Broadening risk factor or disease definition as a driver for overdiagnosis: a narrative review

© 2022 The Authors. Journal of Internal Medicine published by John Wiley & Sons Ltd on behalf of Association for Publication of The Journal of Internal Medicine. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.Medical overuse—defined as the provision of health services for which potential harms exceed potential benefits—constitutes a paradigm of low-value care and is seen as a threat to the quality of care. Value in healthcare implies a precise definition of disease. However, defining a disease may not be straightforward since clinical data do not show discrete boundaries, calling for some clinical judgment. And, if in time a redefinition of disease is needed, it is important to recognize that it can induce overdiagnosis, the identification of medical conditions that would, otherwise, never cause any significant symptoms or lead to clinical harm. A classic example is the impact of recommendations from professional societies in the late 1990s, lowering the threshold for abnormal total cholesterol from 240 mg/dl to 200 mg/dl. Due to these changes in risk factor definition, literally overnight there were 42 million new cases eligible for treatment in the United States. The same happened with hypertension—using either the 2019 NICE guidelines or the 2018 ESC/ECC guidelines criteria for arterial hypertension, the proportion of people overdiagnosed with hypertension was calculated to be between 14% and 33%. In this review, we will start by discussing resource overuse. We then present the basis for disease definition and its conceptual problems. Finally, we will discuss the impact of changing risk factor/disease definitions in the prevalence of disease and its consequences in overdiagnosis and overtreatment (a problem particularly relevant when definitions are widened to include earlier or milder disease).info:eu-repo/semantics/publishedVersio

Breast cancer surgery in older women: outcomes of the bridging age gap in breast cancer study

Background In older women breast cancer (BC) surgery is often non-standard or omitted due to concerns about morbidity. The Age Gap prospective multi-centre cohort study aimed to determine factors influencing selection for and outcomes from surgery for older BC patients. Methods Women >70 with operable BC were recruited from 56 UK breast units between 2013-2018. Data on patient and tumour characteristics were correlated with type of surgery to the breast (breast conservation surgery [BCS], mastectomy) and axilla (axillary node clearance [ANC], sentinel node biopsy [SLNB] or no axillary surgery [NAS]) using univariate and multivariate analysis. Oncologic, adverse event and Quality of life (QoL) outcomes were monitored for 2 years. Results Of 3375 recruited women, surgery was performed in 2816. There were 62 bilateral tumours, giving 2854 surgical events. The median age was 76 (range 70-95). Breast surgery comprised mastectomy in 1138, BCS in 1798. Axillary surgery comprised 575 ANC, 2203 SLNB and 76 NAS. Age, frailty, dementia and comorbidities were predictors of mastectomy (RR 1.06, CI 1.05-1.08). Frailty and comorbidity were significant predictors of NAS (RR 0.91, CI 0.87-0.96). The rate of adverse events was moderate (551/2854, 19.3%) with no 30 day mortality. Long term QoL and functional independence were adversely affected by surgery. Conclusions Age, ill health and frailty all impact on surgical decision making for BC. BC surgery is safe with serious adverse events being rare and no mortality. However surgery has a negative impact on QoL and independence which must be considered when counselling patients about choices

smarter medicine: liste Top-5 pour le traitement des rhumatismes

La Société suisse de rhumatologie (SSR) publie sa liste Top-5 dans le cadre de l’initiative « smarter medicine-Choosing Wisely Switzerland ». Ces dernières années, les risques de surdiagnostic et de surtraitement ont été évoqués également dans le domaine de la rhumatologie. Ce n’est pourtant que récemment que la possibilité d’une réduction de la thérapie chez les patientes et patients dont l’objectif thérapeutique a été atteint, a fait l’objet de recherches et de discussions. Une attention particulière doit être accordée aux traitements coûteux. En plus des aspects financiers, les personnes concernées par un surdiagnostic sont exposées à de fortes tensions psychologiques avec les lourdes conséquences qui en découlent. Dès lors, la SSR a élaboré, à l’instar du modèle de l’American College of Rheuma­tology, une liste de cinq interventions à éviter