Posted by John Ager on 03 April 2012.
A common criticism of our civil justice system is that medical malpractice lawsuits force doctors to practice defensive medicine – that is ordering tests they might not otherwise do at great and unnecessary expense to avoid being sued. Many tests and procedures are very good at identifying and confirming a suspected medical condition. Some tests, however, are not very sensitive, meaning that they are not always good at detecting the particular medical condition they are designed to find. Other tests are not very specific, meaning that a positive result suggests several possible causes, perhaps creating more questions than are answered. And, some conditions are just so rare that extensive testing does not seem to make much sense, even though every once in a while it identifies the needle in the haystack and saves a life. Judgment, public policy and yes, medical malpractice lawsuits, all play a role in the diagnostic care a patient receives.
But what happens when routine and inexpensive testing reveals a condition that needs no treatment 90% of the time, but results in death the other 10%? Defensive overdiagnosis. Believe it or not, that is the problem with breast cancer where overdiagnosis not likely to be the result of a physician’s fear of missing something, but rather the gravity of the downside risk once something is found. A recent Norwegian study concluded that while routine mammography routinely picks up life threatening cancers, 15-25 percent of the breats tumors found would not have caused any problems if left untreated during the woman’s lifetime. Unfortunately, there is not a good way to tell which tumors will be life-threatening and which will not. According to the study, while routine mamography prevents one death for every 2,500 women screened, it also causes 6-10 women to be over-diagnosed and unessessarily treated. Where the choice is between unnecessary treatment and death, there is really no reasonable alternative to treatment, even if it may be unnecessary.
So what is the solution? Patient rresponse to the diagnosis of a breast tumor runs the gamut from patients who do nothing to those who elect a prophylactic bilateral mastectomy for even the smallest lesion, and everything in between. Unfortunately, for every life saved, 6-10 women and their loved ones can be profoundly affected physically and and psychologically. This raises a host of philosophical questions about whether screening is worthwhile for which there are likley to be as many answers as there are people with an opinion. The fact is, there really is no good solution to the over-diagnosis of breast cancer other than the development of increasingly sensitive and specific tests that can predict with greater accuracy the risks associated with breast tumors once they are identified.