Medical Tests and Over-diagnosis

04/17/11 • 0 min

Host: Anti-Aging Psychologist Dr. Michael Brickey Guest: Dr. H. Gilbert Welch

Broadcast and podcast on webtalkradio.net. The podcast is also below.

Your browser does not support the audio element.

I think Dr. Welch is right on—over-diagnosis is one of the biggest problems in medicine and one of the biggest threats to our health and longevity. Further, each year in the US over-diagnosis wastes tens, possibly hundreds of billions of dollars.

To review, Dr. Welch described several ways over-diagnosis happens:

By looking too hard for pathology we may engage in a cascade of further testing and treatment that may do more harm than good. Prostate cancer is the poster child. Early diagnosis can lead to biopsies, radiation treatment, chemotherapy, or surgery that brings the usual treatment risks and can cause impotency and urinary problems. While most men over 60 have some prostate cancer, most do not experience any symptoms and eventually die from some other cause. For women, annual mammograms starting at age 50 also appear to do more harm than good. In a population of 1,000 to 1,500 with women who receive annual mamograms for ten years starting at age 50, one woman would avoid breast cancer, half a dozen women would be needlessly treated, a third would have at least one false alarm, and more than a hundred would be needlessly biopsied. As treatment becomes more effective, the downside of early diagnosis becomes even more pronounced.
A second cause of over-diagnosis comes from changing the cutoff scores, e.g., blood sugar levels for diabetes, cholesterol levels for heart disease, and bone density scores for osteoporosis. Thus with the decision of a committee, the number of people deemed to have a disease can more than double overnight. While the benefits of treatment are usually obvious for people with extreme scores, there are diminishing returns and greater risks for treatment of people with marginal scores.
With increasingly powerful and pervasive MRIs, CAT scans and other tests, doctors stumble onto findings that prompt more testing and possibly treatment. For example, about half of virtual colonoscopies find abnormalities in the kidney, liver, lungs or other tissue. The vast majority of these abnormalities are benign but it is hard to pass on further testing once they have been identified. In scans of other areas of the body, scans need to consider asymptomatic base rates as high as 50% for disc protrusions and 40% for damaged knee cartilage.
With the exception of using genetics to help determine medications for cancer treatments, at least currently DNA testing seems to either tells us what we already know or gives weak correlations that don’t indicate what we need to do differently.

The bottom line is to be cautious about testing when there are no symptoms and when there are no risk factors such as family history, lifestyle risks, exposure to diseases or toxic chemicals, or health or medication concerns.

Dr. Welch also cautions about survival rate data. A man who is diagnosed with prostate cancer at age 60 and dies and 91 of prostate cancer would have had an impressive 30 year survival rate. If his prostate cancer was diagnosed at age 87 and he died at 91 he would fail the 5 year survival criteria. Testimonials from celebrities such as Bob Dole, General Schwarzkopf, and Arnold Palmer illustrate how early detection and survival rate data can be misleading.

Further articles and information from Dr. Welch is at http://www.vaoutcomes.org/welch.php and http://www.beacon.org. Brickey’s other websites are www.DrBrickey.com and www.Anti-Aging-Speaker.com.

Host: Anti-Aging Psychologist Dr. Michael Brickey Guest: Dr. H. Gilbert Welch

Broadcast and podcast on webtalkradio.net. The podcast is also below.

Your browser does not support the audio element.

To review, Dr. Welch described several ways over-diagnosis happens:

By looking too hard for pathology we may engage in a cascade of further testing and treatment that may do more harm than good. Prostate cancer is the poster child. Early diagnosis can lead to biopsies, radiation treatment, chemotherapy, or surgery that brings the usual treatment risks and can cause impotency and urinary problems. While most men over 60 have some prostate cancer, most do not experience any symptoms and eventually die from some other cause. For women, annual mammograms starting at age 50 also appear to do more harm than good. In a population of 1,000 to 1,500 with women who receive annual mamograms for ten years starting at age 50, one woman would avoid breast cancer, half a dozen women would be needlessly treated, a third would have at least one false alarm, and more than a hundred would be needlessly biopsied. As treatment becomes more effective, the downside of early diagnosis becomes even more pronounced.
A second cause of over-diagnosis comes from changing the cutoff scores, e.g., blood sugar levels for diabetes, cholesterol levels for heart disease, and bone density scores for osteoporosis. Thus with the decision of a committee, the number of people deemed to have a disease can more than double overnight. While the benefits of treatment are usually obvious for people with extreme scores, there are diminishing returns and greater risks for treatment of people with marginal scores.
With increasingly powerful and pervasive MRIs, CAT scans and other tests, doctors stumble onto findings that prompt more testing and possibly treatment. For example, about half of virtual colonoscopies find abnormalities in the kidney, liver, lungs or other tissue. The vast majority of these abnormalities are benign but it is hard to pass on further testing once they have been identified. In scans of other areas of the body, scans need to consider asymptomatic base rates as high as 50% for disc protrusions and 40% for damaged knee cartilage.
With the exception of using genetics to help determine medications for cancer treatments, at least currently DNA testing seems to either tells us what we already know or gives weak correlations that don’t indicate what we need to do differently.

Further articles and information from Dr. Welch is at http://www.vaoutcomes.org/welch.php and http://www.beacon.org. Brickey’s other websites are www.DrBrickey.com and www.Anti-Aging-Speaker.com.

Previous Episode

Aging and Mental Health

Host: Anti-Aging Psychologist Dr. Michael Brickey Guest: Geriatric psychiatrist Dr. Marc Agronin

Broadcast and podcast on webtalkradio.net. The podcast is also below.

Your browser does not support the audio element.

Dr. Marc Agronin is Medical Director for Mental Health and Clinical Research at the Miami Jewish Health Systems and author of several books or geriatric psychiatry. His clinical work is in it large nursing home. Our interview focused on his most recent book, How We Age: A Doctor’s Journey into the Heart of Growing Old.

The interview with Dr. Agronin works at several levels. First, it helps us understand our own aging and view our own aging with a good dose of optimism. Second, it helps us focus on how to relate to our own family and friends who are aging, especially when they are in hospitals or nursing homes. And third, it provides a model and ideas for psychotherapists.

Dr. Agronin is especially interested in stage theories such as Eric Erickson’s and Gene Cohen’s theories. One of my principles for choosing philosophies, religious beliefs, and therapy principles, is to favor optimism and positive views. Thus, I especially like Dr. Gene Cohen’s stage theory and Dr. Marc Agronin’s views on therapy with seniors.

What does it take to be a good therapist with people who are old? There is a Yiddish word, mensch, that sums it up. A mensch is a caring person with integrity, values, and character. A therapist who is a mensch takes the time to really listen, care, never give up, and do whatever it takes to help. My role model for a mensch therapist is Dr. Agronin.

Medicine has a financial hierarchy. At the bottom of the hierarchy are family doctors, pediatricians, and psychiatrists. Their average salaries are about a third of the average salaries for neurosurgeons and cardiac surgeons. Consequently, it is not surprising that there is a shortage of psychiatrists. Most psychiatrists today focus on diagnoses and medications and leave the psychotherapy to less expensive practitioners. In nursing homes the house doctor usually takes care of medications for pain, depression, and anxiety and psychiatrists are just consulted on unsual cases and behavior problems. Dr. Marc Agronin is a role model for what psychiatry should be and can be. Fortunately, his influence spreads far beyond Miami Jewish Health Systems through his books like How We Age, his books for psychiatrists and psychotherapists, and his presentations are professional conferences.

Dr. Agronin’s website is www.MarcAgronin.com. Dr. Brickey’s other websites are www.DrBrickey.com and www.Anti-Aging-Speaker.com.

Next Episode

Nutrition, Brains, Appetite and Weight Loss

Host: Anti-Aging Psychologist Dr. Michael Brickey Guest: Dr. Larry McCleary

Broadcast and podcast on webtalkradio.net. The podcast is also below.

Your browser does not support the audio element.

Nutritional advice is a tower of Babble. There are many theories that have little research to support them. The US government’s Food Pyramid and recommendations reflect more of a political process than a scientific process. The marketplace is full of hype for products and services. The answers on what really fosters wellness and longevity will ultimately come from scientific research. The strength of Dr. McCleary’s advice is that it is based in research and clinical experience.

To the extent that there is any consensus among anti-aging researchers and holistic medicine practitioners, it would be a Mediterranean diet, with fresh fruits and vegetables, whole grains, olive oil, fish and lean meats (or vegetarian protein substitutes). Dr. McCleary generally agrees with the Mediterranean diet but would minimize grains and starches, go easy on fruit juices and fruits that have high glycemic indexes, and prefer coconut oil to olive oil. Dr. McCleary developed his recommendations from a perspective of what optimizes brain functioning, what helps energy levels, and what helps with weight loss.

The closest researcher that I am aware of is Barry Sears, Ph.D., a chemist who has spent more than thirty years researching hormones, diabetes, and weight loss. Sears and McCleary agree on the importance of fish oil and that insulin is the key to weight loss. Sears advocates 30% fats, 30% protein, and 40% healthy carbohydrates. Thus, he advocates far less fat than McCleary. He believes his Zone diet can keep insulin levels stable and hormone levels in a healthy balance.

Sears believes a ketogenic diet does reduce blood insulin resistance but increases insulin resistance in the liver and increases cortisol production. Cortisol causes inflammation which Sears sees as the common denominator of most chronic diseases including diabetes and cardiovascular disease. You will recall that McCleary’s interest in ketogenic diets came from using a ketogenic diet with children who had seizures.

Sears characterizes the Atkins diet as rich in (long chain) saturated fats and Omega 6 fatty acids. McCleary tends to favor healthier fats than the typical Atkins diet. Sears sees two destructive mechanisms of an Atkins diet. First, that its (long chain) saturated fats and Omega 6 fatty acids foster inflammation. Second, that when the brain doesn’t get its glucose, the cortisol it produces breaks down muscle tissue to help produce glucose.

Sears says that people lose weight on an Atkins diet for about six months and then gain the weight back and more because of damage from cortisol production, inflammation, and hormonal changes. You can hear my podcast with Dr. Sears in the Ageless Lifestyles archives.

McCleary suggests that while the brain’s main food is glucose, it also thrives on ketones. The question is whether the glucose and ketones in McCleary’s diet would produce enough brain fuel to not prompt cortisol production and the damage cortisol can produce.

Keep in mind that high fat diets and their increased ketone production can be hard on kidneys and need more water to excrete excess ketones. Also, be alert for any signs of hypoglycemia (low blood sugar).

Among anti-aging researchers there seems to be some shift away from high carbohydrate diets. While the jury is still out, carefully observe how your body responds to what you eat, get periodic blood tests, and be careful.

Dr. McCleary’s website is www.DrMcCleary.com. Brickey’s other websites are www.DrBrickey.com and www.Anti-Aging-Speaker.com.