Is Early Diagnosis more Harm than Good?

[Marat]

I read the true story of a physician, the chief of pathology at a large hospital, who was infamous for his persistent, hacking cough all through his career. He stubbornly refused to have it checked, however, but he was allowed to continue his hospital work because of his status. Finally his colleagues prevailed on him to have a chest x-ray and a large carcinoma was found in his lung. He struggled with cancer therapy for less than a year and then died. When they were clearing out his employment records, they discovered the initial employment x-ray he had been required to have on being given his position. It showed a tumor in exactly the same spot as the tumor that killed him, but much larger than when it was detected a year before. Since employment x-rays are just pro forma in hospitals, dating from an era when tuberculosis screening was sensible, no one had checked the results so no one ever brought it to the pathologist's attention. It was obvious that while he could live for 30 years since his initial appointment with a much larger tumor in his lung without it bothering him, as long as he didn't know about it, he could not even survive a single year knowing that he had even a smaller tumor. This inverse placebo effect, where a diagnosis kills a patient who was doing fine prior to the diagnosis, occurs all the time in medical practice.

 

So a rational approach to medicine would weigh this inverse placebo effect against the expected benefits of early diagnosis, which are almost nil for many diseases. Maybe it would be better just not to tell patients about some diseases just because of the inverse placebo effect. But even apart from the negative impact of a serious diagnosis on the physical health of the patient, its impact on the psychological health also has to be taken into account. Perhaps if you calculate the deleterious effects of early diagnosis on health and on mental state, and combine with this the additional suffering the patient undergoes from earlier initiation of some truly hideous treatments, such as chemotherapy, radiation therapy, and radical surgery, then the value of early diagnosis may be quite negative in many instances. Any gains from early diagnosis in the odds of survival, or any improvements in quality of life, have to be discounted in whole or in part by the countervailing negative effects identified here. Unfortunately, medicine always leaves these negative effects out of the equation, and to this extent it fails as a science dedicated to making the lives of patients better.

[CharonY]

And of course you have sources to back up your assertions?

 

There is indeed an issue with diagnostic screenings, but they are different from what you make out of it. They pertain to things like sensitivity, specificity and prevalence, and is partially connected to the inability of physicians to make good risk assessments and hence overtreatment of the patient.

[Cap'n Refsmmat]

It was obvious that while he could live for 30 years since his initial appointment with a much larger tumor in his lung without it bothering him, as long as he didn't know about it, he could not even survive a single year knowing that he had even a smaller tumor.

Alternately, he was going to die after thirty years anyway, but this way he knew what was killing him. It's impossible to tell which is true from one example.

[CharonY]

It is ironic however, that in other posts the OP claims that patients alone should make informed decision about medication and health effects of certain behaviors, yet here you want to keep information from the patients.

[Marat]

In the case of the Chief of Pathology, his tumor was smaller when the cancer was finally diagnosed than it had been thirty years before. Also, even if he was going to die thirty years after the first appearance of the tumor anyway, with the diagnosis he had something to worry about plus the horrors of cancer therapy to endure, both of which he could have avoided, for a while longer, without the diagnosis. So in this case either way you look at it the diagnosis made things worse.

 

My concern is with the recent obsession with 'early diagnosis' as some miracle which will make everything in medicine better, when in fact there are many conditions in which early diagnosis just means the hideous psychological torture of worrying begins sooner, and the treatments which are worse than the disease start earlier. Of course part of the motivation for earlier diagnosis is that this amounts to a statistical manipulation to make the treatments look as if they are getting better, since the patients now live longer than they would have in the days before improvements in diagnostic technique -- but only because we set the clock ticking till their death earlier, not because the treatments actually help.

 

Just consider how medicine triumphed over its new ability to detect the gene for Huntington's Chorea. When sensible people dared to point out that this could only have negative effects on the people diagnosed, since it would make them start worrying sooner and there were no treatments available, medicine shot back with the utterly fatuous observation that it would have 'counsellors' at all the Huntington's diagnostic clinics, so someone could hold your hand while you were considering whether to shoot yourself in the head or take poison after receiving the hopeless diagnosis.

[Cap'n Refsmmat]

I think you will find that there are many comparative studies which look at the lifespan of those with diseases detected early and those without, and no mass screening program is started unless it's shown that it would save lives.