{"id":33176,"date":"2015-01-16T17:31:15","date_gmt":"2015-01-16T16:31:15","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=33176"},"modified":"2015-01-19T15:45:07","modified_gmt":"2015-01-19T14:45:07","slug":"saurabh-jha-the-overdiagnosed-party-the-false-positives-rave","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2015\/01\/16\/saurabh-jha-the-overdiagnosed-party-the-false-positives-rave\/","title":{"rendered":"Saurabh Jha: The overdiagnosed party\/ the false positives rave"},"content":{"rendered":"

\"Saurabh_Jha\"<\/a>Consider this equation.<\/p>\n

Early Diagnosis = Early Diagnosis + Overdiagnosis (1.1)<\/p>\n

This sort of unequal algebra will fail GCSE mathematics. A new NHS initiative is arithmetic defying as\u00a0well. Patients who think they have symptoms of cancer<\/a> will be allowed to book medical imaging directly,\u00a0without seeing their GP<\/a>. This is to catch cancer early. The logic is impenetrable: early diagnosis of cancer\u00a0saves lives.<\/p>\n

Here is the problem. Cancer does not unequivocally announce its arrival. Early cancer presents with non-specific symptoms, such as an uncomfortable niggle in the back.<\/p>\n

Tom<\/strong><\/p>\n

Let\u2019s take Tom, who has advanced pancreatic cancer. He recalls that three years earlier he\u00a0noticed a dull pain in his back during a misguided drinking binge. He would be correct in thinking that\u00a0had he attended the emergency department and had a CAT scan of his abdomen, the cancer would have\u00a0been smaller and would not have spread to other organs. He is right in contending that had the cancer been\u00a0removed then, he would have a longer survival than presently.<\/p>\n

The rationale has implications if extrapolated to everyone. To understand the consequences of\u00a0extrapolation let\u2019s visit a logical fallacy.<\/p>\n

1) All Mr Smiths are over six feet tall.<\/p>\n

2) He is above six feet tall so he must be Mr Smith.<\/p>\n

This is affirming the consequent. Not all men above six feet in height are Mr Smiths. In fact, most are\u00a0not.<\/p>\n

3) Early pancreatic cancer presents with back pain.<\/p>\n

4) All patients with back pain have early pancreatic cancer.<\/p>\n

Similarly, (3) doesn\u2019t imply (4).<\/p>\n

Cancer often presents with non-specific symptoms, such as a vague discomfort, early on. But the majority\u00a0of people with a vague discomfort do not have cancer. That is, the chance that someone with pancreatic\u00a0cancer has dull back pain should not be confused with the chances that someone with dull back pain has\u00a0pancreatic cancer. The chances of the latter are much lower than the former.<\/p>\n

To pick up Tom with back pain who has pancreatic cancer, we will image many Toms with back pain who\u00a0don\u2019t have pancreatic cancer. Because we don\u2019t know which Tom with back pain has cancer and which\u00a0Tom does not have cancer.<\/p>\n

Dick<\/strong><\/p>\n

In the search for a Tom with back pain with pancreatic cancer, we will pick up a Dick with back pain who\u00a0does not have pancreatic cancer. Dick has a small kidney tumour. The tumour was minding its business and\u00a0would not have caused Dick any issues in his life. But we will now remove Dick\u2019s kidney to deal with an\u00a0incidental finding, which has nothing to do with his symptoms.\u00a0Thus, in order to save Tom from pancreatic cancer, Dick loses a kidney. This is collateral damage. Tom\u2019s\u00a0early diagnosis leads to Dick\u2019s overtreatment.<\/p>\n

Harry<\/strong><\/p>\n

We will also pick up a Harry with back pain and a small cyst in his pancreas, which may or may not be\u00a0cancer. We will then scan Harry repeatedly, perhaps every six months, to make sure that it really is a\u00a0harmless cyst. It probably is, but you can never be too careful.<\/p>\n

To save Tom from pancreatic cancer, we end up wasting Harry\u2019s time by CAT scanning him every six\u00a0months, driving his anxiety off the scale. Because when the doctor said \u201cprobably not cancer,\u201d Harry\u00a0heard \u201ccancer.\u201d Harry is a false positive. He won\u2019t know of the \u201cfalse\u201d bit for a very long time.<\/p>\n

The equation can be modified to:<\/p>\n

Early diagnosis = Early Diagnosis + Overdiagnosis + False Positives (1.2)<\/p>\n

Tom Jones<\/strong><\/p>\n

A flamboyant Tom Jones also has back pain. His CAT scan fails to reveal the cancer that presents later.\u00a0CAT scans are good. Very good. But they are not perfect. Tom Jones is very peeved because\u00a0he believed the \u201cearly diagnosis saves life\u201d mantra. As far as he is concerned, he did his bit. He complied.<\/p>\n

But we lied. Tom Jones is a false negative.<\/p>\n

The equation becomes:<\/p>\n

Early Diagnosis = Early Diagnosis + Overdiagnosis + False Positive + False Negative (1.3)<\/p>\n

The right side of the equation has costs. Opportunity costs. There will be less money for other services,\u00a0such as emergency departments.<\/p>\n

Tom, Dick, Harry, and Tom Jones<\/strong><\/p>\n

Tom, Dick, Harry, and Tom Jones will Google “back pain + cancer.” The search will yield “pancreatic\u00a0cancer.” After a while this will become a self fulfilling prophecy, thanks to Google\u2019s ranking algorithms,\u00a0which do not distinguish between the incidence of and anxiety from cancer.<\/p>\n

Del Trotter<\/strong><\/p>\n

When Tom et al can\u2019t get a CAT scan within 48 hours, they will throng the emergency department\u00a0because of anxiety. This will affect the care of Del Trotter from underserved Peckham. Del is having a\u00a0heart attack. Del will die if his left anterior descending artery is not promptly opened. Del\u2019s doctors are\u00a0being distracted by the demanding Toms.<\/p>\n

Britain\u2019s NHS has problems\u2014structural problems, through systematic\u00a0under investment. Emergency departments and intensive care units are in crisis. Is the pursuit of early\u00a0diagnosis of cancer really its highest priority? Why are politicians promising cake when there is not\u00a0enough bread?<\/p>\n

Actually, this pursuit is rewarding. Why? Because the public will be grateful.\u00a0Tom is happy that his pancreatic cancer was detected early. The lucky Toms, the true negatives, are\u00a0even happier that they don\u2019t have cancer. Dick is ecstatic that his kidney tumour was taken out. He\u00a0does not know the whole exercise was an utter waste of his time and an innocent kidney was sent to the\u00a0gallows (surgical pathology). He does not know that he was overdiagnosed and overtreated.<\/p>\n

Harry, the false positive, is relieved. After several surveillance CAT scans, his doctors broke the news that\u00a0the pancreatic lesion was a false alarm. He is not only relieved but prostrating with gratitude. He is\u00a0suffering from a medical variant of the Stockholm syndrome.\u00a0Del Trotter from Peckham, the opportunity cost, has other things on his mind.\u00a0This leaves Tom Jones. He is annoyed. But a root cause analysis, with considerable assistance of\u00a0hindsight, will have found an element missing from the diagnostic pathway. His anger has been\u00a0redirected to the imperfect medical profession, which refuses to adequately self-regulate.<\/p>\n

We can show:<\/p>\n

Early Diagnosis = Early Diagnosis + Overdiagnosis + False Positives + False Negative + Opportunity Costs +\u00a0Votes ++++ (1.4)<\/p>\n

Quod Erat Demonstrandum\u00a0(\u201cthat which was to be proved\u201d).<\/p>\n

If you were a politician, would you honestly see a downside to this?<\/p>\n

Competing interests:<\/strong> I declare that I have read and understood BMJ policy on declaration of interests and I would like to declare the following:\u00a0I have received a speaker’s fee from Toshiba.<\/p>\n

Saurabh Jha<\/strong>\u00a0is an assistant professor of radiology at the University of Pennsylvania School of Medicine. Follow him on Twitter\u00a0@RogueRad<\/a>\u00a0<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

Consider this equation. Early Diagnosis = Early Diagnosis + Overdiagnosis (1.1) This sort of unequal algebra will fail GCSE mathematics. A new NHS initiative is arithmetic defying as\u00a0well. Patients who […]<\/p>\n

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Early Diagnosis = Early Diagnosis + Overdiagnosis (1.1) This sort of unequal algebra will fail GCSE mathematics. A new NHS initiative is arithmetic defying as\u00a0well. 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