Abstract

Letter to the Editor

An asymptomatic, healthy 36-year-old woman attended a routine consultation with a gynaecologist. Even though she was a healthy, asymptomatic young woman, the doctor ordered various tests, including ultrasounds (pelvic, breast, thyroid, abdominal), mammography, bone densitometry, pap smear, complete blood count, thyroid tests, and a biochemistry panel. Most of the imaging tests showed some incidental findings; densitometry showed osteopenia; thyroid ultrasound found a solid 1.2-cm nodule in the right lobe. The woman was fearful with all abnormal findings in her tests. The gynaecologist said that these abnormalities were not alarming, except for the thyroid nodule. A diagnostic procedure showed a papillary carcinoma, and a thyroidectomy was performed. She was discharged taking 100mcg of levothyroxine daily.

This young woman is an everyday practice example of overdiagnosis and medicalization¹1 Moynihan R, Doust J, Henry D. Preventing overdiagnosis: how to stop harming the healthy. BMJ. 2012; 344:e3502.

2 Welch HG, Black WC. Overdiagnosis in cancer. J Natl Cancer Inst. 2010; 102:605-13.

3 Brodersen J, Schwartz LM, Woloshin S. Overdiagnosis: how cancer screening can turn indolent pathology into illness. APMIS. 2014; 122(8):683-9.

4 Brodersen J, Schwartz LM, Heneghan C, O’Sullivan JW, Aronson JK, Woloshin S. Overdiagnosis: what it is and what it isn’t. BMJ Evid Based Med. 2018; 23(1):1-3.^-55 Hofmann B. Medicalization and overdiagnosis: different but alike. Med Health Care Philos. 2016; 19(2):253-64.. She was submitted to a large number of unnecessary tests as part of a routine medical examination. None of the tests she underwent (except for the pap smear) have a formal indication based on the best available evidence⁶6 US Preventive Services Task Force. Screening for gynaecologic conditions with Pelvic Examination. US Preventive Services Task Force Recommendation Statement. JAMA. 2017; 317(9):947-53.. Unfortunately, contemporary medical practice has been based on overuse of medical tests, particularly in preventive consultations. This case report aims at bringing this subject to discussion. Reviews of the drivers and causes of overuse, medicalization and overdiagnosis as well as the difficulties in estimating and communicating overdiagnosis are available elsewhere²2 Welch HG, Black WC. Overdiagnosis in cancer. J Natl Cancer Inst. 2010; 102:605-13.

3 Brodersen J, Schwartz LM, Woloshin S. Overdiagnosis: how cancer screening can turn indolent pathology into illness. APMIS. 2014; 122(8):683-9.

4 Brodersen J, Schwartz LM, Heneghan C, O’Sullivan JW, Aronson JK, Woloshin S. Overdiagnosis: what it is and what it isn’t. BMJ Evid Based Med. 2018; 23(1):1-3.^-55 Hofmann B. Medicalization and overdiagnosis: different but alike. Med Health Care Philos. 2016; 19(2):253-64.^,77 Pathirana T, Clark J, Moynihan R. Mapping the drivers of overdiagnosis to potential solutions. BMJ. 2017; 358:j3879.

8 Hofmann B. Back to basics: overdiagnosis is about unwarranted diagnosis. Am J Epidemiol. 2019; 188(10):1812-7.^-99 Kale MS, Korenstein D. Overdiagnosis in primary care: framing the problem and finding solutions. BMJ. 2018; 362:k2820..

Discussion

Overdiagnosis has been defined as a condition that would have never been known or never caused harm to the patient had it not been found. Put it in a different way: it is the diagnosis of a “disease” that will never cause symptoms or death during a patient’s lifetime²2 Welch HG, Black WC. Overdiagnosis in cancer. J Natl Cancer Inst. 2010; 102:605-13.

3 Brodersen J, Schwartz LM, Woloshin S. Overdiagnosis: how cancer screening can turn indolent pathology into illness. APMIS. 2014; 122(8):683-9.^-44 Brodersen J, Schwartz LM, Heneghan C, O’Sullivan JW, Aronson JK, Woloshin S. Overdiagnosis: what it is and what it isn’t. BMJ Evid Based Med. 2018; 23(1):1-3.. It is a “disease” by its current pathophysiological definition, but it is not destined to be clinically apparent and, therefore, not cause any symptoms or harm. It is a pseudo-disease, a condition whose diagnosis can only cause harm. It turns people into patients unnecessarily, producing anxiety and other negative consequences of labelling; it also results in wasted resources and side effects because of a cascade of further confirmatory testing and overtreatment⁸8 Hofmann B. Back to basics: overdiagnosis is about unwarranted diagnosis. Am J Epidemiol. 2019; 188(10):1812-7.. Overdiagnosis is different from a false positive test result, and most frequently occurs in the context of screening asymptomatic people, but it can also occur in symptomatic people either because of overmedicalization of ordinary life experiences (disease mongering) or because of incidental findings during an investigation of some other health condition. Another way of understanding overdiagnosis is to consider it an “unwarranted diagnosis” or “unwarrantedly giving a person the label of a disease”⁸8 Hofmann B. Back to basics: overdiagnosis is about unwarranted diagnosis. Am J Epidemiol. 2019; 188(10):1812-7..

Who is to blame for the existence of such a condition? Advances in biomedical technologies, ever more sensitive tests and images, expensive screening programs, the culture of excessive and unnecessary testing, the definition of disease itself, just to name a few. Broader concepts such as medicalization are related to overdiagnosis - both expand the extension of the concept of disease - but differ in many aspects. Other concepts such as overuse, disease mongering, overtesting, overtreatment, and “too much medicine”¹⁰10 Moynihan R, Smith R. Too much medicine? Almost certainly. BMJ. 2002; 324:859-60. could be mistaken for overdiagnosis but are separate concepts with some overlap. Treatment of an overdiagnosed condition is a type of overtreatment; overuse or overutilization - practice in health services that do not provide net benefit to people - do not necessarily lead to overdiagnosis but increases the risk of overdiagnosis and overtreatment⁸8 Hofmann B. Back to basics: overdiagnosis is about unwarranted diagnosis. Am J Epidemiol. 2019; 188(10):1812-7..

Conclusion

Overdiagnosis is one of the many faces of medicalization of society. It is intrinsically related to preventive medical activities, particularly the ones involved in screening. When one tries to diagnose a disease early in its course, the incidence of this disease increases, many people will have to be treated, there will be no effect on total mortality, and there might be a small effect on specific mortality. What happens most of the time is overdiagnosis: a condition that would never harm the patient, but its diagnosis will harm in the form of unnecessary treatments, labelling, psychological distress, and waste of time and money. Moreover, the diagnosis of this type of condition (overdiagnosis) will perpetuate the activities that led to them in the first place, as the prognosis of people detected with overdiagnosis is, by definition, excellent (lead-time bias and length time bias) which brings a sense of effectiveness and necessity.

Doctors that care with the wellbeing of their patients, believe that health equity is an ethical imperative and are worried with the sustainability of universal healthcare systems should be aware of this entity and make all efforts to avoid it. There is also urgent need to reconnect diagnosis with patient suffering⁹9 Kale MS, Korenstein D. Overdiagnosis in primary care: framing the problem and finding solutions. BMJ. 2018; 362:k2820., and to reform disease definitions. One possible action to reduce overuse, overdiagnosis, and overtreatment is to focus on the care of sick people and leave the healthy alone¹¹11 Heath I. In defence of a National Sickness Service. BMJ. 2007; 334(7583):19 .. Preventive strategies should be dealt with population strategies (mainly with health promotion practices and intersectoral actions) rather than with pseudo-high risk strategies¹²12 Olmos RD. Subclinical thyroid disorders should not be considered to be a non-classical risk factor for cardiovascular diseases. Sao Paulo Med J. 2021; 139(2):196-7..

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