This book will probably appeal to people like me, who have already been questioning the value of endless screening tests, but I hope others will read it as well. It is a large dose of sanity in the face of all the pressure from doctors, advocacy groups for various diseases, public service ads and commercials from companies offering screening tests who tell us we need to be screened because "early detection saves lives." Usually they throw in some stories of people who got screened, got treated and are still alive. They are all quoted saying "Early detection saved my life."
But did it? Or did it just turn them into patients years before their "disease" would have manifested itself? Worse yet, maybe that tiny growth detected on the X-ray would NEVER have turned into actual disease. In that case, they did not need any treatment and may have been harmed by the treatment they received. Dr. Welch calls this "overdiagnosis."
Dr. Welch points out that these "success" stories lead to more screening which leads to more useless treatment. Proponents often cite the increased "cure" rate of those who are screened versus those who are not. Logically, the time between diagnosis and the time when the patient is considered "cured" (say, five years with no recurrence) will be greater if a tumor was found several years before it would have manifested as symptoms. With or without screening, a tumor would grow (or not grow) at the same rate. Without screening, a tumor that grows will be discovered when the patient has symptoms. That's a later diagnosis, but the course of the disease is the same and early treatment might make no difference at all.
MY MAMMOGRAM STORY
I am in my middle 60s and had always resisted getting a mammogram until recently. I had changed doctors and my new doctor gave me a referral and I decided to do it this time. I think it was mostly out of curiosity and because Medicare would pay for it (a wrong reason, I know!). The screening was done at a huge hospital complex (Beaumont Hospital in Royal Oak Michigan). The procedure was fast and not too unpleasant, but I was surprised to get a phone call a few days later telling me I needed to make another appointment for more views. I asked why and got no real answer, other than the Radiologist wants more views. I said I needed more information before I would come back and they said to call my doctor. I did that, and his staff person had to search for any information about my mammogram, but finally found what the hospital had sent and it merely said that the results were inconclusive for the left breast. This does not tell me what was inconclusive. I then received a letter from the hospital, which said the initial findings showed "a need for additional imaging studies, such as additional mammographic views, ultrasound or MRI for a complete evaluation." This sounded to me like the start of a cascade of expensive and possibly invasive and dangerous services which I did not want. I got several more calls from the hospital urging me to make another appointment, but I was not satisfied with the lack of real information as to why I should do that. Finally another woman called me who would only say she was "Sharon," so I don't know her position, but she must have been a supervisor because she did tell me more (there was an "asymmetrical density " in the left breast), but would not name the Radiologist (I later got her name from my Medicare payment info online). Sharon said (in effect) I was likely called back because this was my first and only mammogram and they had nothing to compare it with. I subsequently received a certified letter from the hospital, which I take to be their "CYA" letter in case I turn up with cancer and sue them. I finally sent them my own certified letter explaining why I was not returning and asking for access to the images and notes from my mammogram. They have never responded.
I do breast self-exam and there are no lumps or any abnormality. I have no symptoms and I feel fine. I am more willing to trust my own instincts that I do not have brest cancer than I am willing to trust the people at the hospital. My only regret is getting the mammogram in the first place.
To hear all the hype about mammograms, you'd think they somehow PREVENTED cancer, whereas they do no such thing. They are X-rays of the breast and the "findings" are the opinion of a Radiologist who does not see you or examine you. I find Radiology a strange kind of medical specialty. It does not involve patient contact, but is based on a person (presumably the Radiologist) studying images and coming to a conclusion. In the book, Dr. Welch has a horrific story of a pregnant lady whose imaging screening could not image one of her baby's feet. The Radiologist decided the baby probably had a club foot. The poor mother-to-be drove herself crazy learning all about club feet and imagining what life would be like for her deformed child. When the baby was born, both feet were perfect. The point is, these images are often going to find anomalies that can't be definitively said to be deformity or disease. But the findings WILL lead to a lot more medical services.
I think Dr. Welch actually underestimates one of the consequences of this and that is the expense. Whether it's the patient paying (increasingly the case) or insurance or Medicare, screening leads to a lot of expensive services that are not needed and can do a lot of harm. Men treated for early signs of prostate cancer can become permanently impotent, and the worst of it is their prostate cancer may never have progressed to a point where they would have symptoms. Many men with prostate cancer eventually die of something else because the cancer is so slow growing, or may not grow at all. Particularly with prostate and breast cancers, studies involving autopsies show many people have small cancers they never knew they had and which never caused any symptoms.
Dr. Welch works for the VA, which is a single-payer government-funded system in which the doctors have no financial incentive for overtreating patients, but I think lots of doctors are biased in favor of treatment when it may not be needed because of the extra income it brings. Radiologists who don't even see the patient have every incentive to say they "need more views." The hospital has every incentive to encourage women to come for mammograms, then to do more imaging if anything at all is found on the screening X-rays.
Dr. Welch also barely mentions the fact that X-rays CAUSE cancer! Yes, we've all heard about how tiny and harmless those doses are in a mammogram or other X-ray, but the effect is cumulative. That is one reason I was not eager to "have more views" taken. When those dose amounts in a mammogram are mentioned, how many "views" are they based on? Why don't screening services release actual information of the dosage of each view? How do I know their machines are working properly or that their technicians are competent? Why should I trust these medical providers on this subject when they have so much incentive to encourage "more views?"
Too much worrying about our health and visiting doctors when we are not sick is adding to our bloated health care bill in the US. Maybe we should just accept our own mortality and not seek ever-more information from inside our bodies via screening. People talk about the supposed benefit of finding disease early, but never about the harm of pursuing tiny ambiguous anomalies leading to treatment that could be unnecessary and surely is expensive.
This book is very well-written, with clear explanations, nice graphs to help illustrate the points made, and plenty of eye-popping examples. Before you buy in to "early diagnosis" and give into the pressure to get screened, read this book and use your head. Dr. Welch makes his case.
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This important book can be read both as an indictment to modern medicine and as a critique to the medicalization of life in general and to the paradigm of “early diagnosis” in particular. According to Dr. Welch, thousands and thousands of healthy individuals are being turned into anxious patients, with dire consequences upon their health and their finances.The main argument of the book can be summarized in a single figure (see below). “New diagnoses” are increasing steadily, but “deaths” are flat. These combined trends show up in a whole range of diseases: prostate cancer, breast cancer, lung cancer, diabetes, hypertension, osteoporosis, and so on. In all these cases more people are being diagnosed, but the increase in diagnosis has not been followed by a decrease in mortality, contradicting the purported advantages of “early diagnosis”. In short, more people are being diagnosed and treated, but no more lives are being saved.Overdiagnosis is creating unnecessary anxiety, unnecessary hassles and unnecessary suffering. According to Dr. Welch, various factors contribute to the epidemic of overdiagnosis. Most decision makers profit from the frenzy of tests and screening. Also, hard evidence (i.e., randomized trails) on the impact of screening and preventive medication is scant to say the least. Finally, several cognitive biases reinforce the paradigm of early diagnosis.This is not an optimist book. Dr. Welch convincingly argues that the problem in question constitutes a dominant paradigm, a stable and perverse equilibrium, and that overdiagnosis begets overdiagnosis. Overturning this sorry states of affairs will be difficult, if not impossible. Many things will have to change. This book, for example, should be required reading for physicians, pundits and politicians. Overdiagnosis is not the way to pursue health, Dr. Welch argues elocuently. We should pay attention to his warnings. There are many lives at risk and much money wasted enriching the peddlers of fear and medical stuff.
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