 2014 alone, there are a diverse number of practices from various areas of medicine that indicate medical overuse is rampant, where the harms of diagnosis or treatment clearly outweigh the benefits.
They commented further on the implications of their research:
Published literature documenting overuse may benefit patients and populations if it stimulates decisions to avoid overused diagnostics and therapeutics. It is difficult to stop using commonly used tests and treatments.20 Explicit recognition that practices shown to be ineffective often continue to be performed has resulted in a focus on methods of deadoption or deimplemention. These approaches incorporate strategies from behavioral economics, such as framing patient discussions around what is available and having guarded enthusiasm about new medical care that is at risk for later being deadopted because of ineffectiveness.20 Health care professionals are well suited to improve these practices at multiple steps when providing patient care, as described by Kroenke.19
Clinicians and patients share the consequences and responsibility for medical overuse. With improved awareness, caution around new tests and treatments, and deimplementation of ineffective practices, there should be improvement in patient outcomes, safety, and satisfaction along with reductions in health care spending. With thoughtful questioning, many current practices that seem logical but are without evidence may be reconsidered and incorporated into a less dogmatic and more patient-centered approach to care.
Reviews like this indicate that many of the most commonly accepted and proffered procedures in modern medicine may be causing more harm than good. Perhaps we need to heed the sage advice of Samuel Shem, who once wrote: "The delivery of good medical care is to do as much nothing as possible." To learn more, read my recent article on the topic, "Good Medicine: Do As Much Nothing As Possible."