Map of life expectancy at birth from Global Education Project.

Thursday, November 06, 2014

Less, in this case, is a whole lot more

This study in NEJM has actually gotten a lot of attention, which I actually didn't expect when I decided to blog about it. (I believe it's behind the paywall but at least you can read the abstract.)

In a nutshell, the incidence of thyroid cancer in South Korea has increased 15 times since the 1990s. Is it radiation? Water or air pollution? A plot by the north? Nope. It's an epidemic of overdiagnosis. The death rate from thyroid cancer hasn't gone up even a tiny little tick. What's happening is that the country offers free screening for other cancers -- cervical, colon, breast, liver -- and they'll throw in thyroid for 35 bucks. So people go for it. They find these tiny little tumors that were never going to cause trouble, remove the thyroid, and the people have to go on pills for the rest of their lives. They may suffer other complications. It turns out that about 1/3 of people die with these "cancers" without even knowing it. All of the increase -- 100% -- is overdiagnosis resulting in iatrogenic harm and wasted money.

This is appalling but it's happening in the U.S. too, to a lesser extent. We don't do screening but people sometimes happen to have ultrasounds or CT scans that include the neck and these meaningless phenomena are discovered. So you're told you have "cancer" and it's all bad from there on. As I have discussed before, something very similar happens with prostate "cancer" but the appallingness is less extreme because prostate cancers are somewhat more likely to cause trouble.

I do have one new point to make based on this atrocity. Doctors are always discovering non-existent diseases that need treatment. Sometimes the people have actual symptoms but the putative cause is not really there. Chronic low back pain is an example. A couple of decades ago the Agency for Healthcare Policy and Research reported that surgery commonly performed for chronic low back pain was useless. Orthopedic surgeons persuaded congress to eliminate the agency. (It has since been restored as the Agency for Healthcare Research and Quality.) This surgery is still performed, though less often than before.

There are many other examples but I won't belabor the point. When the doctors went on strike in Saskatchewan to protest single payer health care in 1962, the death rate went down. Just keep that in mind.

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