We have carefully followed the heated debate about overdiagnosis and overtreatment that is currently ongoing on the BMJ. Per definition, screening programs use diagnostic tests on healthy asymptomatic subjects to perform early diagnosis and reduce mortality. In this setting, it may happen that the disease, generally a tumour, is so indolent or stable that it would not have been clinically relevant during the subject’s life. In other words, that patient would have died from other causes but the tumour. This means that overdiagnosis is intrinsic to any screening programs.
The incidental diagnosis of cancer as additional finding in the context of cross-sectional imaging studies performed for any reason implies a not negligible probability of overdiagnosis. Moreover, technological improvements allow for higher and higher resolution of imaging techniques, making the probability of incidental findings and overdiagnosis higher. Needless to say, we cannot avoid treating a cancer once detected. This is also because, to date, we have no means (including advanced molecular analyses) to decide whether a cancer should be treated or not. Unfortunately, this possibility is not even in sight.
It is agreeable that education and evidence-based medicine are good tools to contrast overdiagnosis. However, we should note that modern doctors have a long series of different diagnostic tests available, including those using imaging techniques, each competing with the other for accuracy, associated risks, invasiveness, cost, etc. Not only the choice of the right test but also the correct sequence with which they are used has become challenging. Also, the unavailability of some tools in specific geographic areas may further complicate the setting.
Thus, if avoiding overdiagnosis seems to be extremely challenging, an option could be to try minimizing the treatment. In this setting, interventional radiology plays a major role. A spectrum of tools (radiofrequency ablation, focused ultrasound, lasertherapy, cryotherapy) under the guidance of various imaging techniques (ultrasound, computed tomography, magnetic resonance) is currently applied to treat tumours throughout the body (liver, breast, lung, thyroid, prostate, etc.). Success rate of these procedures are comparable to those achieved with conventional surgery, with clear advantages of extremely low (or no) invasiveness and cost reduction.
In conclusion, appropriateness may reduce (but not eliminate) overdiagnosis. To compensate for that, interventional radiologists should play a major role reducing the aggressiveness of treatments, especially for asymptomatic small tumors.
References
1. Llewelyn H. Overtreatment can be cured only by education. BMJ 2012;345:e6867
2. Sardanelli, F., 2012. Evidence-based radiology and its relationship with quality. In Bruno MA, Abujudeh HH, eds. Quality and safety in Radiology, New York: Oxford University Press (Chapter 27), pp.256-290.
3. Sardanelli F, Hunink MG, Gilbert FJ, Di Leo G, Krestin GP. Evidence-based radiology: why and how? Eur Radiol. 2010;20(1):1-15
Competing interests:
No competing interests
15 November 2012
Francesco Sardanelli
Associate Professor of Radiology
Luca Maria Sconfienza
IRCCS Policlinico San Donato - Dipartimento di Scienze Biomediche per la Salute, Università degli Studi; Milano (IT)
Rapid Response:
Re: Overtreatment can be cured only by education
We have carefully followed the heated debate about overdiagnosis and overtreatment that is currently ongoing on the BMJ. Per definition, screening programs use diagnostic tests on healthy asymptomatic subjects to perform early diagnosis and reduce mortality. In this setting, it may happen that the disease, generally a tumour, is so indolent or stable that it would not have been clinically relevant during the subject’s life. In other words, that patient would have died from other causes but the tumour. This means that overdiagnosis is intrinsic to any screening programs.
The incidental diagnosis of cancer as additional finding in the context of cross-sectional imaging studies performed for any reason implies a not negligible probability of overdiagnosis. Moreover, technological improvements allow for higher and higher resolution of imaging techniques, making the probability of incidental findings and overdiagnosis higher. Needless to say, we cannot avoid treating a cancer once detected. This is also because, to date, we have no means (including advanced molecular analyses) to decide whether a cancer should be treated or not. Unfortunately, this possibility is not even in sight.
It is agreeable that education and evidence-based medicine are good tools to contrast overdiagnosis. However, we should note that modern doctors have a long series of different diagnostic tests available, including those using imaging techniques, each competing with the other for accuracy, associated risks, invasiveness, cost, etc. Not only the choice of the right test but also the correct sequence with which they are used has become challenging. Also, the unavailability of some tools in specific geographic areas may further complicate the setting.
Thus, if avoiding overdiagnosis seems to be extremely challenging, an option could be to try minimizing the treatment. In this setting, interventional radiology plays a major role. A spectrum of tools (radiofrequency ablation, focused ultrasound, lasertherapy, cryotherapy) under the guidance of various imaging techniques (ultrasound, computed tomography, magnetic resonance) is currently applied to treat tumours throughout the body (liver, breast, lung, thyroid, prostate, etc.). Success rate of these procedures are comparable to those achieved with conventional surgery, with clear advantages of extremely low (or no) invasiveness and cost reduction.
In conclusion, appropriateness may reduce (but not eliminate) overdiagnosis. To compensate for that, interventional radiologists should play a major role reducing the aggressiveness of treatments, especially for asymptomatic small tumors.
References
1. Llewelyn H. Overtreatment can be cured only by education. BMJ 2012;345:e6867
2. Sardanelli, F., 2012. Evidence-based radiology and its relationship with quality. In Bruno MA, Abujudeh HH, eds. Quality and safety in Radiology, New York: Oxford University Press (Chapter 27), pp.256-290.
3. Sardanelli F, Hunink MG, Gilbert FJ, Di Leo G, Krestin GP. Evidence-based radiology: why and how? Eur Radiol. 2010;20(1):1-15
Competing interests: No competing interests