tag:theconversation.com,2011:/fr/topics/overtreatment-25816/articlesOvertreatment – The Conversation2024-02-15T00:00:55Ztag:theconversation.com,2011:article/2202822024-02-15T00:00:55Z2024-02-15T00:00:55ZFeminist narratives are being hijacked to market medical tests not backed by evidence<figure><img src="https://images.theconversation.com/files/575240/original/file-20240213-27-twey75.jpg?ixlib=rb-1.1.0&rect=252%2C97%2C6218%2C4210&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/woman-sitting-on-floor-and-leaning-on-couch-using-laptop-Nv-vx3kUR2A">Thought Catalog/Unsplash</a></span></figcaption></figure><p>Corporations have used feminist language to promote their products for decades. In the 1980s, companies co-opted messaging about female autonomy to encourage women’s consumption of unhealthy commodities, <a href="https://www.mdpi.com/1660-4601/17/21/7902">such as tobacco and alcohol</a>. </p>
<p>Today, feminist narratives around empowerment and women’s rights are being co-opted to market interventions that are not backed by evidence across many areas of women’s health. This includes by commercial companies, industry, mass media and well-intentioned advocacy groups. </p>
<p>Some of these health technologies, tests and treatments are useful in certain situations and can be very beneficial to some women. </p>
<p>However, promoting them to a large group of asymptomatic healthy women that are unlikely to benefit, or without being transparent about the limitations, runs the risk of causing more harm than good. This includes inappropriate medicalisation, overdiagnosis and overtreatment. </p>
<p>In our analysis published today in the <a href="https://www.bmj.com/content/384/bmj-2023-076710">BMJ</a>, we examine this phenomenon in two current examples: the anti-mullerian hormone (AMH) test and breast density notification.</p>
<h2>The AMH test</h2>
<p>The AMH test is a blood test associated with the number of eggs in a woman’s ovaries and is sometimes referred to as the “egg timer” test. </p>
<p>Although often used in fertility treatment, the AMH test cannot reliably predict the <a href="https://jamanetwork.com/journals/jama/fullarticle/2656811">likelihood of pregnancy</a>, timing to pregnancy or <a href="https://academic.oup.com/humupd/article/29/3/327/6990969">specific age of menopause</a>. The American College of Obstetricians and Gynaecologists therefore <a href="https://pubmed.ncbi.nlm.nih.gov/30913192/">strongly discourages testing</a> for women not seeking fertility treatment. </p>
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<img alt="Woman sits in a medical waiting room" src="https://images.theconversation.com/files/575242/original/file-20240213-24-tbgpbk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/575242/original/file-20240213-24-tbgpbk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/575242/original/file-20240213-24-tbgpbk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/575242/original/file-20240213-24-tbgpbk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/575242/original/file-20240213-24-tbgpbk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/575242/original/file-20240213-24-tbgpbk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/575242/original/file-20240213-24-tbgpbk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The AMH test can’t predict your chance of getting pregnant.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/a-woman-sitting-on-a-bench-in-a-waiting-area-UssKpGyrBzw">Anastasia Vityukova/Unsplash</a></span>
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<p>Despite this, several <a href="https://bmjopen.bmj.com/content/11/7/e046927.info">fertility clinics</a> and <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2808552">online companies</a> market the AMH test to women not even trying to get pregnant. Some use feminist rhetoric promising empowerment, selling the test as a way to gain personalised insights into your fertility. For example, “<a href="https://www.ondemand.labcorp.com/lab-tests/womens-fertility-test">you deserve</a> to know your reproductive potential”, “<a href="https://kinfertility.com.au/fertility-test">be proactive</a> about your fertility” and “<a href="https://monashivf.com/services/early-intervention/amh-blood-test/">knowing your numbers</a> will empower you to make the best decisions when family planning”. </p>
<p>The use of feminist marketing makes these companies appear socially progressive and champions of female health. But they are selling a test that has no proven benefit outside of IVF and cannot inform women about their current or future fertility. </p>
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Read more:
<a href="https://theconversation.com/dont-believe-the-hype-egg-timer-tests-cant-reliably-predict-your-chance-of-conceiving-or-menopause-timing-207008">Don't believe the hype. 'Egg timer' tests can't reliably predict your chance of conceiving or menopause timing</a>
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<p>Our <a href="https://academic.oup.com/humrep/article/38/8/1571/7193900?login=false">recent study</a> found around 30% of women having an AMH test in Australia may be having it for these reasons.</p>
<p>Misleading women to believe that the test can reliably predict fertility can create a false sense of security about delaying pregnancy. It can also create unnecessary anxiety, pressure to freeze eggs, conceive earlier than desired, or start fertility treatment when it may not be needed.</p>
<p>While some companies mention the test’s limitations if you read on, they are glossed over and contradicted by the calls to be proactive and messages of empowerment. </p>
<h2>Breast density notification</h2>
<p>Breast density is one of several independent risk factors for breast cancer. It’s also harder to see cancer on a mammogram image of breasts with high amounts of dense tissue than breasts with a greater proportion of fatty tissue. </p>
<p>While estimates vary, approximately 25–50% of women in the breast screening population <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4200066/">have dense breasts</a>.</p>
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<img alt="Young woman has mammogram" src="https://images.theconversation.com/files/575244/original/file-20240213-22-kbvlxa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/575244/original/file-20240213-22-kbvlxa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/575244/original/file-20240213-22-kbvlxa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/575244/original/file-20240213-22-kbvlxa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/575244/original/file-20240213-22-kbvlxa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/575244/original/file-20240213-22-kbvlxa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/575244/original/file-20240213-22-kbvlxa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Dense breasts can make it harder to detect cancer.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-woman-taking-mammogram-xray-test-75178006">Tyler Olsen/Shutterstock</a></span>
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<p>Stemming from valid concerns about the increased risk of cancer, advocacy efforts have used feminist language around women’s right to know <a href="https://insightplus.mja.com.au/2022/34/breast-density-we-can-handle-the-truth/#:%7E:text=%E2%80%9CWomen%20can%20handle%20the%20truth,need%20to%20know%20that%20truth.">such as</a> “women need to know the truth” and “women can handle the truth” to argue for widespread breast density notification. </p>
<p>However, this simplistic messaging overlooks that this is a complex issue and that <a href="https://ebm.bmj.com/content/26/6/309">more data is still needed</a> on whether the benefits of notifying and providing additional screening or tests to women with dense breasts outweigh the harms. </p>
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Read more:
<a href="https://theconversation.com/what-causes-breast-cancer-in-women-what-we-know-dont-know-and-suspect-86314">What causes breast cancer in women? What we know, don't know and suspect</a>
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<p>Additional tests (ultrasound or MRI) are now being recommended for women with dense breasts as they have the ability to detect more cancer. Yet, there is no or little mention of the <a href="https://www.nejm.org/doi/full/10.1056/NEJMe1912943">lack of robust evidence</a> showing that it prevents breast cancer deaths. These extra tests also have out-of-pocket costs and high rates of false-positive results. </p>
<p>Large international advocacy groups are also sponsored by companies that will <a href="https://www.volparahealth.com/news/volpara-announces-expanded-sponsorship-of-densebreast-info-org-at-sbi-2023/">financially benefit from women being notified</a>.</p>
<p>While stronger patient autonomy is vital, campaigning for breast density notification without stating the limitations or unclear evidence of benefit may go against the empowerment being sought. </p>
<h2>Ensuring feminism isn’t hijacked</h2>
<p>Increased awareness and advocacy in women’s health are key to overcoming sex inequalities in health care. </p>
<p>But we need to ensure the goals of feminist health advocacy aren’t undermined through commercially driven use of feminist language pushing care that isn’t based on evidence. This includes more transparency about the risks and uncertainties of health technologies, tests and treatments and greater scrutiny of conflicts of interests. </p>
<p>Health professionals and governments must also ensure that easily understood, balanced information based on high quality scientific evidence is available. This will enable women to make more informed decisions about their health.</p>
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Read more:
<a href="https://theconversation.com/young-women-wont-be-told-how-to-behave-but-is-girlboss-just-deportment-by-another-name-132351">Young women won't be told how to behave, but is #girlboss just deportment by another name?</a>
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<p class="fine-print"><em><span>Brooke Nickel receives fellowship funding from the National Health and Medical Research Council (NHMRC). She is on the Scientific Committee of the Preventing Overdiagnosis Conference.</span></em></p><p class="fine-print"><em><span>Tessa Copp receives fellowship funding from the National Health and Medical Research Council (NHMRC). She is also on the Scientific Committee of the Preventing Overdiagnosis Conference. </span></em></p>Corporate medicine is hijacking feminist narratives around empowerment and women’s rights to market technologies, tests and treatments that aren’t backed by evidence.Brooke Nickel, NHMRC Emerging Leader Research Fellow, University of SydneyTessa Copp, NHMRC Emerging Leader Research Fellow, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2214852024-01-26T13:20:41Z2024-01-26T13:20:41ZTreatment can do more harm than good for prostate cancer − why active surveillance may be a better option for some<figure><img src="https://images.theconversation.com/files/571270/original/file-20240124-15-qajkje.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2120%2C1414&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A cancer diagnosis is serious, but immediately starting treatment sometimes isn't the best course of action.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/male-professional-doctor-touching-shoulder-royalty-free-image/1412852738">ljubaphoto/E+ via Getty Images</a></span></figcaption></figure><p>Although <a href="https://www.cancer.org/cancer/types/prostate-cancer/about/key-statistics.html">about 1 in 8 men in the U.S.</a> will be diagnosed with prostate cancer during their lifetime, only about 1 in 44 will die from it. Most men diagnosed with prostate cancer die from other causes, especially those with a low-risk prostate cancer that usually grows so slowly it isn’t life-threatening.</p>
<p>However, <a href="https://doi.org/10.1001/jama.2015.6036">until about a decade ago</a>, most men diagnosed with low-risk prostate cancer were immediately treated with surgery or radiation. Although both can cure the cancer, they can also have serious, life-changing complications, including urinary incontinence and erectile dysfunction.</p>
<p>I am a <a href="https://www.researchgate.net/profile/Jinping-Xu-2">family physician and researcher</a> studying how patient-physician relationships and decision-making processes affect prostate cancer screening and treatment. In our recently published research, my colleagues and I found that men are increasingly <a href="https://doi.org/10.1002/cncr.35190">opting against immediate treatment</a>. Instead, they are choosing a more conservative approach known as <a href="https://theconversation.com/prostate-cancer-treatment-is-not-always-the-best-option-a-cancer-researcher-walks-her-father-through-his-diagnosis-206975">active surveillance</a>: keeping a close eye on the cancer and holding off on treatment until there are signs of progression.</p>
<h2>Prostate cancer screening trouble</h2>
<p>Prostate cancer screening is controversial because it often leads to overdiagnosis and overtreatment of cancers that would have otherwise been harmless if left undetected and untreated. </p>
<p>Screening for prostate cancer typically uses a blood test that measures levels of a protein that prostate cells produce called <a href="https://www.cancer.gov/types/prostate/psa-fact-sheet">prostate specific antigen, or PSA</a>. Elevated PSA levels may indicate the presence of prostate cancer, but not all cases are aggressive or life-threatening. And PSA levels can also be elevated for reasons other than prostate cancer, like an enlarged prostate gland due to aging. </p>
<p>Due to widespread PSA screening in the U.S., <a href="https://doi.org/10.1001/jama.2018.3710">over half of prostate cancers</a> detected through screening are low-risk. Concerns about overdiagnosis and overtreatment of low-risk cancers are the main reasons why screening is not recommended unless patients still want to be screened after discussing the pros and cons with their doctor.</p>
<h2>What is active surveillance?</h2>
<p><a href="https://www.cancer.org/cancer/types/prostate-cancer/treating/watchful-waiting.html">Active surveillance</a> is a safe and effective way to manage low-risk prostate cancer by limiting treatments such as surgery or radiation only to cancers that are growing or becoming more aggressive. It involves monitoring tumors through regular checkups and tests.</p>
<p>Active surveillance is different from “<a href="https://www.cancer.org/cancer/types/prostate-cancer/treating/watchful-waiting.html">watchful waiting</a>,” another conservative strategy with a less intense type of follow-up that includes fewer tests and only relieves symptoms. In contrast, active surveillance involves more rigorous monitoring, with more tests to keep a close eye on cancer with the intention to cure if needed.</p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/WjD46mm7JRU?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Active surveillance has the same survival rates as aggressive treatment for low-risk prostate cancer.</span></figcaption>
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<p>Active surveillance allows patients to delay or avoid invasive treatments and their associated side effects. It aims to balance keeping a close watch on the cancer while avoiding treatments unless they are truly needed.</p>
<p>All leading medical groups <a href="https://doi.org/10.1097/ju.0000000000002854">recommend active surveillance</a> as the preferred approach to caring for men diagnosed with low-risk prostate cancer. However, until recently, the number of patients who opt for active surveillance in the U.S. <a href="https://doi.org/10.1001/jama.2018.19941">has been low</a>, ranging from under 15% in 2010 to about 40% in 2015. The specific reasons why active surveillance is underutilized in the U.S. are not well understood. </p>
<h2>Facilitators and barriers to active surveillance</h2>
<p>What factors influence treatment decisions? To answer this question, my team and I surveyed 1,341 white and 347 Black men with newly diagnosed low-risk prostate cancer from 2014 to 2017. We recruited participants from two cancer registries in metropolitan Detroit and the state of Georgia, regions with large Black populations.</p>
<p>Overall, <a href="https://doi.org/10.1002/cncr.35190">more than half of the men</a> opted for active surveillance. This was much higher than a similar study our team conducted nearly a decade ago, which found that <a href="https://doi.org/10.1007/s40615-015-0109-8">only 10% of men</a> chose active surveillance.</p>
<p>Increased uptake of active surveillance is good news, but it is not where it needs to be. The U.S. is still lagging behind many European countries, such as Sweden, where <a href="https://doi.org/10.1001/jamaoncol.2016.3600">over 80% of patients</a> diagnosed with low-risk prostate cancer select active surveillance. </p>
<p>To figure out what influenced patients to choose active surveillance, we decided to ask them directly. </p>
<p>A urologist’s recommendation had the strongest effect: <a href="https://doi.org/10.1002/cncr.35190">Nearly 85% of patients</a> who chose active surveillance stated that their urologist recommended it. Other factors included a shared patient-physician treatment decision and greater knowledge about prostate cancer. Interestingly, participants living in metro Detroit were more likely to choose active surveillance than those living in Georgia.</p>
<p>Conversely, men were <a href="https://doi.org/10.1002/cncr.35190">less likely to try</a> active surveillance if they had a strong desire to achieve a cure, expected to live longer with treatment or perceived their diagnosis of low-risk cancer was more serious. Almost three-quarters of patients who chose immediate treatment expected to live at least five years longer than they otherwise would without treatment, which is unrealistic and <a href="https://doi.org/10.1016/j.eururo.2020.02.009">not based on existing evidence</a>. </p>
<p>Misperceptions, unrealistic treatment expectations and biases may lead patients to choose unnecessarily aggressive treatment, suffering its harms with no survival benefit and potentially regretting their decision later.</p>
<h2>Racial and geographic differences</h2>
<p>We also found racial and geographic differences in the rate of active surveillance adoption. </p>
<p>On average, <a href="https://doi.org/10.1002/cncr.35190">Black patients had a higher risk</a> of developing and dying from prostate cancer compared with white patients. Additionally, as data supporting the use of active surveillance has been predominantly based on white men, the risks and benefits of active surveillance in Black patients <a href="https://doi.org/10.1016/j.juro.2011.12.082">are more controversial</a>. Indeed, our study found 51% of Black patients chose active surveillance compared with 61% of white patients.</p>
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<a href="https://images.theconversation.com/files/571274/original/file-20240124-21-yvclop.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Doctor talking with patient and caregiver" src="https://images.theconversation.com/files/571274/original/file-20240124-21-yvclop.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/571274/original/file-20240124-21-yvclop.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/571274/original/file-20240124-21-yvclop.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/571274/original/file-20240124-21-yvclop.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/571274/original/file-20240124-21-yvclop.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/571274/original/file-20240124-21-yvclop.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/571274/original/file-20240124-21-yvclop.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">A urologist’s recommendation can go a long way in encouraging active surveillance.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/compassionate-female-doctor-discusses-medical-royalty-free-image/1401996480">SDI Productions/E+ via Getty Images</a></span>
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<p>Notably, Black men reported receiving fewer active surveillance recommendations from urologists and were less engaged in shared decision-making with their doctors compared with white men. This <a href="https://theconversation.com/doctors-need-to-talk-through-treatment-options-better-for-black-men-with-prostate-cancer-112939">racial difference</a> in active surveillance rates is no longer significant after accounting for urologist recommendations, decision-making style and other factors. </p>
<p>But <a href="https://doi.org/10.1002/cncr.35190">geographic differences</a> persisted: Patients living in Detroit were more likely to undergo active surveillance than those living in Georgia. This likely reflects to some degree the entrenched care patterns of some urologists. Some studies have found that the <a href="https://doi.org/10.1016/j.urology.2020.12.037">longer a urologist was in practice</a>, the less likely they were to recommended active surveillance to their patients.</p>
<h2>Encouraging active surveillance</h2>
<p>Our findings are encouraging in that they show active surveillance has become more acceptable to both patients and urologists over the past decade. However, our results also suggest that greater physician engagement and better patient education can support increased adoption of active surveillance. </p>
<p>For example, when physicians appropriately describe low-risk prostate cancer as small or not aggressive, coupled with a favorable prognosis, this can give patients a sense of relief. Patients in turn <a href="https://doi.org/10.1093/fampra/cmw123">feel more comfortable</a> with undergoing active surveillance.</p>
<p>Conversely, a patient’s misperception of how serious their cancer is may lead to unnecessary treatment. Physicians can reassure patients that active surveillance is a safe and preferred alternative. They can also explain that aggressive treatments <a href="https://doi.org/10.1056/nejmoa1606220">don’t improve survival</a> for most low-risk patients and can cause significant long-term side effects.</p>
<p>More shared treatment decision-making involving patients and their physicians can improve the likelihood of choosing active surveillance compared with patients who make decisions on their own.</p><img src="https://counter.theconversation.com/content/221485/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jinping Xu receives funding from the American Cancer Society and the U.S. Department of Defense. </span></em></p>People with low-risk prostate cancer are more likely to die from something else. Overdiagnosis and overtreatment can lead to life-changing complications.Jinping Xu, Chair of Family Medicine and Public Health Sciences, Wayne State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2059192023-08-14T20:00:06Z2023-08-14T20:00:06Z1 in 6 women are diagnosed with gestational diabetes. But this diagnosis may not benefit them or their babies<figure><img src="https://images.theconversation.com/files/539721/original/file-20230727-18363-k1nhbm.jpg?ixlib=rb-1.1.0&rect=115%2C49%2C5390%2C3615&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/depressed-pregnant-woman-worried-about-her-2210916539">Shutterstock</a></span></figcaption></figure><p>When Sophie was pregnant with her first baby, she had an <a href="https://www.ncbi.nlm.nih.gov/books/NBK279331/#:%7E:text=Oral%20glucose%20tolerance%20tests%20(OGTT,enough%20by%20the%20body's%20cells.)">oral glucose tolerance</a> blood test. A few days later, the hospital phoned telling her she had gestational diabetes.</p>
<p>Despite having only a slightly raised glucose (blood sugar) level, Sophie describes being diagnosed as affecting her pregnancy tremendously. She tested her blood glucose levels four times a day, kept food diaries and had extra appointments with doctors and dietitians. </p>
<p>She was advised to have an induction because of the risk of having a large baby. At 39 weeks her son was born, weighing a very average 3.5kg. But he was separated from Sophie for four hours so his glucose levels could be monitored. </p>
<p>Sophie is not alone. About <a href="https://www.aihw.gov.au/reports/diabetes/diabetes/contents/how-many-australians-have-diabetes/gestational-diabetes">one in six</a> pregnant women in Australia are now diagnosed with gestational diabetes. </p>
<p>That was not always so. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2827530/">New criteria</a> were developed in 2010 which dropped an initial screening test and lowered the diagnostic set-points. Gestational diabetes diagnoses have since <a href="https://www.aihw.gov.au/reports/diabetes/diabetes/contents/how-many-australians-have-diabetes/gestational-diabetes">more than doubled</a>.</p>
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<img alt="" src="https://images.theconversation.com/files/536691/original/file-20230710-23-v8weyw.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/536691/original/file-20230710-23-v8weyw.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=388&fit=crop&dpr=1 600w, https://images.theconversation.com/files/536691/original/file-20230710-23-v8weyw.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=388&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/536691/original/file-20230710-23-v8weyw.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=388&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/536691/original/file-20230710-23-v8weyw.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=487&fit=crop&dpr=1 754w, https://images.theconversation.com/files/536691/original/file-20230710-23-v8weyw.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=487&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/536691/original/file-20230710-23-v8weyw.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=487&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Gestational diabetes rates more than doubled after the threshold changed.</span>
<span class="attribution"><span class="source">AIHW</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>But <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2204091">recent</a> <a href="https://pubmed.ncbi.nlm.nih.gov/33704936/">studies</a> cast doubt on the ways we diagnose and manage gestational diabetes, especially for women like Sophie with only mildly elevated glucose. Here’s what’s wrong with gestational diabetes screening.</p>
<h2>The glucose test is unreliable</h2>
<p>The test used to diagnose gestational diabetes – the oral glucose tolerance test – has poor reproducibility. This means subsequent tests may give a different result.</p>
<p>In a <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2214956">recent Australian trial</a> of earlier testing in pregnancy, one-third of the women initially classified as having gestational diabetes (but neither told nor treated) did not have gestational diabetes when retested later in pregnancy. That is a problem. </p>
<p>Usually when a test has poor reproducibility – for example, blood pressure or cholesterol – we repeat the test to confirm before making a diagnosis. </p>
<p>Much of the increase in the incidence of gestational diabetes after the introduction of new diagnostic criteria was due to the switch from using two tests to only using a single test for diagnosis.</p>
<figure class="align-center ">
<img alt="Pregnant woman cooks dinner with her child" src="https://images.theconversation.com/files/540334/original/file-20230801-157556-lb9vkv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/540334/original/file-20230801-157556-lb9vkv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/540334/original/file-20230801-157556-lb9vkv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/540334/original/file-20230801-157556-lb9vkv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/540334/original/file-20230801-157556-lb9vkv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/540334/original/file-20230801-157556-lb9vkv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/540334/original/file-20230801-157556-lb9vkv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Women with only mildly elevated glucose levels are being diagnosed with gestational diabetes.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/black-pregnant-woman-cooking-her-daughter-2019300152">Shutterstock</a></span>
</figcaption>
</figure>
<h2>The thresholds are too low</h2>
<p>Despite little evidence of benefit for either women or babies, the current Australian criteria diagnose women with only mildly abnormal results as having “gestational diabetes”. </p>
<p>Recent studies have shown this doesn’t benefit women and may cause harms. A <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2204091">New Zealand trial</a> of more than 4,000 women randomly assigned women to be assessed based on the current Australian thresholds or to higher threshold levels (similar to the pre-2010 criteria). </p>
<p>The trial found no additional benefit from using the current low threshold levels, with overall no difference in the proportion of infants born large for gestational age. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/sixteen-pound-baby-born-in-brazil-heres-what-increases-the-risk-of-giving-birth-to-a-giant-baby-198423">Sixteen-pound baby born in Brazil: here's what increases the risk of giving birth to a giant baby</a>
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<hr>
<p>However, the trial found several harms, including more neonatal hypoglycaemia (low blood sugar in newborns), induction of labour, use of diabetic medications including insulin injections, and use of health services. </p>
<p>The study authors also looked at the subgroup of women who were diagnosed with glucose levels between the higher and lower thresholds. In this subgroup, there was some reduction in large babies, and in shoulder problems at delivery. </p>
<p>But there was also an increase in small babies. This is of concern because being small for gestational age can also have consequences for babies, including long-term health consequences.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/540643/original/file-20230802-29-1dw2rw.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/540643/original/file-20230802-29-1dw2rw.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=349&fit=crop&dpr=1 600w, https://images.theconversation.com/files/540643/original/file-20230802-29-1dw2rw.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=349&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/540643/original/file-20230802-29-1dw2rw.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=349&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/540643/original/file-20230802-29-1dw2rw.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=438&fit=crop&dpr=1 754w, https://images.theconversation.com/files/540643/original/file-20230802-29-1dw2rw.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=438&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/540643/original/file-20230802-29-1dw2rw.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=438&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">NEJM</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<h2>Testing too early</h2>
<p>Some centres have begun testing women at higher risk of gestational diabetes earlier in the pregnancy (between 12 and 20 weeks).</p>
<p>However, a <a href="https://pubmed.ncbi.nlm.nih.gov/37144983/">recent trial</a> showed no clear benefit compared with testing at the usual 24–28 weeks: possibly fewer large babies, but again matched by more small babies.</p>
<p>There was a reduction in transient “respiratory distress” – needing extra oxygen for a few hours – but not in serious clinical events. </p>
<h2>Impact on women with gestational diabetes</h2>
<p>For women diagnosed using the higher glucose thresholds, dietary advice, glucose monitoring and, where necessary, insulin therapy has been shown to reduce complications during delivery and the post-natal period. </p>
<p>However, current models of care can also cause harm. Women with gestational diabetes are often denied their preferred model of care – for example, midwifery continuity of carer. In rural areas, they may have to transfer to a larger hospital, requiring longer travel to antenatal visits and moving to a larger centre for their birth – away from their families and support networks for several weeks. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/are-you-at-risk-of-being-diagnosed-with-gestational-diabetes-it-depends-on-where-you-live-112515">Are you at risk of being diagnosed with gestational diabetes? It depends on where you live</a>
</strong>
</em>
</p>
<hr>
<p>Women say the diagnosis often dominates their antenatal care and their whole <a href="https://pubmed.ncbi.nlm.nih.gov/32028931/">experience of pregnancy</a>, reducing time for other issues or concerns. </p>
<p>Women from culturally and linguistically diverse communities <a href="https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-021-03981-5">find it difficult</a> to reconcile the advice given about diet and exercise with their own cultural practices and beliefs about pregnancy.</p>
<p>Some women with gestational diabetes <a href="https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-020-2745-1">become</a> extremely anxious about their eating and undertake extensive calorie restrictions or disordered eating habits.</p>
<figure class="align-center ">
<img alt="Woman stands in garden looking at her pregnant belly" src="https://images.theconversation.com/files/540324/original/file-20230801-241351-uvur05.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/540324/original/file-20230801-241351-uvur05.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/540324/original/file-20230801-241351-uvur05.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/540324/original/file-20230801-241351-uvur05.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/540324/original/file-20230801-241351-uvur05.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/540324/original/file-20230801-241351-uvur05.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/540324/original/file-20230801-241351-uvur05.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Some pregnant women become extremely anxious after being diagnosed with gestational diabetes.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/gYnEka3-tCI">Unsplash/Jordan Bauer</a></span>
</figcaption>
</figure>
<h2>Time to reassess the advice</h2>
<p>Recent evidence from both randomised controlled trials and from qualitative studies with women diagnosed with gestational diabetes suggest we need to reassess how we currently diagnose and manage gestational diabetes, particularly for women with only slightly elevated levels.</p>
<p>It is time for a review to consider all the problems described above. This review should include the views of all those impacted by these decisions: women in childbearing years, and the GPs, dietitians, diabetes educators, midwives and obstetricians who care for them.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/had-gestational-diabetes-here-are-5-things-to-help-lower-your-future-risk-of-type-2-diabetes-114298">Had gestational diabetes? Here are 5 things to help lower your future risk of type 2 diabetes</a>
</strong>
</em>
</p>
<hr>
<p><em>This article was co-authored by maternity services consumer advocate Leah Hardiman.</em></p><img src="https://counter.theconversation.com/content/205919/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Glasziou receives funding from an NHMRC Investigator grant.</span></em></p><p class="fine-print"><em><span>Jenny Doust receives funding from NHMRC and MRFF. </span></em></p>About one in six pregnant women in Australia are now diagnosed with gestational diabetes. Rates have more than doubled since the thresholds for diagnosis were changed.Paul Glasziou, Professor of Medicine, Bond UniversityJenny Doust, Clinical Professorial Research Fellow, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2069752023-08-08T12:30:04Z2023-08-08T12:30:04ZProstate cancer treatment is not always the best option – a cancer researcher walks her father through his diagnosis<figure><img src="https://images.theconversation.com/files/541121/original/file-20230803-13641-htmsv0.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2147%2C1394&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many patients with less aggressive prostate cancer elect active surveillance instead of treatment.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/daughter-analyzing-test-results-of-old-father-in-royalty-free-image/1394729033">triloks/E+ via Getty Images</a></span></figcaption></figure><p>“Me encontraron càncer en la pròstata,” my father told me. They found cancer in my prostate. </p>
<p>As a <a href="https://scholar.google.com/citations?user=nqSJ0d8AAAAJ&hl=en">cancer researcher</a> who knows very well about the high incidence and decreased survival rates of <a href="https://doi.org/10.1016/j.lana.2022.100295">prostate cancer in the Caribbean</a>, I anguished over these words. Even though I study cancer in my day job, I struggled to take in this news. At the time, all I could muster in response was “What did the doctor say?” </p>
<p>“The urologist wants me to see the radiation oncologist to discuss ‘semillas’ [seeds],” he said. “They are recommending treatment.” </p>
<p>However, I understood from my work that not undergoing treatment was also an option. In some cases, that is the better choice. So I took it upon myself to educate my father on his disease and assist him with the life-changing decisions he would have to make. Our journey can give you a preview of what a cancer diagnosis can be like.</p>
<h2>Prostate cancer diagnosis</h2>
<p>Prostate cancer was not a new topic for my father and me. His battle with his prostate health started 10 years ago with an initial diagnosis of <a href="https://doi.org/10.1016/j.eururo.2008.11.011">benign prostate hyperplasia, or BPH</a>. </p>
<p>The prostate <a href="https://www.niddk.nih.gov/health-information/urologic-diseases/prostate-problems/prostate-enlargement-benign-prostatic-hyperplasia">gets bigger with age</a> for a number of reasons, including changing hormone levels, infection or inflammation. Two of the most frequent symptoms of BPH are difficulty urinating and a sudden, urgent need to urinate, both of which my father experienced. </p>
<p>Although research suggests that the factors that contribute to BPH similarly contribute to prostate cancer, there is no evidence that an enlarged prostate will necessarily <a href="https://doi.org/10.1038/nrurol.2012.192">develop into cancer</a>.</p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/_Jcq4FDTheg?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Prostate cancer diagnoses have risen in the U.S. in recent years.</span></figcaption>
</figure>
<p>Upon my father’s initial BPH diagnosis, I asked about his <a href="https://www.cancer.gov/types/prostate/psa-fact-sheet">PSA levels</a>, or the amount of prostate-specific antigens in his blood. PSA is a protein that both normal and cancerous prostate cells produce, and elevated amounts are considered red flags for prostate cancer. When combined with a <a href="https://www.cancer.net/navigating-cancer-care/diagnosing-cancer/tests-and-procedures/digital-rectal-exam-dre">digital rectal exam</a>, a PSA test can allow doctors to more accurately predict a person’s risk of having prostate cancer.</p>
<p>My father said his PSA levels were elevated but that the doctors would begin <a href="https://www.pcf.org/about-prostate-cancer/prostate-cancer-treatment/active-surveillance/">active surveillance</a>, or what he called “watchful waiting,” and monitor his PSA every six months to see if it rose.</p>
<p>After eight years of monitoring his PSA, doctors found my father’s PSA level had doubled. He then got a biopsy that indicated he had intermediate-risk prostate cancer.</p>
<h2>Cancer risk categorization</h2>
<p>After his diagnosis, my father was faced with the decision of how to proceed with treatment. I explained that categorizing how aggressive the cancer is and how far it has spread can help determine the best course of treatment.</p>
<p>Prostate cancer can be <a href="https://www.cancer.org/cancer/prostate-cancer/detection-diagnosis-staging/staging.html">grouped into four stages</a>. Stages 1 and 2, when the tumor is still confined to the prostate, are considered early-stage or intermediate risk. Stages 3 and 4, when the tumor has spread beyond the borders of the prostate, are considered more advanced and high risk.</p>
<p>Some patients with early-stage or intermediate-risk prostate cancer undergo <a href="https://www.cancer.gov/types/prostate/patient/prostate-treatment-pdq#_142">additional treatment</a>, including surgery, radiation or radioactive seed implants called brachytherapy. Patients with late-stage prostate cancer typically undergo hormone therapy along with surgery or radiation, or chemotherapy with or without radiation.</p>
<p>Although I was not surprised by my father’s diagnosis, given his advanced age and his battle with prostate disease over the past decade, I still struggled emotionally. I struggled with our conversations about what “curing” his cancer meant and how to explain his treatment options to him. I wanted to ensure he would have the best outcome and could still live his best life.</p>
<p>Our initial inclination was to undergo <a href="https://www.cancer.gov/publications/dictionaries/cancer-terms/def/active-surveillance">active surveillance</a>. That meant we would monitor his PSA every six months instead of immediately starting treatment. That is appropriate for patients with early-stage and less aggressive tumors.</p>
<h2>Prostate cancer screening problems</h2>
<p>My father was leaning on me to help him decide how to proceed. I felt overwhelming anxiety because I did not want to fail him or my family. Even with all my expertise studying cancer genetics and working with cancer patients, I couldn’t help second-guessing our decisions, and I sometimes questioned our decision not to immediately treat his cancer.</p>
<p>Some people diagnosed with prostate cancer don’t immediately start treatment, because many of the tumors found through PSA testing grow so slowly that they are <a href="https://doi.org/10.7326/0003-4819-158-11-201306040-00008">unlikely to be life-threatening</a>. Detecting these slow-growing tumors is <a href="https://doi.org/10.1038/s41568-019-0142-8">considered overdiagnosis</a>, because the cancer ultimately will not harm the patient during their lifetime. <a href="https://doi.org/10.1016/j.eururo.2013.12.062">Nearly half of all patients</a> with prostate cancer are overdiagnosed, often leading to overtreatment. </p>
<p>Research suggests that many prostate cancer patients undergo unnecessarily aggressive treatments, which are often associated with <a href="https://doi.org/10.1001/jama.2018.3712">significant harms</a>, like urinary and bowel incontinence, sexual impotence and, in some cases, death. Several studies in the U.S. have shown that patients with early-stage prostate cancer have a <a href="https://doi.org/10.1200%2FJCO.2012.44.0586">good prognosis, and the cancer rarely progresses</a> further. With careful observation, most will never need treatment and can be spared the burdens of unnecessary therapy until there are clear signs of progression.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/tYii98gcejA?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">The U.S. Preventive Services Task Force recommended individualized PSA-based screening in 2018 to avoid overdiagnosis and overtreatment.</span></figcaption>
</figure>
<p>Overdiagnosis and overtreatment of prostate cancer led the U.S. Preventive Services Task Force to recommend against PSA-based screening in 2012, with caveats for high-risk groups including African American men and those with a family history of prostate cancer. The recommendation was updated in 2018 to make screening a <a href="https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/prostate-cancer-screening">personal choice after discussion</a> with a clinician. </p>
<p>Those recommendations have resulted in reduced screening and <a href="https://www.nbcnews.com/health/cancer/men-diagnosed-advanced-prostate-cancer-psa-testing-drops-rcna65277">increased prostate cancer diagnoses</a>. Given that Black men are <a href="https://doi.org/10.1002/cncr.34433">more likely to see the cancer progress</a> to aggressive forms of the disease after initial diagnosis, this may worsen existing health disparities.</p>
<p>Developing tests that better identify patients at risk of dying from prostate cancer can decrease overtreatment. In the meantime, educating patients can help them decide if screening is appropriate for them. For underserved and marginalized communities, <a href="https://doi.org/10.4102/safp.v65i1.5621">community outreach</a> can help improve health literacy and enhance awareness and screening.</p>
<p>When I looked through my father’s stack of medical records, I found a beacon of light that eased my apprehension. His doctor had ordered a <a href="https://doi.org/10.1038/modpathol.2017.168">genetic test</a> that estimates how aggressive a tumor may be by measuring the activity of specific genes in cancer cells. An increase in gene activity linked to cancer would indicate that it is likely to grow fast and spread.</p>
<p>The test predicted that my father’s risk of dying from the disease in the next five years was less than 5%. Based on these results, we both understood that he had adequate time to make a decision and seek additional guidance. </p>
<p>My father ultimately decided to continue active surveillance and forgo immediate treatment. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/541105/original/file-20230803-23-jtzdmj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Person holding hand of patient lying in hospital bed" src="https://images.theconversation.com/files/541105/original/file-20230803-23-jtzdmj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/541105/original/file-20230803-23-jtzdmj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/541105/original/file-20230803-23-jtzdmj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/541105/original/file-20230803-23-jtzdmj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/541105/original/file-20230803-23-jtzdmj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/541105/original/file-20230803-23-jtzdmj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/541105/original/file-20230803-23-jtzdmj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Because of disparities in access to screening and treatment, African American men are more likely to be diagnosed with advanced prostate cancer.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/son-holding-fathers-hand-at-the-hospital-royalty-free-image/1341484868?phrase=patient+family&adppopup=true">FG Trade/E+ via Getty Images</a></span>
</figcaption>
</figure>
<h2>Surviving prostate cancer</h2>
<p>I still worry about my father’s diagnosis, because his cancer is at risk for progression. So every six months, I inquire about his PSA levels. His doctors are monitoring his PSA levels as part of his <a href="https://www.cdc.gov/cancer/survivors/life-after-cancer/survivorship-care-plans.htm">survivorship plan</a>, which is a record of information about his cancer diagnosis, treatment history and potential follow-up tests.</p>
<p>My father’s decision to undergo active surveillance was controversial among our friends and family. Many were under the impression that prostate cancer required immediate treatment. Several shared successful treatment stories, sometimes followed by stories of adverse treatment-related side effects.</p>
<p>To date, my father believes that active surveillance was the best decision for him and understands that this may not be the same for someone else. Talk to your doctor to see what the best options are for you or your loved ones.</p><img src="https://counter.theconversation.com/content/206975/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Luisel Ricks-Santi does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Prostate cancer is one of the most common cancers in men. Although watchful waiting is appropriate for low-risk cases, many are diagnosed at an advanced stage because of racial health disparities.Luisel Ricks-Santi, Associate Professor of Pharmacy, University of FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2032452023-04-26T00:57:18Z2023-04-26T00:57:18ZMy scan shows I have thyroid nodules. Should I be worried?<figure><img src="https://images.theconversation.com/files/521228/original/file-20230417-14-8bpm4a.jpg?ixlib=rb-1.1.0&rect=60%2C34%2C5689%2C3990&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/woman-getting-ultrasound-thyroid-doctor-83108125">Shutterstock</a></span></figcaption></figure><p>The thyroid is a <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/thyroid-gland">gland</a> located at the base of the neck. It makes thyroid hormones, which control the way the body uses energy.</p>
<p>A thyroid nodule is a solid or fluid-filled lump found within the thyroid. The majority of thyroid nodules are small, can’t be felt by touch and do not cause symptoms. They are caused by an overgrowth of cells in the thyroid gland. In a few people, the nodules grow and cause symptoms such as pressure, difficulty swallowing or breathing.</p>
<p>Thyroid nodules are very common, with <a href="https://www.acpjournals.org/doi/10.7326/0003-4819-126-3-199702010-00009?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed">more than half of people scanned</a> show small nodules. </p>
<p>So, they might never cause problems are only discovered incidentally. But when should you follow up and get treatment? </p>
<hr>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/im-approaching-a-milestone-birthday-what-health-checks-should-i-have-at-my-age-172047">I'm approaching a 'milestone' birthday. What health checks should I have at my age?</a>
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</p>
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<h2>Who gets them</h2>
<p>Nodules tend to be more commonly <a href="https://www.acpjournals.org/doi/10.7326/0003-4819-69-3-537?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed">detected in women</a>, at three times the rate seen in men. The incidence also <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4667162/">increases with age</a>. </p>
<p>At age 30 it is estimated around 30% of women will have a nodule. By age 70, approximately 70% of women will have at least one. The risk of a thyroid nodule is also higher if you have other thyroid conditions such as Hashimoto’s disease or have been exposed to radiation. However, only <a href="https://jamanetwork.com/journals/jama/fullarticle/2673975">a very small proportion</a> of the adult population will need treatment or review for nodules.</p>
<p>People often find out that they have thyroid nodules during a routine check-up or when investigating another unrelated health issue. Thyroid nodules are <a href="https://onlinelibrary.wiley.com/doi/10.1111/j.1365-2362.2009.02162.x">readily seen on common imaging tests</a> such as an ultrasound or CT scans. Because there is rapidly growing access to and use of clinical imaging, and also, we tend to visit the doctors a lot more as we age, the chances of incidentally finding thyroid nodules has increased.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/521232/original/file-20230417-22-wtmdba.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="x-ray image of person's neck and thyroid gland" src="https://images.theconversation.com/files/521232/original/file-20230417-22-wtmdba.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/521232/original/file-20230417-22-wtmdba.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/521232/original/file-20230417-22-wtmdba.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/521232/original/file-20230417-22-wtmdba.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/521232/original/file-20230417-22-wtmdba.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/521232/original/file-20230417-22-wtmdba.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/521232/original/file-20230417-22-wtmdba.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The vast majority of thyroid nodules cause no symptoms and don’t lead to cancer that needs treatment.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/3d-rendered-medically-accurate-illustration-thyroid-1470850277">Shutterstock</a></span>
</figcaption>
</figure>
<h2>When should you worry?</h2>
<p>Understandably, people worry a thyroid nodule might mean cancer. But we now know around <a href="https://www.liebertpub.com/doi/10.1089/thy.2012.0156?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed">10% of patients</a> with thyroid nodules harbour cancer – so approximately 90% of those detected don’t pose a cancer risk. </p>
<p>Generally, the risk is only increased with past radiation exposure, a family history of thyroid cancer, obesity, or if aged younger than 20 at the time of discovery of the nodule. Symptoms of concern are: an enlarging thyroid nodule, recent onset of hoarseness, difficult swallowing, neck pain or discomfort, large firm nodule or surrounding enlarged lymph nodes.</p>
<p>Your medical history and any physical symptoms related to the thyroid should always been discussed with a doctor. They may recommend further investigation, or to watch for changes over time. The idea of observing may sound counter-intuitive, but it can be important because doing further investigations may not always be in your best interest.</p>
<p>Treatment for thyroid nodules depends on whether the nodule is suspected of being a cancer or is causing symptoms, such as neck discomfort or an overproduction of thyroid hormones. Often, there will be no formal treatment required for thyroid nodules.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/29-000-cancers-overdiagnosed-in-australia-in-a-single-year-127791">29,000 cancers overdiagnosed in Australia in a single year</a>
</strong>
</em>
</p>
<hr>
<h2>When detection leads to poorer health</h2>
<p>There is an important problem that exists with “incidentally” found thyroid nodules. </p>
<p>In recent decades, the <a href="https://www.nejm.org/doi/full/10.1056/NEJMp1604412">dramatic increase</a> in new cases of thyroid cancer has largely been driven by findings of small, low-risk thyroid cancers; found when investigating thyroid nodules. Strong evidence exists overdiagnosis – that is, a correct but unnecessary diagnosis – accounts for a <a href="https://www.thelancet.com/journals/landia/article/PIIS2213-8587%2820%2930115-7/fulltext">large proportion</a> of thyroid cancer cases. </p>
<p>We know that despite a rapid increase in the diagnosis of thyroid cancer, the number of people who die from it (the mortality rate) has remained steady. This means most of these cancers are found unnecessarily. And finding them can cause worry and sometimes lead to treatments and financial costs that ultimately may not have been necessary at all.</p>
<p>Overdiagnosis and subsequent <a href="https://www.liebertpub.com/doi/abs/10.1089/thy.2020.0694">overtreatment</a> of this condition has been extensively documented. But working out how to avoid and address these issues remains difficult. The American Thyroid Association is a leading treatment group for the management of thyroid nodules. It <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4739132/">recommends</a> nodules smaller than 1 centimetre should not be routinely biopsied. In line with this, systems for ultrasound reporting have been introduced to reduce overtreatment of <a href="https://academic.oup.com/jcem/article/104/1/95/5115830?login=true">small thyroid nodules</a>.</p>
<p>In 2020, we conducted <a href="https://www.liebertpub.com/doi/abs/10.1089/thy.2020.0694">community research</a> and found Australians were unaware of the harms of overdiagnosing low-risk thyroid cancers. They wanted more community education and supported the idea of clinical guidelines to minimise over-investigating and over-treating low-risk conditions.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/521233/original/file-20230417-28-ntt3gb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="woman's neck with protruding bump at front of throat" src="https://images.theconversation.com/files/521233/original/file-20230417-28-ntt3gb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/521233/original/file-20230417-28-ntt3gb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/521233/original/file-20230417-28-ntt3gb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/521233/original/file-20230417-28-ntt3gb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/521233/original/file-20230417-28-ntt3gb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/521233/original/file-20230417-28-ntt3gb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/521233/original/file-20230417-28-ntt3gb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Larger thyroid nodules may make swallowing more difficult or cause discomfort.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/asian-lady-woman-patient-have-abnormal-1175855908">Shutterstock</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/low-and-middle-income-countries-struggle-to-provide-health-care-to-some-while-others-get-too-much-medicine-190446">Low- and middle-income countries struggle to provide health care to some, while others get too much medicine</a>
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</p>
<hr>
<h2>Take-home advice</h2>
<p>While there is a small proportion of thyroid nodules that cause harm, the large majority are found incidentally and are unlikely to cause further problems. </p>
<p>Investigating and treating these nodules can lead to unwarranted physical, psychological and financial consequences including overdiagnosis, overtreatment, anxiety and out-of-pocket costs.</p>
<p>It is important to be aware of the issues involved in finding a thyroid nodule, and ask questions – for ourselves and our loved ones – about what this means and whether further investigation or treatment is really needed.</p><img src="https://counter.theconversation.com/content/203245/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Brooke Nickel receives Fellowship funding from the National Health and Medical Research Council (NHMRC). </span></em></p><p class="fine-print"><em><span>Anthony Glover receives funding from Cancer Institute NSW.</span></em></p><p class="fine-print"><em><span>Patti Shih's research projects are funded by the National Health and Medical Research Council (NHMRC)</span></em></p><p class="fine-print"><em><span>Anna Story does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>More and more healthy women and men are found to have thyroid nodules. What are they? And should you be worried about them?Brooke Nickel, NHMRC Emerging Leader Research Fellow, University of SydneyAnna Story, Senior Clinical Lecturer, University of SydneyAnthony Glover, Endocrine Surgeon, University of SydneyPatti Shih, Research Fellow & Lecturer, University of WollongongLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1904462022-11-01T19:00:42Z2022-11-01T19:00:42ZLow- and middle-income countries struggle to provide health care to some, while others get too much medicine<figure><img src="https://images.theconversation.com/files/492022/original/file-20221027-4274-s7w36k.jpg?ixlib=rb-1.1.0&rect=487%2C311%2C4842%2C2676&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/african-doctor-white-medical-gown-walking-1245191041">Shutterstock</a></span></figcaption></figure><p>Access to quality health care is a fundamental human right. Yet more than half the world’s population can’t obtain even the most <a href="https://www.who.int/news/item/13-12-2017-world-bank-and-who-half-the-world-lacks-access-to-essential-health-services-100-million-still-pushed-into-extreme-poverty-because-of-health-expenses">essential health care</a>. Out-of-pocket costs drive hundreds of millions into <a href="https://www.who.int/news/item/12-12-2021-more-than-half-a-billion-people-pushed-or-pushed-further-into-extreme-poverty-due-to-health-care-costs">extreme poverty</a> </p>
<p>The solution the <a href="https://apps.who.int/iris/handle/10665/272465">World Health Organization</a> and many nations promote is to provide universal health coverage, like Australia’s Medicare system. Achieving that is one of the key targets of the United Nation’s <a href="https://sdgs.un.org/goals/goal3">Sustainable Development Goals</a>. </p>
<p>Surprisingly, one of the challenges with increasing access to health care is the danger of getting too much of it. Too many unnecessary tests, treatments and diagnoses cause people harm and waste precious resources. </p>
<p><a href="https://theconversation.com/au/topics/overdiagnosis-3771">Overdiagnosis and overuse</a> of health care wastes <a href="https://www.oecd.org/health/tackling-wasteful-spending-on-health-9789264266414-en.htm">an estimated 20%</a> of health spending in high-income countries. </p>
<p>With a global team of more than 30 researchers, we’ve been assessing the situation in <a href="https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups">low- and middle-income countries</a>. This included analysing more than 500 scientific articles reporting on studies involving close to 8 million participants or health care services, from more than 80 low- and middle-income countries.</p>
<p>Our world-first scoping reviews – published today in <a href="https://gh.bmj.com/content/bmjgh/7/10/e008696.full.pdf">BMJ Global Health</a> and the <a href="https://cdn.who.int/media/docs/default-source/bulletin/online-first/blt.22.288293.pdf?sfvrsn=505d7048_2">Bulletin of the World Health Organization</a> – suggest the problems of too much medicine are already widespread in low- and middle-income countries. Here’s a snapshot of what we found.</p>
<h2>Overdiagnosing thyroid cancer</h2>
<p>Awareness has grown in recent years that many tiny thyroid tumours are wrongly diagnosed and treated as cancer, including <a href="https://theconversation.com/29-000-cancers-overdiagnosed-in-australia-in-a-single-year-127791">in Australia</a>. Based on the evidence we uncovered, this is affecting health systems everywhere.</p>
<p>Thyroid <a href="https://theconversation.com/29-000-cancers-overdiagnosed-in-australia-in-a-single-year-127791">cancer overdiagnosis</a> occurs when a person is diagnosed with a “harmless” cancer that either never grows or grows very slowly – and wouldn’t have caused any problem even if left untreated. </p>
<p>Overdiagnosis of thyroid tumours can cause psychological, financial, and physical harms, including unnecessary removal of the thyroid and related complications.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/29-000-cancers-overdiagnosed-in-australia-in-a-single-year-127791">29,000 cancers overdiagnosed in Australia in a single year</a>
</strong>
</em>
</p>
<hr>
<p>One <a href="https://onlinelibrary.wiley.com/doi/10.1002/ijc.31884">analysis</a> included more than 5 million patients with thyroid cancers from more than 50 countries. It found very high rates of thyroid cancer in some low- and middle-income countries. However, death rates from thyroid cancer had remained unchanged in these countries, strongly suggesting much unnecessary diagnosis. </p>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/33891886/">A recent study</a> of more than 27,000 people in China estimated that three in four patients diagnosed with thyroid cancer might be overdiagnosed. That study also found huge variations in the estimate of overdiagnosis across regions in China.</p>
<figure class="align-center ">
<img alt="Empty hospital bed" src="https://images.theconversation.com/files/492023/original/file-20221027-19202-onwv4e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/492023/original/file-20221027-19202-onwv4e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/492023/original/file-20221027-19202-onwv4e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/492023/original/file-20221027-19202-onwv4e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/492023/original/file-20221027-19202-onwv4e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/492023/original/file-20221027-19202-onwv4e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/492023/original/file-20221027-19202-onwv4e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Many thyroid tumours diagnosed as ‘cancer’ would never cause harm.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/KF-h9HMxRKg">Martha Moninguez/Unsplash</a></span>
</figcaption>
</figure>
<h2>Overdiagnosing malaria</h2>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/22833603/">Malaria overdiagnosis</a> occurs when people who don’t carry malaria parasites are wrongly diagnosed, and given malaria treatment. </p>
<p>One <a href="https://pubmed.ncbi.nlm.nih.gov/19362256/">study</a> of more than 3,000 patients from 95 health centres in Sudan found a growing recognition of malaria overdiagnosis, and calculated that this wasted more than US$80 million in the year 2000.</p>
<p>Malaria is endemic in in many Asian and African countries. However, when malaria is wrongly diagnosed, serious non-malarial infections might be missed and drugs are wasted.</p>
<h2>Wasteful imaging tests</h2>
<p>In 2014 in Iran, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4258662/">a study</a> found half of the requests for magnetic resonance imaging (MRI) for low back pain were inappropriate or unnecessary. </p>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/33663526/">Another study</a> from 2021 in Iran, estimated the cost of inappropriate use of brain imaging in just three teaching hospitals to be greater that US$100,000. </p>
<p>Unnecessary imaging tests diverts scarce resources and may lead to unnecessary treatments. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-media-is-overhyping-early-detection-tests-and-this-may-be-harming-the-healthy-158229">The media is overhyping early detection tests, and this may be harming the healthy</a>
</strong>
</em>
</p>
<hr>
<h2>Overprescribing medicines</h2>
<p>In Lebanon, <a href="https://pubmed.ncbi.nlm.nih.gov/33564384/">a 2020 study</a> found massive overuse of stomach drugs called proton pump inhibitors, with more than two in three people taking them unnecessarily. Approximately US$25 million was being wasted annually.</p>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/31843383/">A large global study in 2020</a> examined antibiotic use among more than 65,000 children under five in eight low- and middle-income countries: Haiti, Kenya, Malawi, Namibia, Nepal, Senegal, Tanzania, and Uganda. The researchers found antibiotics were prescribed to more than 80% of children diagnosed with respiratory illness and most of these prescriptions were deemed unnecessary. </p>
<p><a href="https://www.bmj.com/content/354/bmj.i3482">Unnecessary use of antibiotics</a> has potential harms including antibiotic resistance – when bacteria adapt and antibiotics become less effective. Antibacterial resistance is one of the <a href="https://pubmed.ncbi.nlm.nih.gov/35065702/">leading causes of death</a> around the world, with the highest burdens in countries and services with limited resources.</p>
<h2>Disparities based on wealth</h2>
<p>Our reviews found examples of too much medicine alongside underuse in low- and middle-income countries. </p>
<p>One <a href="https://pubmed.ncbi.nlm.nih.gov/29367432/">large study</a> of more than 70 low- and middle-income countries found huge inequality in rates of caesarean sections. While the poorest people had inadequate access to emergency caesarean sections, the richest could obtain them when they were not needed.</p>
<figure class="align-center ">
<img alt="Indian women stand in line at a pregnancy clinic" src="https://images.theconversation.com/files/492024/original/file-20221027-24547-lwyx09.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/492024/original/file-20221027-24547-lwyx09.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/492024/original/file-20221027-24547-lwyx09.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/492024/original/file-20221027-24547-lwyx09.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/492024/original/file-20221027-24547-lwyx09.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/492024/original/file-20221027-24547-lwyx09.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/492024/original/file-20221027-24547-lwyx09.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">There is huge disparity in access to caesarean sections.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/adapur-indianov-8-indian-women-rural-341874809">Shutterstock</a></span>
</figcaption>
</figure>
<h2>Time to tackle waste and harm</h2>
<p>The <a href="https://apps.who.int/iris/handle/10665/272465">World Health Organization</a> notes that as the world moves towards universal health coverage, it’s a good time to tackle the waste and harm caused by overdiagnosis and overuse. </p>
<p>It’s also a problem we can work together to solve. As the <a href="https://iebh.bond.edu.au/news/69098/25m-nhmrc-grant-awarded-aiming-provide-better-value-care-all-australians">WHO noted</a>, “the 194 Ministries of health with whom WHO works all face this problem”. </p>
<p>Solutions are already being tested, though not often enough. One example is <a href="https://pubmed.ncbi.nlm.nih.gov/25739769/">a large study</a> in Ghana, which found introducing new rapid diagnostic tests could halve the rates of unnecessary treatment for Malaria.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/five-warning-signs-of-overdiagnosis-110895">Five warning signs of overdiagnosis</a>
</strong>
</em>
</p>
<hr>
<p>However, without more action, too many people in low- and middle-income countries will find themselves lacking access to effective health services, coupled with overuse in some areas. </p>
<p>Building on the results of our reviews, we aim to help build a global alliance to reduce overdiagnosis and overuse of health services in low- and middle-income countries. This collaborative effort will seek to develop and evaluate potential solutions.</p><img src="https://counter.theconversation.com/content/190446/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Loai Albarqouni receives funding from the National Health and Medical Research Council (NHMRC).</span></em></p><p class="fine-print"><em><span>Ray Moynihan received funding from the National Health and Medical Research Council, and helped lead the Preventing Overdiagnosis initiative and conferences for several years. </span></em></p>As access to health care increases, there’s also a danger of getting too much of it.Loai Albarqouni, Assistant Professor | NHMRC Emerging Leadership Fellow, Bond UniversityRay Moynihan, Assistant Professor, Bond UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1793702022-03-24T03:56:05Z2022-03-24T03:56:05Z3 orthopaedic surgeries that might be doing patients (and their pockets) more harm than good<figure><img src="https://images.theconversation.com/files/453721/original/file-20220323-17-nhnah2.jpg?ixlib=rb-1.1.0&rect=14%2C0%2C4718%2C3157&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Orthopaedic surgery (surgery for problems related to bones, joints, tendons and ligaments) is the <a href="https://www.aihw.gov.au/reports-data/myhospitals/intersection/activity/eswt">third most common reason</a> Australians go under the knife. </p>
<p>Last year, more than 100,000 orthopaedic surgeries were performed in Australian public hospitals. As most orthopaedic surgeries are performed in private hospitals, the real number is much higher (and unfortunately unknown).</p>
<p>But what most people don’t know is that many common orthopaedic surgeries <a href="https://pubmed.ncbi.nlm.nih.gov/33090742/">are not better for reducing pain</a> than non-surgical alternatives that are both cheaper and safer, such as exercise programs. Some surgeries provide the same result as a placebo surgery, where the surgeon only conducts a joint examination, rather than performing the real surgery. </p>
<p>And contrary to popular opinions, placebos are <a href="https://www.nejm.org/doi/full/10.1056/nejm200105243442106">not actually very powerful</a>, so real surgery that isn’t better than a placebo should not be recommended.</p>
<p>In this article we discuss the evidence behind three commonly performed orthopaedic surgeries for back, knee and shoulder pain that might be doing patients (and their pockets) more harm than good.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/antibiotics-for-colds-x-rays-for-bronchitis-internal-exams-with-pap-tests-the-latest-list-of-tests-to-question-56007">Antibiotics for colds, x-rays for bronchitis, internal exams with pap tests – the latest list of tests to question</a>
</strong>
</em>
</p>
<hr>
<h2>Spinal fusion for back pain</h2>
<p>Spinal fusion is the riskiest type of surgery for back pain and the <a href="https://www.safetyandquality.gov.au/sites/default/files/2020-08/prioritisation_criteria.pdf">most expensive</a> orthopaedic procedure performed in Australia. Depending on your health insurance arrangements, the total cost of the surgery can be around A$58,000 and <a href="https://www.hcf.com.au/cost-calculator?pid=43">out-of-pocket costs might be close to A$10,000</a>. </p>
<p>It involves permanently fusing two or more vertebrae together to stop them moving on each other, typically using metal implants and bone from other areas of the body.</p>
<p>It was originally conceived to treat broken spinal bones and some spine deformities, such as severe scoliosis (abnormal curvature of the spine). Surgeons’ justification for using this surgery has expanded over time and it is now the most common surgery to treat everyday back pain that isn’t caused by a serious issue like a fracture or infection.</p>
<p>This is despite evidence that spinal fusion is <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/imj.14120">not more effective</a> than non-surgical treatments (such as an exercise program) and often results in complications. <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/imj.14120">About one in six patients</a> experience a serious complication, such as an infection, blood clot, nerve injury, or heart failure. In <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-021-06900-8">New South Wales</a>, only one in five workers who have spinal fusion return to work after two years and one in five have another spine surgery within two years.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/453723/original/file-20220323-21-jh6k7y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Man grabs his lower back as though in pain" src="https://images.theconversation.com/files/453723/original/file-20220323-21-jh6k7y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/453723/original/file-20220323-21-jh6k7y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=351&fit=crop&dpr=1 600w, https://images.theconversation.com/files/453723/original/file-20220323-21-jh6k7y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=351&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/453723/original/file-20220323-21-jh6k7y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=351&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/453723/original/file-20220323-21-jh6k7y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=442&fit=crop&dpr=1 754w, https://images.theconversation.com/files/453723/original/file-20220323-21-jh6k7y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=442&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/453723/original/file-20220323-21-jh6k7y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=442&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Spinal fusion is not more effective than non-surgical treatments like exercise programs, and often results in complications.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-coronavirus-ban-on-elective-surgeries-might-show-us-many-people-can-avoid-going-under-the-knife-135325">The coronavirus ban on elective surgeries might show us many people can avoid going under the knife</a>
</strong>
</em>
</p>
<hr>
<h2>Arthroscopy for knee and shoulder pain</h2>
<p>Arthroscopy is a type of keyhole surgery commonly used to treat knee osteoarthritis and shoulder pain. The surgery is used to remove or repair damaged pieces of bone or cartilage that are thought to cause pain.</p>
<p>Thousands of knee arthroscopies are performed every year. In 2013, more than <a href="https://www.safetyandquality.gov.au/sites/default/files/migrated/SAQ201_04_Chapter3_v6_FILM_tagged_merged_3-1.pdf">33,000 knee arthroscopies</a> were performed in Australian hospitals. Since then, this number has <a href="https://www.mja.com.au/system/files/issues/212_01/mja250436.pdf">reduced by around 40%</a>.</p>
<p>Australian data shows the number of shoulder arthroscopies increased nearly 50% from 2000 to 2009. Since then, numbers have remained stable, at about 6,500 surgeries per year from <a href="http://medicarestatistics.humanservices.gov.au/statistics/do.jsp?_PROGRAM=%2Fstatistics%2Fmbs_item_standard_report&DRILL=ag&group=48900%2C+48903%2C+48906%2C+48909%2C+48912&VAR=services&STAT=count&RPT_FMT=by+time+period+and+state&PTYPE=calyear&START_DT=200001&END_DT=202201">2009 until 2021</a>.</p>
<p>The cost of these surgeries is substantial. Typical out-of-pocket costs for patients with private health insurance is <a href="https://www.health.gov.au/resources/apps-and-tools/medical-costs-finder/medical-costs-finder#/ih-result?area=Joint%20reconstructions&procedure=Arthroscopy">A$400</a> and <a href="https://www.health.gov.au/resources/apps-and-tools/medical-costs-finder/medical-costs-finder#/ih-result?area=Joint%20reconstructions&procedure=Acromioplasty%20%28remove%20some%20shoulder%20bone%20surface%29">A$500</a> for knee and shoulder arthroscopy, respectively. Sometimes, out-of-pocket costs can be as high as A$1,900 to A$2,400, respectively.</p>
<p>High-quality research shows arthroscopy to treat <a href="https://www.nejm.org/doi/full/10.1056/nejmoa013259">osteoarthritis</a>, <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa1305189">wear and tear of the meniscus in the knee</a>, and to <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-67361732457-1/fulltext">remove inflamed and thickened bone and tissue in the shoulder</a> is no better than placebo surgery.</p>
<p>Even though these surgeries are minimally invasive, they still result in <a href="https://bmjopen.bmj.com/content/11/8/e054032">substantial inconveniences</a>. For example, it may take up to six weeks after shoulder arthroscopy for patients to perform simple daily activities like reaching above the head or driving, and up to three months to return to heavy work or sport.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/453726/original/file-20220323-13-61iwgl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Surgeon drills into a knee in operating theatre" src="https://images.theconversation.com/files/453726/original/file-20220323-13-61iwgl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/453726/original/file-20220323-13-61iwgl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=419&fit=crop&dpr=1 600w, https://images.theconversation.com/files/453726/original/file-20220323-13-61iwgl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=419&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/453726/original/file-20220323-13-61iwgl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=419&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/453726/original/file-20220323-13-61iwgl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=527&fit=crop&dpr=1 754w, https://images.theconversation.com/files/453726/original/file-20220323-13-61iwgl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=527&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/453726/original/file-20220323-13-61iwgl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=527&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Knee and shoulder arthroscopies for common complaints have been found to be no more effective than placebo – which is to say – not very effective.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/surgery-rates-are-rising-in-over-85s-but-the-decision-to-operate-isnt-always-easy-116814">Surgery rates are rising in over-85s but the decision to operate isn't always easy</a>
</strong>
</em>
</p>
<hr>
<h2>So what are the alternatives?</h2>
<p>Knowing what treatment options are available to you, and their benefits, harms, and costs is important to ensure you make the best choice for yourself. Luckily, there are tools available to help you. We’ve <a href="https://bmjopen.bmj.com/content/11/8/e054032">developed decision aids to help people with shoulder pain</a> decide whether to have surgery or not (the tool is available <a href="https://bmjopen.bmj.com/content/11/8/e054032#DC1">here</a>).</p>
<p>Our <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-022-07771-3">research</a> has shown that people with back pain who seek a second opinion can avoid unnecessary spine surgery, including spinal fusion.</p>
<p>And avoid Dr Google. Information on the internet usually oversells the benefits and downplays the harms of common surgeries such as <a href="https://www.sciencedirect.com/science/article/pii/S1413355522000090">spinal fusion</a>, <a href="https://pubmed.ncbi.nlm.nih.gov/34129832/">shoulder arthroscopy</a>, and <a href="https://www.sciencedirect.com/science/article/pii/S2468781222000546?dgcid=coauthor">surgery for a torn ACL</a> (ligament in the knee). You will find misleading information even on websites from <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6529212/">trustworthy sources</a> such as government and university websites.</p>
<p>Before making a decision, make sure you ask your doctor the following questions: </p>
<ol>
<li><p>am I more likely to get better with surgery than without it? </p></li>
<li><p>what happens if I choose not to have surgery?</p></li>
<li><p>what are the risks of having this surgery? Both during surgery (for example, anaesthesia) and after surgery (for example, complications)</p></li>
<li><p>have I received enough information about the benefits and harms of having surgery compared to other treatments (including doing nothing)?</p></li>
</ol>
<p>Sometimes surgery is recommended because non-surgical treatment has not worked. Unfortunately, the failure of non-surgical treatment does not make the ineffective surgery any more effective. It still doesn’t work any more than not operating.</p>
<p>The available evidence tells us that the risks and inconveniences of the three surgeries discussed here outweigh the potential benefits.</p><img src="https://counter.theconversation.com/content/179370/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Giovanni Ferreira receives funding from a National Health and Medical Research Council (NHMRC) Emerging Leadership Level 1 Investigator Grant.</span></em></p><p class="fine-print"><em><span>Joshua Zadro receives funding from a National Health and Medical Research Council (NHMRC) Emerging Leadership Level 1 Investigator Grant. </span></em></p><p class="fine-print"><em><span>Mary O'Keeffe receives funding from a National Health and Medical Research Council (NHMRC) Centre for Research Excellence (CRE) Grant.
Mary O'Keeffe has previously received funding from a European Commission Marie Sklodowska Curie Grant. </span></em></p><p class="fine-print"><em><span>Ian Harris does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>These 3 common surgeries have been found to be of little to no benefit, but thousands are still performed every year.Giovanni E Ferreira, NHMRC Emerging Leader Research Fellow, University of SydneyIan Harris, Professor of Orthopaedic Surgery, UNSW SydneyJoshua Zadro, NHMRC Emerging Leader Research Fellow, University of SydneyMary O'Keeffe, Postdoctoral Research Fellow, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1622502021-06-08T04:35:36Z2021-06-08T04:35:36ZMedicare needs to change with the times, but rushing this could leave patients with higher gap fees<p>The federal government has announced <a href="http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/factsheet-current">more than 850 changes</a> to the Medicare Benefits Schedule (MBS) will take effect from July 1. </p>
<p>This has prompted concerns the changes could lead to <a href="https://thenewdaily.com.au/news/national/2021/06/07/medicare-rebate-changes-explained/">greater out of pocket costs for consumers</a>.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1401632233660641281"}"></div></p>
<p>While changes to the Medicare schedule are needed, three weeks isn’t enough time for the system to adapt. Surgeons and private health insurers need time to work through the changes and adjust their fees. </p>
<p>With hasty implementation, patients may face higher gap fees. The government should delay the changes so patients aren’t left in the lurch.</p>
<h2>Remind me, what’s the MBS?</h2>
<p>The Medicare Benefits Schedule is the list of tests, treatments, procedures and “attendance items” for (mostly) doctors’ and some other clinicians’ services. It sets out the government-determined fee and the associated Medicare rebate for each item. </p>
<p>Doctors in Australia can and do set their own fees, resulting in patients often facing significant out-of-pocket payments. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-medicare-and-how-does-it-work-22523">Explainer: what is Medicare and how does it work?</a>
</strong>
</em>
</p>
<hr>
<p>Changes to the MBS Schedule have to be implemented carefully – balancing the need for the MBS to reflect contemporary practice and ensuring value for tax-payers’ money, but avoiding patients being left further out of pocket.</p>
<p>For item numbers when patients are in private hospitals, the Medicare rebate is 75% of the fee. Private insurers must pay the 25% balance, and generally pay more on top of that, as part of a “known gap” agreement – where the insurer has entered into an agreement with the surgeon so that the patient’s out-of-pocket payment is fixed and known in advance, say $1000 – or a “no gap” agreement. </p>
<p>If the insurer hasn’t entered into an agreement with a surgeon, the patient may have to pay the full gap between the MBS fee and what the specialist charges.</p>
<p>Each item in the MBS has a “descriptor” which defines precisely what the item means. </p>
<h2>The MBS needs to change with the times</h2>
<p>Medicine changes with new technology, new anaesthetic techniques and new surgical procedures. </p>
<p>Laparoscopic (key hole) procedures <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5703920/">may take longer than open procedures</a> but have better outcomes and reduced length of hospital stay. </p>
<p>New approaches to aneasthesia for other procedures may <a href="https://pubmed.ncbi.nlm.nih.gov/32896372/">reduce the time needed for operations</a>, again with better outcomes. </p>
<p>The MBS needs to recognise and adapt to these changes. This means the prices for procedures should be updated regularly.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1400929108146769920"}"></div></p>
<h2>The process so far</h2>
<p>Historically, Australia hasn’t had a good track record of regularly updating the schedule. </p>
<p>Then in 2015, health minister Sussan Ley <a href="https://consultations.health.gov.au/medicare-reviews-unit/mbs-review-taskforce-obsolete-items1/">launched a complete overhaul of the MBS</a>. Every section was to be reviewed to ensure the item numbers were still relevant and the descriptors were appropriate and reflected contemporary practice. </p>
<p>The review examined whether some MBS descriptors were no longer reflective of contemporary practice, or didn’t properly describe contemporary procedures. </p>
<p>The review was also to look at problematic billing practices, where some doctors used ambiguity in the MBS to claim multiple items for a procedure, while others only claimed for one item. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/dodgy-treatment-its-not-us-its-the-other-lot-say-the-experts-so-who-do-we-believe-124638">Dodgy treatment: it's not us, it's the other lot, say the experts. So who do we believe?</a>
</strong>
</em>
</p>
<hr>
<p>The review process involved separate committees for each area of the MBS. The <a href="https://www.health.gov.au/resources/collections/mbs-review-final-taskforce-reports-findings-and-recommendations">reports of each area were published</a> in dribs and drabs, with the final tranche published late last year. </p>
<h2>The changes to the MBS</h2>
<p>The government has been slowly responding to the recommendations.</p>
<p>Last year it <a href="https://www.health.gov.au/initiatives-and-programs/mbs-review">announced changes</a> to intensive care, diagnostic imaging (including breast imaging and nuclear), chemotherapy, blood products and several specialist areas. </p>
<p>In last month’s budget, it announced changes to varicose veins, gynaecology, pain management and some types of surgery.</p>
<p>The latest round of announcements include:</p>
<ul>
<li>156 changes to <a href="http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/factsheet-advanced-july-gss">general surgery</a> items</li>
<li>594 to <a href="http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/factsheet-ortho-july21">orthopaedic surgery</a></li>
<li>135 in <a href="http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/factsheet-modernising-cardiac-services">cardiac (heart) surgical services</a>. </li>
</ul>
<p>Almost half involve amending existing items (see the chart below).</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/404985/original/file-20210608-28372-1o1n7a4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/404985/original/file-20210608-28372-1o1n7a4.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=452&fit=crop&dpr=1 600w, https://images.theconversation.com/files/404985/original/file-20210608-28372-1o1n7a4.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=452&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/404985/original/file-20210608-28372-1o1n7a4.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=452&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/404985/original/file-20210608-28372-1o1n7a4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=568&fit=crop&dpr=1 754w, https://images.theconversation.com/files/404985/original/file-20210608-28372-1o1n7a4.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=568&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/404985/original/file-20210608-28372-1o1n7a4.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=568&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">Grattan Institute</span></span>
</figcaption>
</figure>
<p>The process of getting to these recommendations has involved <a href="https://www.health.gov.au/initiatives-and-programs/mbs-review">extensive consultation</a>, and the changes have generally been supported by the relevant parts of the profession. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1401778760001593345"}"></div></p>
<p>The proposed changes are consistent with those widely consulted recommendations. The <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/mbs-review-2019-taskforce-reports-cp/$file/MBS-Reviews-Taskforce-Report-on-Orthopaedics-Final-for-Government-Endorsement-2019.pdf">MBS Review recommendations say what should happen</a> and the government announcement brings that to reality both with a date for the changes to be implemented and the <a href="http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/F3E1DA9A21343EA6CA258646007893F7/$File/itemmap-ortho-jul21.pdf">precise wording of the new item descriptor in the MBS</a>. </p>
<p>The unwelcome surprise is not necessarily the changes themselves but the process of implementation. The general direction of reform was known, but the precise wording wasn’t. The timing of all the proposed changes also came as a surprise.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1401358781649276932"}"></div></p>
<h2>Will patients have to pay more?</h2>
<p>Most of the changes are to hospital-based procedures, where the MBS only covers part of the fee, with much of the rest covered by private health insurance, and the remainder as out-of-pocket payments for patients. Our <a href="https://grattan.edu.au/report/stopping-the-death-spiral/">recent Grattan Institute report</a> shows only about one-quarter of in-hospital services are billed at the MBS fee: </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/404972/original/file-20210608-136167-18k62on.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/404972/original/file-20210608-136167-18k62on.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/404972/original/file-20210608-136167-18k62on.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=454&fit=crop&dpr=1 600w, https://images.theconversation.com/files/404972/original/file-20210608-136167-18k62on.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=454&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/404972/original/file-20210608-136167-18k62on.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=454&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/404972/original/file-20210608-136167-18k62on.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=571&fit=crop&dpr=1 754w, https://images.theconversation.com/files/404972/original/file-20210608-136167-18k62on.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=571&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/404972/original/file-20210608-136167-18k62on.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=571&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="attribution"><span class="source">Grattan Institute</span></span>
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<p>The <a href="https://www.apra.gov.au/quarterly-private-health-insurance-statistics">MBS rebate is</a>, on average, just less than half (48%) the fee charged; private insurers pay about 40% and the balance is the patient out-of-pocket fee. </p>
<p>What private health insurers are prepared to pay determines the size of any gap a patient has to pay.</p>
<p>The response of private health insurers to the new MBS items is crucial. Insurers will have “no-gap” and “known-gap” arrangements with surgeons, and all of these will need to be reviewed as a result of the MBS restructure in the three specialties. </p>
<p>Insurers should negotiate with specialists to ensure they recognise the MBS umpire has decided what the base MBS fee is – and that specialists don’t respond by increasing patients’ out-of-pocket expenses. </p>
<p>Indeed, insurers might use this opportunity to bring down excess fees, which is a core part of making the insurance product more attractive. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/4-ways-to-fix-private-health-insurance-so-it-can-sustain-a-growing-ageing-population-161171">4 ways to fix private health insurance so it can sustain a growing, ageing population</a>
</strong>
</em>
</p>
<hr>
<p>Each insurer will have their own separate process for doing this, and each will do it on their own timeline.</p>
<p>Although it appears <a href="https://www.linkedin.com/feed/update/urn:li:activity:6807506878550175744/">insurers may have been given more notice than doctors</a>, it’s almost certain that some insurers will not have updated their view about what is a reasonable fee, nor finalised new contracts with surgeons about no-gap or known-gap arrangements by the current implementation date of July 1. </p>
<p>This will almost inevitably mean that patients will face increased out-of-pocket costs.</p>
<p>The remedy is simple: the government should defer the changes to allow adequate time for implementation. But it should stress that the delay is about implementation, not about reopening the debate about what is included in the revisions to the MBS.</p><img src="https://counter.theconversation.com/content/162250/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Grattan Institute began with contributions to its endowment of $15 million from each of the Federal and Victorian Governments, $4 million from BHP Billiton, and $1 million from NAB. In order to safeguard its independence, Grattan Institute’s board controls this endowment. The funds are invested and contribute to funding Grattan Institute's activities. Grattan Institute also receives funding from corporates, foundations, and individuals to support its general activities, as disclosed on its website. Medibank is an affiliate partner of Grattan.</span></em></p>With more than 850 changes to Medicare on the cards, the system needs time to adjust. Hasty implementation may mean patients face higher gap fees.Stephen Duckett, Director, Health Program, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1582272021-04-22T22:40:53Z2021-04-22T22:40:53ZStandard IVF is fine for most people. So why are so many offered an expensive sperm injection they don’t need?<figure><img src="https://images.theconversation.com/files/394939/original/file-20210414-13-10bvrbn.jpg?ixlib=rb-1.1.0&rect=0%2C4%2C1000%2C727&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/intracytoplasmic-sperm-injection-icsi-part-ivf-1394225165">from www.shutterstock.com</a></span></figcaption></figure><p>An expensive IVF technique, routinely offered in fertility clinics around the world, offers no extra benefits to standard IVF in the vast majority of cases, our new research shows.</p>
<p>The technique, known as intracytoplasmic sperm injection or ICSI, was developed to help couples where the man has a low sperm count. But it is now the main fertilisation method clinics use in Australia and New Zealand, even when sperm counts are normal. </p>
<p>In an article published today in <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00535-3/fulltext">The Lancet</a> we show that when there’s a normal sperm count, ICSI does not improve the chance of a baby when compared with standard IVF. So why do clinics routinely offer it?</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/considering-using-ivf-to-have-a-baby-heres-what-you-need-to-know-108910">Considering using IVF to have a baby? Here's what you need to know</a>
</strong>
</em>
</p>
<hr>
<h2>What is ICSI?</h2>
<p>In IVF, several thousand sperm compete to be the one to fertilise an egg. However, for the small percentage of couples with what doctors call severe male-factor infertility — for instance, where there is a very low sperm count or the sperm doesn’t look or move normally — IVF is not an option. </p>
<p>In 1992, ICSI <a href="https://pubmed.ncbi.nlm.nih.gov/1351601/">was introduced</a>, where a single sperm was injected into the egg using a glass needle. This allowed the expansion of IVF to people where low sperm counts or poor sperm quality was an issue.</p>
<p>Its introduction across the world has helped thousands of couples have biologically related children, who otherwise would have needed donor sperm or remained childless.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/396213/original/file-20210421-19-1aj9ka7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="IVF versus ICSI" src="https://images.theconversation.com/files/396213/original/file-20210421-19-1aj9ka7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/396213/original/file-20210421-19-1aj9ka7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=376&fit=crop&dpr=1 600w, https://images.theconversation.com/files/396213/original/file-20210421-19-1aj9ka7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=376&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/396213/original/file-20210421-19-1aj9ka7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=376&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/396213/original/file-20210421-19-1aj9ka7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=472&fit=crop&dpr=1 754w, https://images.theconversation.com/files/396213/original/file-20210421-19-1aj9ka7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=472&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/396213/original/file-20210421-19-1aj9ka7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=472&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">With IVF, thousands of sperm compete to fertilise an egg. But with ICSI, a single sperm is injected into the egg.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/types-artificial-fertilization-egg-spermotozoydami-plant-1437755195">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<h2>How common is it?</h2>
<p>ICSI was expected to be used only where male infertility was an issue, but over time it has become the most used method of fertilisation even when it isn’t.</p>
<p>In the United States, between 1996 and 2012, ICSI use <a href="https://jamanetwork.com/journals/jama/fullarticle/2091303">increased</a> from 15% to 67% of couples where the male has a normal sperm count; in Europe about <a href="https://pubmed.ncbi.nlm.nih.gov/30032255/">70% of cycles</a> use ICSI.</p>
<p>In <a href="https://npesu.unsw.edu.au/sites/default/files/npesu/data_collection/Assisted%20Reproductive%20Technology%20in%20Australia%20and%20New%20Zealand%202018_0.pdf">Australia</a> around 60% of cycles used ICSI in 2018. This is even though <a href="https://www.auanet.org/guidelines/azoospermic-male-best-practice-statement">only</a> 30% of infertile couples have male infertility and 15% severe male infertility.</p>
<p>Clinics in Australia use ICSI to different extents. For instance, in Victoria in 2019-20, ICSI was used between <a href="https://www.varta.org.au/sites/default/files/2021-01/varta-annual-report-2020.pdf.pdf">34% and 89%</a> of the time, depending on the clinic.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/sperm-why-these-secretive-swimmers-are-the-key-to-the-future-of-fertility-and-contraception-81773">Sperm: why these secretive swimmers are the key to the future of fertility – and contraception</a>
</strong>
</em>
</p>
<hr>
<h2>What we did and what we found</h2>
<p>Today we report, with our collaborators in Vietnam, the results of a large study in which more than 1,000 infertile couples with a normal sperm count were randomly allocated to ICSI or IVF. We found couples in either group were just as likely to have a baby.</p>
<p>This adds to evidence from other <a href="https://pubmed.ncbi.nlm.nih.gov/29897449/#:%7E:text=What%20is%20known%20already%3A%20The,with%20non%2Dmale%20factor%20infertility">large observational studies</a> in as many as 15,000 women that the widespread use of the more expensive and technically demanding ICSI does not offer any benefit to couples where the man has a normal sperm count. </p>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/32896391/">Excellent clinics</a> internationally and in Australia perform ICSI in fewer than 35% of their treatments, while achieving success rates equal to or better than clinics using ICSI more commonly.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/fertility-miracle-or-fake-news-understanding-which-ivf-add-ons-really-work-118585">Fertility miracle or fake news? Understanding which IVF 'add-ons' really work</a>
</strong>
</em>
</p>
<hr>
<h2>How did ICSI become so popular?</h2>
<p>There are a <a href="https://www.hfea.gov.uk/treatments/treatment-add-ons/">growing number</a> of fertility treatments that <a href="https://www.fertstert.org/article/S0015-0282(19)32454-9/fulltext">aren’t backed by reasonable evidence</a>. </p>
<p>Some are relatively cheap, such as vitamins and antioxidants. Others are invasive or expensive. These include <a href="https://www.hfea.gov.uk/treatments/treatment-add-ons/endometrial-scratching/">endometrial scratching</a> (where the lining of the uterus is scraped with a thin tube, which is said to improve the chance of an embryo implanting), video microscopy of embryos, and <a href="https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2020/03/preimplantation-genetic-testing">pre-implantation genetic diagnosis</a> for potential chromosome abnormalities (where an embryo is tested for genetic disease before being implanted).</p>
<p>In fact, ICSI is about A$500 more expensive than standard IVF, although costs vary between clinics, and some costs can be claimed on <a href="http://www9.health.gov.au/mbs/fullDisplay.cfm?type=item&q=13218&qt=item">Medicare</a> under specific circumstances.</p>
<p>So why are these so-called “add-ons” or “adjuvants” so common?</p>
<p>Fertility treatment, especially IVF and ICSI, is overwhelmingly practised in the private sector in Australia and New Zealand. It is strongly marketed to the public and promoted in social media by individual doctors, clinics and corporations. Doctors and clinics also compete for patients, often offering <a href="https://theconversation.com/fertility-miracle-or-fake-news-understanding-which-ivf-add-ons-really-work-118585">unproven therapies</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-business-of-ivf-how-human-eggs-went-from-simple-cells-to-a-valuable-commodity-119168">The business of IVF: how human eggs went from simple cells to a valuable commodity</a>
</strong>
</em>
</p>
<hr>
<p>Couples may overlook a doctor seeking to practise fertility medicine based solely on evidence, and instead find a nearby clinic or doctor <a href="https://obgyn.onlinelibrary.wiley.com/doi/abs/10.1111/ajo.13321">prepared to offer</a> add-ons they believe will improve their chance of a baby.</p>
<p>In the case of ICSI, doctors may recommend it for fear of patients’ reactions if the eggs don’t fertilise, even if ICSI doesn’t improve the ultimate chance of a baby for those with a normal sperm count.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1191669372747538439"}"></div></p>
<h2>What can we do about it?</h2>
<p>Infertility is distressing and, in most cases, can be easily treated with good advice, simple drugs and, if needed, quality assisted reproductive procedures such as IVF.</p>
<p>However, unrestrained, unnecessary use of ICSI is a salutary example of why we need to act on widely accepted evidence.</p>
<p>Until now, the fertility industry has promoted <a href="https://www.abc.net.au/radio/programs/pm/ivf-specialists-hit-back-at-four-corners-story-on/7464870">self-regulation</a> over being made to follow government-imposed, evidence-based guidelines of which fertility treatments are needed. And there’s a <a href="https://www.fertstert.org/article/S0015-0282(19)32454-9/fulltext">growing concern</a> the industry is not doing enough to combat unproven and expensive treatments.</p>
<p>Couples with infertility belong to a <a href="https://pubmed.ncbi.nlm.nih.gov/18025030/">very vulnerable group</a> who will do almost anything to achieve a pregnancy. They deserve our dedicated care and evidence-based treatment.</p><img src="https://counter.theconversation.com/content/158227/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Robert Norman is not involved financially in any IVF or fertility clinic </span></em></p><p class="fine-print"><em><span>Ben W. Mol receives funding from NHMRC (Investigatorgrant GNT1176437) Guerbet, and Ferring.
</span></em></p>Our new study shows a widely used fertility treatment, known as ICSI, is no better than standard IVF for most people. Yet, it’s being routinely offered around the world.Robert Norman, Professor of Reproductive and Periconceptual Medicine, The Robinson Institute, University of AdelaideBen W. Mol, Professor of Obstetrics and Gynaecology, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1561152021-04-12T19:19:24Z2021-04-12T19:19:24ZMore kids are being diagnosed with ADHD for borderline (yet challenging) behaviours. Our new research shows why that’s a worry<figure><img src="https://images.theconversation.com/files/388957/original/file-20210311-15-194jg99.jpg?ixlib=rb-1.1.0&rect=1%2C5%2C997%2C660&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/little-asian-hyperactive-difficult-boy-hold-1596946339">from www.shutterstock.com</a></span></figcaption></figure><p>During my daughter’s challenging first year of school, we discovered how much effort it took her to sit and learn.</p>
<p>She was the youngest in her class, placing her at <a href="http://dx.doi.org/10.1056/NEJMoa1806828">higher risk</a> of being diagnosed with <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/attention-deficit-hyperactivity-disorder-adhd">ADHD</a> (attention deficit hyperactivity disorder).</p>
<p>While she struggled with attention and hyperactivity, her problems were always more frustrating than truly impairing. Still, constant battles over finishing tasks, the amount of time (and nerves) spent on a child that needs that extra bit of attention and the anger or sadness on her face made me wonder if we should try to get some support. </p>
<p>Maybe a diagnosis could be a straightforward fix to the problem?</p>
<h2>What’s the problem?</h2>
<p>Increasing awareness of ADHD has led to <a href="https://www.cdc.gov/ncbddd/adhd/timeline.html">consistent rises</a> in the number of children diagnosed with and <a href="https://www.safetyandquality.gov.au/our-work/healthcare-variation/atlas-2018/5-repeat-analyses/56-adhd-medicines-dispensing-17-years-and-under">treated for</a> it, both internationally and in Australia. This would be good if it meant we were getting better at finding, diagnosing and helping children impaired by inattention or hyperactivity. </p>
<p>However, my <a href="http://jamanetwork.com/journals/jamanetworkopen/fullarticle/10.1001/jamanetworkopen.2021.5335?utm_source=For_The_Media&utm_medium=referral&utm_campaign=ftm_links&utm_term=041221">newly published study</a> in JAMA Network Open finds these increases in ADHD diagnoses may be largely due to children like my daughter, whose behaviours fall within a normal (but frustrating) range. I conducted this research with colleagues from the University of Sydney and Bond University.</p>
<p>Our study concluded these children are unlikely to benefit from being labelled with ADHD and may, in fact, be harmed by it. </p>
<p>This surge in diagnoses also results in limited resources being stretched thinner <a href="https://www.smh.com.au/national/nsw/schools-must-prepare-for-50-per-cent-rise-in-students-with-disabilities-report-20200902-p55rrm.html">among more children</a>, ultimately taking away from those with severe problems who would benefit from more support.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-do-i-know-if-my-child-is-developing-normally-129137">How do I know if my child is developing normally?</a>
</strong>
</em>
</p>
<hr>
<h2>What is ADHD? And why is it so controversial?</h2>
<p>ADHD <a href="https://www.cdc.gov/ncbddd/adhd/diagnosis.html">is a</a> “persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development”.</p>
<p>It’s one of the most common childhood disorders, affecting about <a href="https://pubmed.ncbi.nlm.nih.gov/17541055/">5</a>-<a href="https://pediatrics.aappublications.org/content/135/4/e994">7%</a> of children. Over the past decades, debate on the appropriateness of diagnoses has grown in line with the rate of diagnosis.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/388966/original/file-20210311-18-1r1bx4v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Anonymous child holding up ADHD label" src="https://images.theconversation.com/files/388966/original/file-20210311-18-1r1bx4v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/388966/original/file-20210311-18-1r1bx4v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/388966/original/file-20210311-18-1r1bx4v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/388966/original/file-20210311-18-1r1bx4v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/388966/original/file-20210311-18-1r1bx4v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/388966/original/file-20210311-18-1r1bx4v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/388966/original/file-20210311-18-1r1bx4v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Being labelled with ADHD has consequences, both positive and negative, so it’s important to get the diagnosis right.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-boy-holds-adhd-text-written-507420409">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>Allen Frances, a prominent American psychiatrist, has been one of the most vocal critics of the trend. He <a href="https://www.cochrane.org/news/recommended-dose-episode-2-dr-allen-frances">describes it</a> as the medicalisation of “every day experiences that are part of the human condition”. </p>
<p>However, others suggest the increases in diagnosed children are largely due to <a href="https://knowablemagazine.org/article/mind/2020/adhd-in-girls-and-women">improved detection</a> in previously undiagnosed children. </p>
<p><a href="https://www.huffpost.com/entry/conclusive-proof-adhd-is-overdiagnosed_b_10107214">Both</a> <a href="https://www.washingtonpost.com/national/health-science/adhd-numbers-are-rising-and-scientists-are-trying-to-understand-why/2018/09/07/a918d0f4-b07e-11e8-a20b-5f4f84429666_story.html">sides</a> of the debate claim to have proof. But we were surprised to discover no-one had ever summarised the scientific evidence for the key reasons behind increasing diagnosis rates.</p>
<p>So we reviewed the results from over 300 studies on ADHD over the past 40 years to determine which children are being newly diagnosed and if they benefit. Our <a href="https://theconversation.com/five-warning-signs-of-overdiagnosis-110895">study design</a> allowed us to summarise a huge variety of studies in a way not done before.</p>
<h2>What we did and what we found</h2>
<p>We found that since the 1980s, increasing numbers of school-aged children and adolescents around the world have been diagnosed with ADHD and medicated for it.</p>
<p>We know ADHD-related behaviours exist on <a href="https://pubmed.ncbi.nlm.nih.gov/27965331/">a spectrum</a> with no or minimal hyperactivity and inattention on one end and severe ADHD on the other.</p>
<p>Many children can get distracted easily, are forgetful, find it difficult to sit still or wait their turn. In most children, these behaviours are mild enough to not interfere with a “normal” life. </p>
<p>However, there is no clear biological cut-off point above which someone just “has” ADHD. Ways of diagnosing ADHD also vary between countries and change over time, with criteria generally becoming less stringent.</p>
<p>Together, this ensures many potentially new cases could be discovered, depending on how low the bar is set.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/five-warning-signs-of-overdiagnosis-110895">Five warning signs of overdiagnosis</a>
</strong>
</em>
</p>
<hr>
<p><a href="http://dx.doi.org/10.1016/j.jaac.2013.09.001">In the US</a>, for example, almost half of all children diagnosed with ADHD have mild symptoms, with only around 15% presenting with severe problems. Only about <a href="http://dx.doi.org/10.1017/S2045796014000523">1% of all children</a> in an Italian study had severe ADHD-related behaviours. And, in general, children today are <a href="https://pubmed.ncbi.nlm.nih.gov/26084287/">no more hyperactive or inattentive</a> than 20 years ago.</p>
<p>All this led us to conclude a substantial proportion of these additional diagnoses (children who would not have been diagnosed 20 years ago) are, at best, borderline cases. </p>
<p>For example, <a href="https://pubmed.ncbi.nlm.nih.gov/29484650/">one study</a> shows while diagnoses increased more than five-fold over ten years in Sweden, there was no increase in clinical ADHD symptoms over the same time. This means that with the lowering of the diagnostic bar, children diagnosed with ADHD are, on average, <a href="https://www.sciencedirect.com/science/article/pii/S1566277205000770">less impaired</a> and more similar to those without an ADHD diagnosis.</p>
<p>As a result children like my daughter, who are <a href="http://dx.doi.org/10.1016/S2215-0366%2817%2930394-2">the youngest in their class</a>, are at risk of being labelled with ADHD because their relative immaturity can be enough to push them over the threshold into the zone of “abnormal” behaviour.</p>
<h2>Why it’s important to get it right</h2>
<p><strong>For children with mild symptoms</strong></p>
<p>Children with mild ADHD symptoms are unlikely to benefit from a diagnosis. They (and their families) also incur <a href="https://www.abc.net.au/news/2021-03-17/adhd-report-reveals-huge-financial-costs-challenges-families/13255902">substantial costs</a> as well as potential harms from the diagnosis and treatment. That’s because:</p>
<ul>
<li><p>instead of drumming up extra support, an ADHD label can have <a href="https://doi.org/10.1177/0038040720909296">negative</a> social, psychological and academic effects, when compared to similar young people without a diagnosis</p></li>
<li><p>medication <a href="https://doi.org/10.1097/00004583-200405000-00009">reduces symptoms to a lesser extent</a> in children with mild ADHD (however it is beneficial in many severe cases)</p></li>
<li><p>medication for young people with milder symptoms also has no positive, but a potential negative, effect on <a href="http://dx.doi.org/10.1016/j.ssresearch.2016.06.018">academic outcomes</a> (such as maths and reading scores) when compared to unmedicated young people with similar behaviour. Also, medication doesn’t reduce the risks of <a href="https://dx.doi.org/10.1016/j.jhealeco.2014.05.005">injuries, criminal behaviour</a> and <a href="https://doi.org/10.1016/j.cnr.2005.09.010">social impairment</a> as much as in those with severe symptoms.</p></li>
</ul>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/weekly-dose-ritalin-helpful-for-many-with-adhd-but-dangerous-if-abused-by-those-without-it-67704">Weekly Dose: Ritalin, helpful for many with ADHD but dangerous if abused by those without it</a>
</strong>
</em>
</p>
<hr>
<p><strong>For children with severe symptoms</strong></p>
<p>It’s also important children with more severe ADHD symptoms are correctly diagnosed so they don’t miss out on much-needed support.</p>
<p>With <a href="https://www.smh.com.au/national/nsw/schools-must-prepare-for-50-per-cent-rise-in-students-with-disabilities-report-20200902-p55rrm.html">ever-increasing diagnosis rates</a> of ADHD, schools are increasingly struggling to adequately support every child with a diagnosis: the slice of funding and support every child can receive gets smaller and smaller, the more children are included. </p>
<p>In turn, this often means those with the most severe problems <a href="https://www.smh.com.au/education/caught-in-a-vice-why-one-in-four-students-with-adhd-has-been-suspended-20190429-p51i7p.html">get left behind</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/adhd-prescriptions-are-going-up-but-that-doesnt-mean-were-over-medicating-108474">ADHD prescriptions are going up, but that doesn't mean we're over-medicating</a>
</strong>
</em>
</p>
<hr>
<h2>What can we do?</h2>
<p>In light of the potential risks associated with diagnosing a child with milder ADHD symptoms, we recommend doctors, parents and teachers work together following a “<a href="https://pubmed.ncbi.nlm.nih.gov/24847990/">stepped diagnosis approach</a>”. This ensures swift and efficient diagnosis and treatment in severe cases. For those with milder symptoms, taking some time to watch and wait may mean many of them won’t need to be labelled or treated.</p>
<p>Not only will this avoid potential harm for individual children, it also ensures resources are allocated where they are needed most and will be most effective.</p>
<hr>
<p><em>Co-authors on this article were: <a href="https://theconversation.com/profiles/alexandra-barratt-6143">Alexandra Barratt</a>, Professor of Public Health, University of Sydney; <a href="https://theconversation.com/profiles/katy-bell-134554">Katy Bell</a>, Associate Professor in Clinical Epidemiology, Sydney School of Public Health, University of Sydney; and <a href="https://theconversation.com/profiles/rae-thomas-12031">Rae Thomas</a>, Associate Professor, Bond University.</em></p><img src="https://counter.theconversation.com/content/156115/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Luise Kazda receives funding from the National Health and Medical Research Council (NHMRC). She'd like to acknowledge Alexandra Barratt, Katy Bell, and Rae Thomas who co-authored this article.</span></em></p>How do you know if your child’s behaviour is normal or a sign of ADHD? The answer is not so clear cut. And now we have the evidence to show the consequences.Luise Kazda, PhD candidate, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1579582021-04-04T20:36:35Z2021-04-04T20:36:35ZHow your doctor describes your medical condition can encourage you to say ‘yes’ to surgery when there are other options<figure><img src="https://images.theconversation.com/files/392709/original/file-20210331-15-vdznal.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C6240%2C4156&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>There are many factors that influence whether you choose to have surgery for a health condition.</p>
<p>But one you might not have considered is the very name your doctor uses to describe your condition can make you more or less likely to go under the knife, according to a growing body of research.</p>
<p>This is concerning because there are often less invasive options than surgery that are equally effective and safer.</p>
<h2>What’s in a name?</h2>
<p>Let’s take shoulder pain as an example.</p>
<p>Three of us (Joshua, Mary and Giovanni) <a href="https://doi.org/10.2519/jospt.2021.10375">published new research</a> last week finding health professionals’ use of certain medical terms might be encouraging patients to say yes to unnecessary shoulder surgery.</p>
<p>Our world-first trial involved 1,308 people from five countries, some with and without shoulder pain, who were randomly allocated to read one of six hypothetical scenarios. The only difference between the scenarios was the medical term used by the health professional to describe the person’s shoulder pain.</p>
<p>In our study, we used the <a href="https://pubmed.ncbi.nlm.nih.gov/25560729">most common type of shoulder pain</a> where people feel pain at the front of one of their shoulders which is made worse by lifting the arm and lying on it.</p>
<figure class="align-center ">
<img alt="Man holding is shoulder in pain at the gym" src="https://images.theconversation.com/files/392710/original/file-20210331-15-1qglsfu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/392710/original/file-20210331-15-1qglsfu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/392710/original/file-20210331-15-1qglsfu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/392710/original/file-20210331-15-1qglsfu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/392710/original/file-20210331-15-1qglsfu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/392710/original/file-20210331-15-1qglsfu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/392710/original/file-20210331-15-1qglsfu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">There’s an abundance of terms for common shoulder pain, and it’s often difficult to determine what the specific cause is.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>Health professionals use a <a href="https://pubmed.ncbi.nlm.nih.gov/27806952/">variety of terms</a> for this pain, including “subacromial impingement syndrome”, “rotator cuff tear”, “bursitis”, and “rotator cuff related shoulder pain”.</p>
<p>The terms doctors use vary so widely because it’s currently impossible to pinpoint the exact cause of most shoulder pain, even <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6099421">with the help</a> of <a href="https://pubmed.ncbi.nlm.nih.gov/28122541">sophisticated technology</a> such as magnetic resonance imaging (MRI).</p>
<p>We found people told they had a “rotator cuff tear” wanted shoulder surgery the most. Those told they had “bursitis” (inflammation of a fluid-filled sac in the shoulder) wanted surgery the least. People told they had a rotator cuff tear had 24% higher perceived need for surgery than those told they had bursitis.</p>
<h2>Unnecessary shoulder surgery is a growing problem</h2>
<p>The use of surgery for common types of shoulder pain <a href="https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-015-0639-6">is</a> <a href="https://pubmed.ncbi.nlm.nih.gov/24395314/">increasing</a> <a href="https://pubmed.ncbi.nlm.nih.gov/23375667/">worldwide</a>, including <a href="https://pubmed.ncbi.nlm.nih.gov/27490156">in Australia</a>.</p>
<p>Yet some shoulder surgery provides limited benefit to patients. <a href="https://pubmed.ncbi.nlm.nih.gov/29169668/">One such example</a> is a type of surgery called “subacromial decompression”, which involves reducing pressure on a tendon by removing surrounding tissue. This procedure is no better than placebo surgery (where patients were put to sleep and researchers only conducted a joint examination, rather than surgery). </p>
<p>Other surgeries to repair torn tendons <a href="https://pubmed.ncbi.nlm.nih.gov/31813166">provide</a> little or no benefit compared with non-surgical treatments such as exercise.</p>
<p>Also, there’s no reliable way to determine that a rotator cuff tear is the cause of a patient’s symptoms. <a href="https://www.sciencedirect.com/science/article/abs/pii/S1058274614004480">Up to 21%</a> of people aged 30-39 years who don’t have any shoulder symptoms have rotator cuff tears when they are scanned.</p>
<p><a href="http://medicarestatistics.humanservices.gov.au/statistics/mbs_item.jsp">More than 20,000</a> potentially unnecessary shoulder surgeries are performed in Australia each year, which we estimate to cost <a href="https://pubmed.ncbi.nlm.nih.gov/27490156/">over A$200 million</a> per year. </p>
<p>Use of surgery is also increasing across many other conditions. For example, <a href="https://www.mja.com.au/journal/2018/208/8/increasing-rates-anterior-cruciate-ligament-reconstruction-young-australians">knee reconstructions</a> for anterior cruciate ligament (ACL) ruptures, and spinal fusions for some <a href="https://pubmed.ncbi.nlm.nih.gov/28441309/">spinal conditions</a>. However, evidence suggests surgery is <a href="https://www.nejm.org/doi/full/10.1056/nejmoa0907797">not superior</a> <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/imj.14120?fbclid=IwAR3BjuVv-t8jNFL_KnfZz1AtkFX7ue0gZ_dNl4f2jHGyff8J_iE7bRmWwN4">to non-surgical management</a> for either of these surgeries.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/australians-are-undergoing-unnecessary-surgery-heres-what-we-can-do-about-it-46089">Australians are undergoing unnecessary surgery – here's what we can do about it</a>
</strong>
</em>
</p>
<hr>
<h2>What about other conditions?</h2>
<p>Our study adds to <a href="https://bmjopen.bmj.com/content/bmjopen/7/7/e014129.full.pdf">increasing evidence</a> showing the name your doctor uses to describe your condition can encourage you to consider unnecessary treatments.</p>
<p><strong>Low-risk “cancer”</strong></p>
<p>There’s a type of abnormal breast cells that can build up in the milk ducts called “ductal carcinoma in situ”. For many people, these cells are low-risk and won’t grow, or grow so slowly they’ll never cause harm.</p>
<p>Using the terms “cancer” or “carcinoma” to describe this condition <a href="https://pubmed.ncbi.nlm.nih.gov/26376460">elicits strong</a> <a href="https://bmjopen.bmj.com/content/5/11/e008094.short">negative reactions</a> from patients, and increases their desire for more aggressive treatments, <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1731962">including surgery</a>.</p>
<p>For patients with these low-risk cells, surgery, radiotherapy and/or hormonal treatments <a href="https://www.nytimes.com/2015/08/21/health/breast-cancer-ductal-carcinoma-in-situ-study.html">may not improve overall survival</a>. Instead, these interventions may cause harm through surgical complications such as persistent pain or skin burns, as well as financial costs and the psychological impact of being diagnosed with “cancer”.</p>
<p><strong>Acid reflux</strong></p>
<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3639462/">One study</a> asked parents to consider a hypothetical scenario in which their otherwise healthy infant cries a lot and “spits up excessively”.</p>
<p>It found parents who were told their child had gastroesophageal reflux disease (commonly known as “acid reflux”) were more interested in medication compared to parents who didn’t receive a diagnosis at all. This was true even when parents were told medication wasn’t beneficial. Medication in babies shows <a href="https://pubmed.ncbi.nlm.nih.gov/21464183/">no difference to placebo</a> in reducing these symptoms.</p>
<figure class="align-center ">
<img alt="Baby in bed crying" src="https://images.theconversation.com/files/392711/original/file-20210331-17-ahi982.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/392711/original/file-20210331-17-ahi982.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/392711/original/file-20210331-17-ahi982.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/392711/original/file-20210331-17-ahi982.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/392711/original/file-20210331-17-ahi982.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/392711/original/file-20210331-17-ahi982.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/392711/original/file-20210331-17-ahi982.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Hearing your baby might have a scary-sounding reflux disease can increase the likelihood you request medication.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p><strong>‘Pink-eye’</strong></p>
<p>A <a href="https://journals.sagepub.com/doi/abs/10.1177/0009922815601983">similar study</a> presented a hypothetical scenario to parents about viral conjunctivitis. One group of parents were told their kids had “pink-eye”, and another were told their kids had an “eye infection”. </p>
<p>Parents told their children had “pink-eye” remained interested in antibiotics despite being told the medications were ineffective. Conversely, parents told their children had an “eye infection” became significantly less interested in antibiotics when told they were ineffective.</p>
<p>Parents given the “pink-eye” label perceived the infection as more contagious than those given the “eye infection” label, even though both are simply other ways of saying conjunctivitis.</p>
<p><strong>Polycystic ovary syndrome</strong></p>
<p>This is a common hormonal condition affecting many women. But <a href="https://theconversation.com/4-myths-about-polycystic-ovary-syndrome-and-why-theyre-wrong-131908">symptoms</a> are on a spectrum of severity, with no clear line separating normal from abnormal.</p>
<p><a href="https://academic.oup.com/humrep/article/32/4/876/3003211">One study</a> found young women told their symptoms indicated “polycystic ovary syndrome” — in a hypothetical scenario of a doctor’s visit — were more likely to want further medical testing than those given the term “hormonal imbalance”. These women also perceived their condition to be more severe and had lower self-esteem.</p>
<h2>What should health professionals do?</h2>
<p>It’s vital health professionals consider whether the terms they use to describe a condition might be causing unnecessary fear and anxiety, and leading patients to consider unnecessary tests and treatments.</p>
<p>Health professionals may find it challenging to avoid terms they’ve been using for many years. But the potential cost of increasing patient’s fear and anxiety, and making people feel they need surgery when they don’t, cannot be ignored.</p>
<p>Changing how health professionals describe conditions to their patients is a simple strategy that could curb the rise of unnecessary health care.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1026460631724187648"}"></div></p>
<p>For patients with shoulder pain not caused by severe trauma, we suggest health professionals avoid telling patients they have rotator cuff tears as this may make some patients think shoulder surgery is needed (which it isn’t).</p>
<p>Health professionals could instead label people with this type of shoulder pain as having bursitis (inflammation), as this was the label that mostly made people think surgery was unnecessary.</p><img src="https://counter.theconversation.com/content/157958/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Joshua Zadro receives fellowship funding from The National Health and Medical Research Council (NHMRC). </span></em></p><p class="fine-print"><em><span>Brooke Nickel receives fellowship funding from The National Health and Medical Research Council (NHMRC). </span></em></p><p class="fine-print"><em><span>Mary O'Keeffe has received funding from the European Commission. </span></em></p><p class="fine-print"><em><span>Tessa Copp receives funding from the NHMRC Centre for Research Excellence in Creating Sustainable Healthcare. </span></em></p><p class="fine-print"><em><span>Giovanni E Ferreira does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Health professionals should carefully consider the terms they use to avoid needless anxiety and unnecessary surgeries.Joshua Zadro, NHMRC Emerging Leader Research Fellow, University of SydneyBrooke Nickel, NHMRC Emerging Leader Research Fellow, University of SydneyGiovanni E Ferreira, Postdoctoral research fellow, University of SydneyMary O'Keeffe, Postdoctoral Research Fellow, University of SydneyTessa Copp, Postdoctoral research fellow, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1560292021-02-25T04:52:20Z2021-02-25T04:52:20ZTiger Woods’ car crash injuries explained, according to a trauma surgeon<p>Tiger Woods’ medical team has <a href="https://twitter.com/TigerWoods/status/1364447580520738820/photo/1">released a statement on Twitter</a> to explain the injuries he sustained <a href="https://edition.cnn.com/2021/02/23/us/tiger-woods-car-accident-intl-spt/index.html">in his car crash</a> earlier this week.</p>
<p>The statement was from the Harbor-UCLA Medical Center, a trauma centre, where golfer Woods was taken for emergency treatment after the <a href="https://www.espn.co.uk/golf/story/_/id/30951717/tiger-woods-hospitalized-vehicle-rolls-crash">single-vehicle accident</a>.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1364738492778090497"}"></div></p>
<p>I’m a practising orthopaedic surgeon specialising in trauma surgery and I lecture nationally and internationally on the orthopaedic treatment of fractures. </p>
<p>Here’s my explanation of some of the technical terms in the statement, and what this might mean for Woods’ recovery.</p>
<h2>What were his injuries?</h2>
<p>It appears from the statement his injuries were confined to his right lower leg. This may appear surprising to many who have seen the footage of the accident and heard that his vehicle rolled over. </p>
<p>However, it is common these days to have people admitted after bad car accidents with only injuries to their lower leg. This is because of seat belts, airbags and vehicle construction. These have done a lot to prevent the previously common facial injuries (from windscreens and steering wheels) and head, chest and abdominal injuries.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/smallpox-seatbelts-and-smoking-3-ways-public-health-has-saved-lives-from-history-to-the-modern-day-128300">Smallpox, seatbelts and smoking: 3 ways public health has saved lives from history to the modern day</a>
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<p>The statement says he had “comminuted open fractures affecting both the upper and lower portions of the tibia and fibula”.</p>
<p>Let me break that down. “<a href="https://medlineplus.gov/ency/imagepages/1096.htm">Comminuted</a>” means the bones had broken into many fragments, the opposite of a “simple” fracture where the bone breaks into two parts. </p>
<p>The “upper and lower portions” suggests he has what is called a “<a href="https://pssjournal.biomedcentral.com/articles/10.1186/s13037-015-0086-1/figures/13">segmental</a>” fracture, where the bone is broken in two separate locations.</p>
<p>The comminuted and segmental nature of the injury is not unexpected after high-energy injuries like car accidents and doesn’t change the treatment too much.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/curious-kids-why-do-we-have-bones-90246">Curious Kids: Why do we have bones?</a>
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<p>People place a lot of importance on how many pieces bones are broken into, but as long as the bones heal, they all end up in one piece regardless of how many pieces there were to start with. </p>
<p>The fact that it was a bad fracture, however, means it might be harder to get it to heal and that it might take longer. </p>
<p>“<a href="https://orthoinfo.aaos.org/en/diseases--conditions/open-fractures/">Open</a>” fractures mean the skin overlying the broken bone was broken. The main concern is that having an open fracture increases the risk of infection. However, given Woods remained in the vehicle (he had to be broken out of it with special equipment), there is unlikely to be any dirt or highly contaminated material involved.</p>
<h2>How did doctors treat his injuries?</h2>
<p>The tibia and fibula are the two bones that link the knee to the ankle, the tibia being the much larger, main bone. His tibia and fibula were “stabilized by inserting a rod into the tibia”. </p>
<p>It is routine to treat fractures like this with a rod inserted inside the bone from top to bottom to line it up. The rod only needs to go into the tibia because the fibular usually follows the tibia into alignment, as the two bones are connected.</p>
<p>The statement also said that trauma to the soft-tissues of the leg required “surgical release of the covering of the muscles to relieve pressure due to swelling”. </p>
<p>This refers to a procedure called a <a href="https://www.ncbi.nlm.nih.gov/books/NBK556153/">fasciotomy</a> which is performed for actual or impending “<a href="https://orthoinfo.aaos.org/en/diseases--conditions/compartment-syndrome/">compartment syndrome</a>” — a build-up of pressure in the leg.</p>
<p>We do not have information on whether the muscle was damaged as a result of the increased pressure (in which case there could be permanent weakness) or whether the muscle is intact. If the fasciotomy was done early and adequately, it is likely there will be no permanent muscle damage.</p>
<h2>Will he recover?</h2>
<p>The interesting thing about Woods’ injuries is that, while the “open” and “comminuted” fractures of the tibia and fibula sound very bad, if he can avoid the early problem of infection, these injuries on their own do not necessarily mean that he will have any permanent problems. </p>
<p>Once healed, the leg can potentially be just as straight and strong as it was before. Muscles can be strengthened and skin and bones usually heal.</p>
<p>The point of most concern relating to his long-term function is the part of the statement that said: “additional injuries to the bones of the foot and ankle were stabilized with a combination of screws and pins”. </p>
<p>Injuries that involve the joints — the parts where one bone joins another bone — are the ones that commonly lead to long-term problems. This is especially the case in the foot and ankle, as these joints take our whole body weight when walking. And these joints allow us to not only walk normally, but also swing a golf club. </p>
<p>If, for example, he has fractures that involve the ankle joint or any of the foot joints, this can result in permanent loss of flexibility and pain on walking.</p>
<h2>Did Woods get special treatment?</h2>
<p>People may be wondering if Woods got <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC315491/">special treatment, or was even overtreated</a>, which is something that can occur with famous people, and when people seek treatment and have the resources to pay for it. </p>
<p>With trauma though, particularly the type of trauma in this case, the treatment usually follows fairly standard practice. Although some surgeons and hospitals vary in exactly how they treat certain injuries, the management of these lower limb injuries is fairly uniform. So it is unlikely he was treated differently to any other patient who would present to that hospital.</p><img src="https://counter.theconversation.com/content/156029/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ian Harris does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Once his leg fracture heals, his leg can potentially be just as straight and strong as it was before. But his foot and ankle are more of a worry.Ian Harris, Professor of Orthopaedic Surgery, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1362592020-04-16T03:04:47Z2020-04-16T03:04:47ZHospitals have stopped unnecessary elective surgeries – and shouldn’t restart them after the pandemic<figure><img src="https://images.theconversation.com/files/328245/original/file-20200416-140729-1f1dm3w.jpg?ixlib=rb-1.1.0&rect=62%2C161%2C5928%2C3206&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/illness-asia-patient-women-hospital-concept-546904408">Shutterstock</a></span></figcaption></figure><p>Part of Australia’s response to the coronavirus pandemic was a severe reduction in elective surgery, and so private hospitals have stood almost empty for a month now. </p>
<p>People who might otherwise have had a procedure are experiencing <a href="https://www.cancer.gov/publications/dictionaries/cancer-terms/def/watchful-waiting">“watchful waiting”</a>, where their condition is monitored to assess how it develops rather than having a surgical procedure. </p>
<p>The big question is whether all those procedures which didn’t happen were even necessary. There has now been a steady stream of work which suggests many procedures don’t provide any benefits to patients at all – so called low- or no-value care.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/dodgy-treatment-its-not-us-its-the-other-lot-say-the-experts-so-who-do-we-believe-124638">Dodgy treatment: it's not us, it's the other lot, say the experts. So who do we believe?</a>
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<p>Bringing about change in health policy is usually difficult (or slow, at best) because it’s like turning a big ship around. But in the past six weeks that ship has made a sudden about-turn. </p>
<p>Australia’s elective procedure system after the pandemic should be different from before the pandemic. We should dramatically reduce the number of low- or no-value procedures.</p>
<h2>What is low- or no-value health care?</h2>
<p><a href="https://www.thelancet.com/series/right-care">Low- or no-value health care</a> mean the intervention provides no or very little benefit to patients, or where the risk of harm exceeds the likely benefit. </p>
<p>Reducing such “care” <a href="https://onlinelibrary.wiley.com/doi/abs/10.5694/mja14.01664">will improve</a> both health outcomes for patients and the efficiency of the health system.</p>
<p>Research in New South Wales public hospitals <a href="https://qualitysafety.bmj.com/content/28/3/205">showed up to 9,000 low-value operations were performed in just one year</a>, and these consumed almost 30,000 hospital bed days that could have been used for high-value care. </p>
<p>One example of low-value care is <a href="https://theconversation.com/needless-treatments-spinal-fusion-surgery-for-lower-back-pain-is-costly-and-theres-little-evidence-itll-work-91829">spinal fusion surgery for low back pain</a>. This is <a href="https://orthoinfo.aaos.org/en/treatment/spinal-fusion/">a procedure on the small bones in the spine</a>, essentially welding them together. The alternative is pain management, physiotherapy and exercise.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/328250/original/file-20200416-140697-1gryh4z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/328250/original/file-20200416-140697-1gryh4z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=421&fit=crop&dpr=1 600w, https://images.theconversation.com/files/328250/original/file-20200416-140697-1gryh4z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=421&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/328250/original/file-20200416-140697-1gryh4z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=421&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/328250/original/file-20200416-140697-1gryh4z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=529&fit=crop&dpr=1 754w, https://images.theconversation.com/files/328250/original/file-20200416-140697-1gryh4z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=529&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/328250/original/file-20200416-140697-1gryh4z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=529&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Spinal fusion for low back pain is an example of low-value care.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/man-has-low-back-pain-789555475">Shutterstock</a></span>
</figcaption>
</figure>
<p>The <a href="https://qualitysafety.bmj.com/content/28/3/205">NSW analysis revealed</a> up to 31% of all spinal fusions were inappropriate. But even this figure is likely an <a href="https://qualitysafety.bmj.com/content/early/2020/03/12/bmjqs-2019-010564">underestimate</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/needless-treatments-spinal-fusion-surgery-for-lower-back-pain-is-costly-and-theres-little-evidence-itll-work-91829">Needless treatments: spinal fusion surgery for lower back pain is costly and there's little evidence it'll work</a>
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<hr>
<p>Other <a href="https://theconversation.com/australians-are-undergoing-unnecessary-surgery-heres-what-we-can-do-about-it-46089">examples include</a>:</p>
<ul>
<li><p>vertebroplasty for osteoporotic spinal fractures: surgery to fill a backbone (vertebrae) with cement</p></li>
<li><p>knee arthroscopy for osteoarthritis: inserting a tube to remove tissue</p></li>
<li><p>laparoscopic uterine nerve ablation for chronic pelvic pain: surgery to destroy a ligament that contains nerve fibres</p></li>
<li><p>removing healthy ovaries during a hysterectomy</p></li>
<li><p>hyperbaric oxygen therapy (breathing pure oxygen in a pressurised room) for a range of conditions including osteomyelitis (inflammation of the bone), cancer, and non-diabetic wounds and ulcers.</p></li>
</ul>
<p>Low-value care can harm patients because of the risks inherent in any procedure. If a patient having a low-value procedure gets even one complication, the time they spend in hospital <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2725081">doubles, on average</a>.</p>
<p>For some patients, the hospital stay can be much longer. For example, a low-value <a href="https://www.healthdirect.gov.au/arthroscopy">knee arthroscopy</a> with no complications consumes one bed day. If a complication occurs, that length of stay <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2725081">increases to 11 days</a>, on average. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/needless-procedures-knee-arthroscopy-is-one-of-the-most-common-but-least-effective-surgeries-102705">Needless procedures: knee arthroscopy is one of the most common but least effective surgeries</a>
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</em>
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<hr>
<p>For most low-value procedures, the most common complication is infection.</p>
<p>The situation is even worse in private hospitals, where a <a href="https://treasury.gov.au/sites/default/files/2019-03/private_healthcare_australia.pdf">much greater proportion of elective procedures are low value</a>.</p>
<h2>Prioritise treatments that work</h2>
<p>Most state health departments and private insurers now know the size of the low-value care problem and which hospitals are providing that “care”. </p>
<p>Due to the COVID-19 response, the tap for these procedures has been turned down for some and off for others. This is a <a href="https://theconversation.com/the-coronavirus-ban-on-elective-surgeries-might-show-us-many-people-can-avoid-going-under-the-knife-135325">risk for some patients</a>, but others will benefit from not having the surgery. We must grasp the opportunity to learn from this enforced break.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-coronavirus-ban-on-elective-surgeries-might-show-us-many-people-can-avoid-going-under-the-knife-135325">The coronavirus ban on elective surgeries might show us many people can avoid going under the knife</a>
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</p>
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<p>One of the challenges for policymakers in the past in controlling low-value care has been <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)30947-3/fulltext">difficulty in ratcheting down supply</a> by reducing or redirecting a hospital’s surgical capacity and staff. </p>
<p>In many ways, the COVID-19 response has done this for them. After the pandemic, we can reassess and reorient to high-value care.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/328248/original/file-20200416-140711-qfur1o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/328248/original/file-20200416-140711-qfur1o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/328248/original/file-20200416-140711-qfur1o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/328248/original/file-20200416-140711-qfur1o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/328248/original/file-20200416-140711-qfur1o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/328248/original/file-20200416-140711-qfur1o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/328248/original/file-20200416-140711-qfur1o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Some people will need catch-up surgeries after the pandemic, but some won’t.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/recovery-room-beds-comfortable-medical-interior-1406833052">Shutterstock</a></span>
</figcaption>
</figure>
<p>This does not necessarily mean reducing capacity. Some people aren’t currently getting the care they need. When the tap comes back on, this unmet backlog of care must be performed. </p>
<p>But this needn’t detract from a focused effort to keep the low-value care from re-emerging. The last thing we need is for low-value care to take the place of high-value care that has been delayed because of the COVID-19 response.</p>
<h2>So how do you do it?</h2>
<p>Australia should take three immediate steps to ensure we don’t return to the bad old days of open slather. </p>
<p>First, <a href="https://grattan.edu.au/report/questionable-care-avoiding-ineffective-treatment/">states should start reporting the rates of low-value care</a>, using established measures. This reporting should identify every relevant hospital – public and private – and it should be retrospective, showing rates for the past few years. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/australians-are-undergoing-unnecessary-surgery-heres-what-we-can-do-about-it-46089">Australians are undergoing unnecessary surgery – here's what we can do about it</a>
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</em>
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<hr>
<p>Second, states should require all public hospitals to take steps to limit low-value care – and hospitals that don’t comply should be called to account. </p>
<p>States have the insights and data necessary to do this. </p>
<p>Hospital strategies might include requiring a second opinion from another specialist before a procedure identified as low-value care is scheduled for surgery, or a retrospective review of decisions to perform such surgery.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/328249/original/file-20200416-140706-1yhzqyn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/328249/original/file-20200416-140706-1yhzqyn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/328249/original/file-20200416-140706-1yhzqyn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/328249/original/file-20200416-140706-1yhzqyn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/328249/original/file-20200416-140706-1yhzqyn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/328249/original/file-20200416-140706-1yhzqyn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/328249/original/file-20200416-140706-1yhzqyn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Hospitals could require second opinions before scheduling low-value procedures.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/many-people-waiting-room-see-doctor-778331905">Shutterstock</a></span>
</figcaption>
</figure>
<p>In the post-pandemic world, states should also consolidate elective surgery, so the number of centres performing elective procedures in metropolitan areas is reduced, with decision-making tools to highlight downsides of low-value care and the alternatives. </p>
<p>Third, private insurers know low-value care is provided in private hospitals, but currently have fewer levers at their disposal to reduce such care. The Commonwealth government should legislate to empower funds to address this issue. Given the Commonwealth government is providing financial support to the private hospitals during their downturn, perhaps a requirement should be that they work with the insurers and Medicare to police the re-emergence of low-value care. </p>
<p>It would be a dreadful shame to waste this unprecedented opportunity, and revert to the old status quo of low- and no-value care.</p><img src="https://counter.theconversation.com/content/136259/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Adam Elshaug receives sitting fees from the Australian government as a member of the Medicare Benefits Schedule (MBS) Review Taskforce and as an advisor to Cancer Australia. He is a Board Member of the NSW Bureau of Health Information (BHI), and has consulted to provide low-value care related analyses and advice to the Australian Department of Veterans Affairs, Private Healthcare Australia, and the NSW, Queensland, Victoria and South Australia state health departments. He holds a HCF Research Foundation Professorial Fellowship which is paid to The University of Sydney and is a Chief Investigator on NHMRC grants.</span></em></p><p class="fine-print"><em><span>Grattan Institute began with contributions to its endowment of $15 million from each of the Federal and Victorian Governments, $4 million from BHP Billiton, and $1 million from NAB. In order to safeguard its independence, Grattan Institute’s board controls this endowment. The funds are invested and contribute to funding Grattan Institute's activities. Grattan Institute also receives funding from corporates, foundations, and individuals to support its general activities, as disclosed on its website. </span></em></p>Elective surgeries have been halted as part of the health system’s response to coronavirus. But many are unnecessary and shouldn’t be rescheduled after the pandemic ends.Adam Elshaug, HCF Research Foundation Professorial Fellow, Professor in Health Policy and Co-Director, Menzies Centre for Health Policy, University of SydneyStephen Duckett, Director, Health Program, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1353252020-04-08T04:35:11Z2020-04-08T04:35:11ZThe coronavirus ban on elective surgeries might show us many people can avoid going under the knife<figure><img src="https://images.theconversation.com/files/326002/original/file-20200407-36391-1qxwlzw.jpg?ixlib=rb-1.1.0&rect=0%2C7%2C5066%2C2866&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>As part of the government’s response to the COVID-19 pandemic, all elective surgeries <a href="https://www.abc.net.au/news/2020-03-26/coronavirus-what-do-the-changes-to-elective-surgery-mean-for-you/12091804">across Australia</a> have been temporarily cancelled. </p>
<p>Elective surgery is non-urgent surgery people choose (elect) to have: things like cataract surgery, joint replacement, tonsillectomy, hernia repair and cosmetic surgery. </p>
<p>There are <a href="https://www.aihw.gov.au/reports/hospitals/hospitals-at-a-glance-2017-18/contents/surgery-in-australias-hospitals">more than two million</a> hospital admissions involving elective surgery in Australia each year; two-thirds in private hospitals and one-third in public hospitals. Accordingly, elective surgeries make up a huge part of overall health expenditure. </p>
<p>So when they stop all of a sudden, it’s a big deal.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/private-hospitals-get-grace-period-before-freeze-on-non-urgent-elective-surgery-134684">Private hospitals get grace period before freeze on non-urgent elective surgery</a>
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</em>
</p>
<hr>
<h2>What does this mean for patients?</h2>
<p>People who were booked in for surgery will simply have to wait. Because their surgery was deemed non-urgent, this might not be too bad if the shutdown lasts for six weeks. But what if it lasts for six months?</p>
<p>Private patients will face delays that are probably less than the usual waiting lists in public hospitals (up to <a href="https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2012_011.pdf">12 months</a> for elective surgery), but public patients may have to wait even longer. </p>
<p>This large scale halt on elective surgeries is unprecedented, so we don’t have any data on what kinds of consequences we might expect. But <a href="https://www.ncbi.nlm.nih.gov/pubmed/26013773">research suggests</a> people who wait for surgery can deteriorate proportional to the length of time they wait. So a few risks come to mind.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/326316/original/file-20200408-108526-1cub5u0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/326316/original/file-20200408-108526-1cub5u0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/326316/original/file-20200408-108526-1cub5u0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/326316/original/file-20200408-108526-1cub5u0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/326316/original/file-20200408-108526-1cub5u0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/326316/original/file-20200408-108526-1cub5u0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/326316/original/file-20200408-108526-1cub5u0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">People waiting for elective surgeries may have to cope for longer with restricted mobility and pain.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>Patients may need to rely on strong pain medications for a longer time, and could be more likely to become dependent on these.</p>
<p>Older people in particular may have to cope for longer with restricted mobility while waiting for a hip replacement. Or they may be at increased risk of falls due to poor eyesight while waiting to have their cataracts fixed.</p>
<p>So while this move has been designed to reduce pressure on our hospitals, we may end up with more acute presentations to emergency departments.</p>
<h2>It’s not all bad news</h2>
<p>Some people, however, might find their condition improves. While cataracts won’t clear up on their own, many elective procedures are done for conditions that can improve without surgery. </p>
<p>My area of specialty is orthopaedics, the branch of surgery concerned with conditions involving the musculoskeletal system. </p>
<p>In all <a href="https://academic.oup.com/painmedicine/article/18/4/736/2924731">recent</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/24369076">studies</a> where researchers have tested common <a href="https://bjsm.bmj.com/content/51/24/1759">elective orthopaedic surgical procedures</a> <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30778-5/fulltext">against a placebo</a> (just an incision, for example), the improvement in symptoms has been <a href="https://www.bmj.com/content/362/bmj.k2860">quite good</a>, regardless of whether or not participants had the surgery or the placebo.</p>
<p>My colleagues and I currently have a review <a href="https://journals.lww.com/pain/pages/default.aspx">in press</a> looking at studies where patients have been randomised to surgery or no surgery for chronic musculoskeletal pain. These procedures include spine fusions and decompressions for back and leg pain, carpal tunnel decompression, arthroscopic surgery for shoulder and knee pain, and joint replacement surgery.</p>
<p>We found only 14% of the studies showed surgery was clearly better than not doing the surgery. In most studies it was a toss-up, or the patients who had surgery fared worse.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/surgery-isnt-always-the-best-option-and-the-decision-shouldnt-just-lie-with-the-doctor-64228">Surgery isn't always the best option, and the decision shouldn't just lie with the doctor</a>
</strong>
</em>
</p>
<hr>
<p>Even elective procedures we know to be effective, such as knee replacements, have alternatives. One <a href="https://www.oarsijournal.com/article/S1063-4584(18)31221-4/fulltext">study</a> compared patients who underwent knee replacement surgery to patients who didn’t, where both groups were given a 12-week physiotherapy program.</p>
<p>While the surgery group demonstrated better results, those treated without surgery also improved. And two-thirds had avoided surgery up to two years later.</p>
<p>Maximising patient education about the risks and benefits of treatment options using specially designed “decision aids” is another technique that has <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001431.pub5/full">reduced the uptake</a> of elective surgery.</p>
<p>In New South Wales, education and non-surgical treatment for people on waiting lists for knee replacements has resulted in <a href="https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0008/570869/OACCP-evaluation-feb-2015.pdf">more than 10% of patients</a> coming off the waiting list because of improved symptoms. (<a href="https://ard.bmj.com/content/66/4/433">Weight loss</a> alone can significantly reduce symptoms from knee arthritis.)</p>
<p>Decision aids are not not commonly used for elective surgery in Australia but could be taken up more widely.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/326321/original/file-20200408-156764-krriim.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/326321/original/file-20200408-156764-krriim.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/326321/original/file-20200408-156764-krriim.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/326321/original/file-20200408-156764-krriim.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/326321/original/file-20200408-156764-krriim.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/326321/original/file-20200408-156764-krriim.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/326321/original/file-20200408-156764-krriim.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Surgery isn’t always the only option.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<h2>What will happen after the pandemic?</h2>
<p>We will obviously see an increase in elective surgery once the ban is lifted, but I predict the increase will not equate to the decline during this shutdown.</p>
<p>First, the demand for surgery is generated during surgical consultations, and these have declined considerably.</p>
<p>Second, financial strain will mean people will be less likely to agree to any out of pocket costs, and possibly fewer people will be insured. </p>
<p>Finally, people will realise they might not need the surgery. In effect, we may be “flattening the curve” of post-virus elective surgery partly by realising much of it can be avoided.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-steps-hospitals-can-take-if-coronavirus-leads-to-a-shortage-of-beds-134385">What steps hospitals can take if coronavirus leads to a shortage of beds</a>
</strong>
</em>
</p>
<hr>
<p>But unless the forces that dictate our usual rates of elective surgery change, the rates will eventually return to normal. This is because we have a health system that drives specific, quantifiable treatments for diagnosed conditions.</p>
<p>For example, the system is geared at providing and reimbursing knee replacements, not the education, weight loss and exercise programs that might reduce the need for them. </p>
<p>There is considerable room to lower the rates of many common elective procedures, even without a forced shutdown.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-do-we-wait-so-long-in-hospital-emergency-departments-and-for-elective-surgery-54384">Why do we wait so long in hospital emergency departments and for elective surgery?</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/135325/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ian Harris does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Last month, Australia announced a pause on all elective surgeries. This could have mixed effects now and in the longer term.Ian Harris, Professor of Orthopaedic Surgery, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1319082020-02-26T18:56:23Z2020-02-26T18:56:23Z4 myths about polycystic ovary syndrome – and why they’re wrong<figure><img src="https://images.theconversation.com/files/317253/original/file-20200226-24680-vi85vv.jpg?ixlib=rb-1.1.0&rect=27%2C32%2C3639%2C2407&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/stylish-girl-denim-shorts-high-waist-309987251">Shutterstock</a></span></figcaption></figure><p>Polycystic ovary syndrome (PCOS) is a common hormonal condition. When using the definition supported by the international <a href="https://www.monash.edu/__data/assets/pdf_file/0004/1412644/PCOS_Evidence-Based-Guidelines_20181009.pdf">guidelines</a>, it affects just under <a href="https://www.ncbi.nlm.nih.gov/pubmed/19910321">one in six young Australian women</a>. </p>
<p>To meet the diagnostic criteria of PCOS, women need to have two of the following three criteria: </p>
<ul>
<li>irregular periods</li>
<li>signs of increased levels of androgens (hormones that give “male” characteristics) such as excess hair growth, acne or hair loss </li>
<li>enlarged ovaries with lots of small follicles containing immature eggs (known as polycystic ovaries). </li>
</ul>
<p>But polycystic ovaries aren’t ovaries with cysts. And having polycystic ovaries doesn’t mean you have PCOS. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-polycystic-ovary-syndrome-37203">Explainer: what is polycystic ovary syndrome?</a>
</strong>
</em>
</p>
<hr>
<p>Our new research among <a href="https://www.ncbi.nlm.nih.gov/pubmed/31687475">women</a> and <a href="https://academic.oup.com/humrep/advance-article/doi/10.1093/humrep/deaa005/5754094?searchresult=1">clinicians</a> found confusion over the name PCOS, limited evidence about the condition, and <a href="https://www.ncbi.nlm.nih.gov/pubmed/30189451">large amount of misinformation</a> online fed into common misconceptions about PCOS. </p>
<p>These myths and assumptions are harming women and standing in the way of appropriate health care.</p>
<h2>Myth #1: Single symptoms indicate you have PCOS</h2>
<p>PCOS is a syndrome, or a group of symptoms, so just one sign or symptom is not enough for a diagnosis.</p>
<p>In our <a href="https://academic.oup.com/humrep/advance-article/doi/10.1093/humrep/deaa005/5754094?searchresult=1">new study</a> of 36 clinicians (GPs, endocrinologists and gynaecologists), many raised concerns about misdiagnosis and overdiagnosis of PCOS. They described seeing many women who had self-diagnosed or had been incorrectly diagnosed based on irregular cycles alone, or on an ultrasound showing polycystic ovaries. </p>
<p>But <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2968725/">many young women have polycystic ovaries</a> but don’t have PCOS. </p>
<p>Symptoms are also on a spectrum of severity, with no clear line separating normal from abnormal. </p>
<p>Women of different ethnicities, for example, have <a href="https://academic.oup.com/jcem/advance-article/doi/10.1210/clinem/dgaa063/5728530">different amounts</a> of facial and body hair.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/317254/original/file-20200226-24690-gfizpq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/317254/original/file-20200226-24690-gfizpq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=395&fit=crop&dpr=1 600w, https://images.theconversation.com/files/317254/original/file-20200226-24690-gfizpq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=395&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/317254/original/file-20200226-24690-gfizpq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=395&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/317254/original/file-20200226-24690-gfizpq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=497&fit=crop&dpr=1 754w, https://images.theconversation.com/files/317254/original/file-20200226-24690-gfizpq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=497&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/317254/original/file-20200226-24690-gfizpq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=497&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Some women have more noticeable facial hair than others.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/attractive-woman-beauty-salon-on-facial-148182860">Shutterstock</a></span>
</figcaption>
</figure>
<p>And acne is common. <a href="https://www.ncbi.nlm.nih.gov/pubmed/22171979">One study found</a> 45% of women in their 20s had clinical acne, as well as 25% of women in their 30s and 12% of women in their 40s.</p>
<p>There are also several other factors and conditions that can mimic PCOS symptoms, such as stress, hormonal contraceptives such as the pill, obesity, <a href="https://www.womenshealth.gov/a-z-topics/thyroid-disease">thyroid issues</a> (which can affect metabolism), over-exercising and disordered eating. </p>
<p>Mislabelling women with PCOS prevents them from receiving care for their actual issue. Some conditions can have serious health consequences if left untreated, such as <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6374026/">hypothalamic amenorrhea</a> (when periods stop because of stress, weight loss and/or excessive physical exercise), which can lead to bone loss.</p>
<h2>Myth #2: Women with PCOS don’t need to use contraception</h2>
<p>Some women with PCOS may have trouble conceiving naturally and may need medication to help them ovulate when they want to conceive. But many women with PCOS conceive spontaneously and achieve their desired family size. In fact, women with and without PCOS have <a href="https://www.ncbi.nlm.nih.gov/pubmed/29939804">similar numbers of children</a>. </p>
<p>Despite this, <a href="https://www.ncbi.nlm.nih.gov/pubmed/29052216">many women with PCOS believe</a> they won’t become pregnant. This can have <a href="https://www.ncbi.nlm.nih.gov/pubmed/31687475">life-changing consequences</a>. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/i-have-pcos-and-i-want-to-have-a-baby-what-do-i-need-to-know-109800">I have PCOS and I want to have a baby, what do I need to know?</a>
</strong>
</em>
</p>
<hr>
<p>In our <a href="https://www.ncbi.nlm.nih.gov/pubmed/31687475">recent study</a>, women with PCOS talked about how fear of infertility caused long-lasting psychological distress. They felt pressure to conceive early, had difficult conversations with their partners, and a few even altered their parenthood goals and no longer planned to have children. </p>
<p>Many took risks with contraception and a few ended up with unintended pregnancies. Reduced contraceptive use has also <a href="https://www.ncbi.nlm.nih.gov/pubmed/22273414">been shown</a> in <a href="https://www.ncbi.nlm.nih.gov/pubmed/32003425">other studies</a>. </p>
<p>Women with PCOS need reassurance and accurate information about the likelihood of pregnancy so they know contraception is needed if they don’t want to get pregnant. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/317282/original/file-20200226-24651-hn40rr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/317282/original/file-20200226-24651-hn40rr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/317282/original/file-20200226-24651-hn40rr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/317282/original/file-20200226-24651-hn40rr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/317282/original/file-20200226-24651-hn40rr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/317282/original/file-20200226-24651-hn40rr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/317282/original/file-20200226-24651-hn40rr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Women with PCOS still need to use contraception.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/oral-contraceptive-pill-on-pharmacy-counter-660070831">Shutterstock</a></span>
</figcaption>
</figure>
<h2>Myth #3: All women with PCOS are at risk of ‘metabolic complications’</h2>
<p>PCOS is associated with an increased risk of developing <a href="https://www.diabetes.co.uk/insulin-resistance.html">insulin resistance</a> (when the body doesn’t respond properly to the hormone insulin), type 2 diabetes and metabolic syndrome (a collection of factors such as high blood pressure and poor cholesterol levels).</p>
<p>Consequently, some women with PCOS <a href="https://www.ncbi.nlm.nih.gov/pubmed/31687475">report persisting anxiety</a> about their long-term health. </p>
<p>However, the potential consequences are not the same for all women diagnosed. Women with no signs of androgen excess, so those who are diagnosed due to irregular menstrual cycles and polycystic ovaries, <a href="https://www.ncbi.nlm.nih.gov/pubmed/27233760">don’t have the same metabolic risks</a> as women with <a href="https://www.ncbi.nlm.nih.gov/pubmed/31306504">androgen excess</a>. </p>
<p>Yet most doctors we interviewed were unaware of this. As a result, some women with PCOS are being wrongly labelled as high risk, causing unnecessary anxiety. </p>
<p>Another assumption frequently stated online is that women with PCOS are more likely to get heart disease. However, the <a href="https://www.ncbi.nlm.nih.gov/pubmed/31638273">limited data</a> to date suggests otherwise. </p>
<h2>Myth #4: PCOS causes weight gain or prevents weight loss</h2>
<p>Although women with PCOS are more likely to be overweight than women without the condition, the relationship between PCOS and weight remains unclear. </p>
<p>While many women with PCOS report <a href="https://www.ncbi.nlm.nih.gov/pubmed/27906550">difficulty losing weight</a> and perceive a greater susceptibility to <a href="https://academic.oup.com/humrep/article/33/1/91/4647370">weight gain</a>, weight management interventions, such as diet and behaviour change programs, have found women with and without PCOS <a href="https://www.ncbi.nlm.nih.gov/pubmed/28885578">lose the same amount of weight</a>. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/317255/original/file-20200226-24655-7rpfag.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/317255/original/file-20200226-24655-7rpfag.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/317255/original/file-20200226-24655-7rpfag.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/317255/original/file-20200226-24655-7rpfag.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/317255/original/file-20200226-24655-7rpfag.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/317255/original/file-20200226-24655-7rpfag.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/317255/original/file-20200226-24655-7rpfag.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Women with PCOS can lose weight.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/portrait-young-obese-woman-working-out-589121444">Shutterstock</a></span>
</figcaption>
</figure>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/30496407/">A recent analysis</a> suggests a high body mass index (BMI) is one of the causes of PCOS, with weight gain making symptoms worse. But having PCOS does not appear to affect BMI. We need more research to understand these relationships more clearly. </p>
<p>Encouragingly, even a small amount of weight loss can improve PCOS symptoms. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/weight-loss-improves-polycystic-ovary-symptoms-but-dont-wait-until-middle-age-start-now-113449">Weight loss improves polycystic ovary symptoms. But don't wait until middle age – start now</a>
</strong>
</em>
</p>
<hr>
<p>Optimising healthy lifestyle (eating healthily, being active and avoiding smoking) is <a href="https://www.monash.edu/__data/assets/pdf_file/0004/1412644/PCOS_Evidence-Based-Guidelines_20181009.pdf">first line management</a> for women with PCOS. However, women with PCOS may face additional barriers to implementing these changes, such as <a href="https://www.ncbi.nlm.nih.gov/pubmed/22127370">higher levels of anxiety</a> and <a href="https://www.ncbi.nlm.nih.gov/pubmed/21173657">depression</a>, highlighting the importance of access to support.</p>
<p>We must be careful with assumptions and generalisations in the absence of high-quality data. Women with PCOS each have different contributing factors and therefore different levels of risk. Having truly patient-centred health care will help them better manage their condition, improve their outcomes and reduce unwarranted anxiety.</p><img src="https://counter.theconversation.com/content/131908/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tessa Copp receives funding from the NHMRC Centre for Research Excellence in Creating Sustainable Healthcare. She is on the Junior Researcher Committee for the Preventing Overdiagnosis Conference. </span></em></p><p class="fine-print"><em><span>Jenny Doust receives funding from the NHMRC Centre for Research Excellence in Creating Sustainable Healthcare.</span></em></p><p class="fine-print"><em><span>Jesse Jansen receives funding from the NHMRC. </span></em></p><p class="fine-print"><em><span>Kirsten McCaffery receives funding from the NHMRC Centre for Research Excellence in Creating Sustainable Healthcare and an NHMRC Program Grant 'Using healthcare wisely.</span></em></p>Just under one in six Australian women have PCOS but some are being diagnosed when they don’t meet the criteria.Tessa Copp, PhD candidate, University of SydneyJenny Doust, Clinical Professorial Research Fellow, The University of QueenslandJesse Jansen, Senior research fellow, University of SydneyKirsten McCaffery, NHMRC Principal Research Fellow, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1277912020-01-26T19:06:45Z2020-01-26T19:06:45Z29,000 cancers overdiagnosed in Australia in a single year<figure><img src="https://images.theconversation.com/files/307817/original/file-20191218-11924-3kufdx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Men are 17% more likely to be diagnosed with cancer than they were 30 years ago.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/frustrated-older-mature-retired-man-feeling-1185179038">fizkes/Shutterstock</a></span></figcaption></figure><p>Almost one in four cancers detected in men were overdiagnosed in 2012, according to our new research, published today in the <a href="https://www.mja.com.au/">Medical Journal of Australia</a>. </p>
<p>In the same year, we found that approximately one in five cancers in women were overdiagnosed. </p>
<p>Overdiagnosis is when a person is diagnosed with a “harmless” cancer that either never grows or grows very slowly. These cancers are sometimes called low or ultra-low-risk cancers and wouldn’t have spread or caused any problems even if left untreated.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/is-it-time-to-remove-the-cancer-label-from-low-risk-conditions-101331">Is it time to remove the cancer label from low-risk conditions?</a>
</strong>
</em>
</p>
<hr>
<p>This level of overdiagnosis means Australian men are 17% more likely to be diagnosed with cancer in their lifetime than they were 30 years ago, while women are 10% more likely. </p>
<p>Cancer overdiagnosis can result in people having unnecessary treatments, such as surgery, radiotherapy and hormone therapy. Being diagnosed with cancer and having cancer treatments can cause physical, psychological and financial harms.</p>
<h2>How many cancers were overdiagnosed?</h2>
<p>In 2012, 77,000 cancers were diagnosed among Australian men. We estimated that 24% of these (or 18,000 in total) were overdiagnosed, including:</p>
<ul>
<li>8,600 prostate cancers</li>
<li>8,300 melanomas</li>
<li>860 kidney cancers</li>
<li>500 thyroid cancers.</li>
</ul>
<p>Some 55,000 cancers were diagnosed in women; 18% of them (11,000) were overdiagnosed. This includes:</p>
<ul>
<li>4,000 breast cancers</li>
<li>5,600 melanomas</li>
<li>850 thyroid cancers</li>
<li>660 kidney cancers.</li>
</ul>
<p>These calculations are based on changes since 1982 in the lifetime risk of cancers, after adjusting for other causes of death and changing risk factors.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/307819/original/file-20191218-11896-18a61i1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/307819/original/file-20191218-11896-18a61i1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/307819/original/file-20191218-11896-18a61i1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/307819/original/file-20191218-11896-18a61i1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/307819/original/file-20191218-11896-18a61i1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/307819/original/file-20191218-11896-18a61i1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/307819/original/file-20191218-11896-18a61i1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Mammograms sometimes detect cancers that wouldn’t grow, spread, or cause the woman any harm.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/woman-40s-about-undergoing-mammography-test-195635468">GagliardiPhotography/Shutterstock</a></span>
</figcaption>
</figure>
<p>Because they are more common, prostate and breast cancer and melanoma accounted for the greatest number of overdiagnosed cancers, even though larger percentages of thyroid cancers were overdiagnosed. </p>
<p>In women, for example, 73% of thyroid cancers were overdiagnosed, while 22% of breast cancers were overdiagnosed.</p>
<p>The harms to patients come from the unnecessary surgery, and other treatments, as well as the anxiety and expenses. </p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/29042396">Three in four patients with thyroid “cancers” that are overdiagnosed</a>, for example, will almost all have their thyroid completely removed, risk complications, and have to take replacement thyroid medication for the rest of their life. </p>
<p>In addition, there are substantial costs to the health system, and delays in necessary surgery. </p>
<p>Some “good news” is that overdiagnosis appears to be largely confined to the five main cancers mentioned above. </p>
<h2>What causes cancer overdiagnosis?</h2>
<p>The cause of overdiagnosis differs for each cancer. </p>
<p>For prostate cancer, the cause is the quest for early detection of prostate cancer using the prostate specific antigen (PSA) blood test. A downside of PSA testing is the risk of detecting large numbers of low-risk prostate cancers which may be overtreated. </p>
<p>For breast cancer, the cause is also early detection, through mammography screening which can detect low-risk cancers. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/five-warning-signs-of-overdiagnosis-110895">Five warning signs of overdiagnosis</a>
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</em>
</p>
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<p>Likewise, detection of low-risk melanoma accounted for most of the melanoma overdiagnosis we observed. Early detection activities again are the likely cause, with many times more skin biopsies being done today than 30 years ago.</p>
<p>Overdiagnosis of kidney and thyroid cancer is due largely to “incidentalomas” – abnormalities found incidentally on imaging done for other reasons – or through over-investigation of mild thyroid problems.</p>
<h2>What can we do about it?</h2>
<p>Some level of overdiagnosis is unavoidable in a modern health-care system committed to screening to reduce the disease and death burden from cancer.</p>
<p>We want to maximise the timely detection of high-risk cancers that allows the best chance of cure through early surgery and other treatments. </p>
<p>But this is still possible while taking measures to prevent overdiagnosis and overtreatment of low-risk cancers that are better left undetected. </p>
<p>Take South Korea, for example. Following the introduction of a screening program for thyroid cancer, the country saw a <a href="https://www.nejm.org/doi/full/10.1056/NEJMc1507622?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed">15-fold increase</a> in small, low-risk thyroid cancers. Then it cut back on early detection. This led to a major drop in thyroid cancer rates without any change in death rates. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/307820/original/file-20191218-11914-1lyx0sn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/307820/original/file-20191218-11914-1lyx0sn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=408&fit=crop&dpr=1 600w, https://images.theconversation.com/files/307820/original/file-20191218-11914-1lyx0sn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=408&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/307820/original/file-20191218-11914-1lyx0sn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=408&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/307820/original/file-20191218-11914-1lyx0sn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=512&fit=crop&dpr=1 754w, https://images.theconversation.com/files/307820/original/file-20191218-11914-1lyx0sn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=512&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/307820/original/file-20191218-11914-1lyx0sn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=512&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Rates of PSA testing are comparatively high in Australia.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/man-laboratory-during-blood-research-68481031">ariadna de raadt/Shutterstock</a></span>
</figcaption>
</figure>
<p>Rates of PSA testing in Australia are <a href="https://cancercouncil.com.au/wp-content/uploads/2015/03/World-Journal-of-Urology_2015_Prostate_mortality-AUS.pdf">among the highest in the world</a>. Countries where there is less PSA testing, such as the <a href="https://researchonline.nd.edu.au/cgi/viewcontent.cgi?article=1777&context=med_article">United Kingdom</a>, detect less low-risk prostate cancer, and therefore have less overtreatment.</p>
<p>Rather than simply accepting PSA testing, a wiser strategy is to <a href="https://www.bmj.com/content/362/bmj.k3581.full">make an informed decision whether to go ahead with it or not</a>. Tools to help you choose are available <a href="http://psatesting.org.au/info/?utm_source=pcfa&utm_medium=redirect&utm_campaign=pcam19">here</a> and <a href="https://www.racgp.org.au/download/Documents/Guidelines/prostate-cancer-screening-infosheetpdf.pdf">here</a>.</p>
<p>A <a href="https://ses.library.usyd.edu.au/bitstream/2123/16658/1/2017%20updated%20breast%20screening%20DA%20%28Hersch%20et%20al%29.pdf">decision aid</a> is also available for Australian women to consider whether to go ahead with mammogram screening or not.</p>
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Read more:
<a href="https://theconversation.com/three-questions-to-ask-about-calls-to-widen-breast-cancer-screening-82894">Three questions to ask about calls to widen breast cancer screening</a>
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<p>Trials to wind back treatment of low-risk prostate cancer have resulted in <a href="https://www.nice.org.uk/guidance/ng131/chapter/Recommendations#localised-and-locally-advanced-prostate-cancer">clinical practice guidelines</a> which recommend men with low-risk prostate cancer be offered active surveillance as an alternative to immediate surgery or radiation therapy. </p>
<p>Trials to evaluate less treatment for low-risk breast cancer are now under way and should help wind back breast cancer overtreatment one day.</p>
<p>New screening tests that identify clinically important cancers, while leaving slow- and never-growing cancers undetected, are the holy grail. But they could be some time coming. </p>
<p>In the meantime, health services need to be vigilant in <a href="https://annals.org/aim/fullarticle/2724039/recognizing-potential-overdiagnosis-high-sensitivity-cardiac-troponin-assays-example">monitoring new areas of overdiagnosis</a>, particularly when investing in new technologies with potential to further increase overdiagnosis.</p><img src="https://counter.theconversation.com/content/127791/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alexandra Barratt receives funding from NHMRC. She is a lead investigator on Wiser Healthcare, an NHMRC funded research collaboration to reduce overdiagnosis and overtreatment. </span></em></p><p class="fine-print"><em><span>Katy Bell receives funding from NHMRC. She is Chief Investigator on an Investigator Grant "Using early detection tests to benefit health without causing harm" and a member of the Wiser Healthcare research collaboration that aims to reduce overdiagnosis and overtreatment. </span></em></p><p class="fine-print"><em><span>Paul Glasziou receives funding from an NHMRC program grant on overdiagnosis and overtreatment.</span></em></p><p class="fine-print"><em><span>Mark Jones and Thanya Pathirana do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>New research estimates 24% of cancers in men that were detected in 2012 were overdiagnosed, meaning they never would have caused harm if left untreated.Alexandra Barratt, Professor of Public Health, University of SydneyKaty Bell, Associate in Clinical Epidemiology in the School of Public Health, University of SydneyMark Jones, Associate Professor, Biostatistician, Institute for Evidence-Based Healthcare, Bond UniversityPaul Glasziou, Professor of Medicine, Bond UniversityThanya Pathirana, Senior Lecturer, School of Medicine, Griffith UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1274952019-12-03T18:35:55Z2019-12-03T18:35:55ZTime to end drug company distortion of medical evidence<figure><img src="https://images.theconversation.com/files/304845/original/file-20191203-66994-10ui9bw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Doctors' prescribing habits are influenced by drug reps and other industry marketing.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/">Monkey Business Images/Shutterstock</a></span></figcaption></figure><p>While there’s much to celebrate in medicine, it’s now beyond doubt that we have <a href="https://www.bmj.com/content/347/bmj.f7141">too much</a> of it. Too many tests, diagnoses, pills and procedures are wasting resources that could be better spent meeting genuine need. </p>
<p>As a recent <a href="http://www.oecd.org/health/tackling-wasteful-spending-on-health-9789264266414-en.htm">OECD report</a> concluded, up to one-fifth of health spending may be wasted, and many patients “unnecessarily harmed” by treatments they didn’t need.</p>
<p>Antidepressants, for example, can be life-savers for some people. But drug company-funded studies have <a href="https://ebm.bmj.com/content/early/2019/09/24/bmjebm-2019-111238">overplayed their benefits</a> and <a href="https://www.bmj.com/content/351/bmj.h4320">downplayed</a> their harms, contributing to overuse and unnecessary side effects. </p>
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Read more:
<a href="https://theconversation.com/antidepressants-may-not-be-as-effective-as-we-thought-and-shouldnt-be-the-only-treatment-for-depression-59236">Antidepressants may not be as effective as we thought, and shouldn't be the only treatment for depression</a>
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<p><a href="http://www.nationalacademies.org/hmd/Reports/2009/Conflict-of-Interest-in-Medical-Research-Education-and-Practice.aspx">Widespread industry influence</a> is jeopardising the integrity of research and medical education, and threatening the quality of patient care.</p>
<p>Today in <a href="https://www.bmj.com/content/367/bmj.l6576">The BMJ</a> a global group of researchers, doctors, editors, regulators and advocates outline key strategies to reduce the financial entanglement with industry. The first step is ensuring the evaluation of any new tests, treatments and technologies are free from industry influence. </p>
<h2>Distorted research, education and clinical practice</h2>
<p>A huge proportion of medical research is currently funded by industry – in the United States <a href="https://jamanetwork.com/journals/jama/article-abstract/2089358">almost 60%</a>. Yet there’s a <a href="https://www.cochrane.org/MR000033/METHOD_industry-sponsorship-and-research-outcome">mountain of evidence</a> that company-sponsored studies tend to overstate product benefits and playdown harms. </p>
<p>One example is cholesterol-lowering drugs, or statins. A <a href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0040184">review</a> analysing almost 200 studies of statins found that company-sponsored studies were much more likely to find results favourable to the sponsors’ drug.</p>
<p>There’s similar distortion with devices, like <a href="https://www.bmj.com/content/359/bmj.j5515">pelvic mesh</a>, used to treat pelvic organ prolapse. In this case, poor testing meant many women received the mesh without knowing the risks of horrendous harms, including severe pain, infection, and repeated surgery.</p>
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<strong>
Read more:
<a href="https://theconversation.com/vaginal-mesh-controversy-shows-collective-failure-of-the-tga-and-australias-specialists-78605">Vaginal mesh controversy shows collective failure of the TGA and Australia's specialists</a>
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<p>Those same companies then <a href="https://bmjopen.bmj.com/content/7/6/e016701">sponsor the “education” of your doctor</a>, often with the evidence they’ve funded, and good food and wine. </p>
<p>As a <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2528290">study of 280,000 doctors reveals</a>, accepting just one sponsored meal is associated with higher prescribing of the sponsor’s products: a 20% increase in statins, and a doubling of antidepressants. </p>
<p>Industry argues it’s information helps patients, but a <a href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1000352">systematic review</a> found differently. Doctors who accept marketing, including sales representatives, tend to prescribe more, at higher cost, and lower quality, such as prescribing an inappropriate drug, or prescribing that is not in line with guidelines.</p>
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<strong>
Read more:
<a href="https://theconversation.com/whos-paying-for-lunch-heres-exactly-how-drug-companies-wine-and-dine-our-doctors-78395">Who's paying for lunch? Here's exactly how drug companies wine and dine our doctors</a>
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<p>Just look at the opioid epidemic in the United States. One <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2720914">study</a> found the amount of marketing, including payments to doctors, was associated with small but significant increases in both prescriptions and deaths from overdose. </p>
<h2>How to end commercial influence</h2>
<p>Evidence of the dangers of financial relationships with industry has caused many groups to seek more freedom. As we show in today’s <a href="https://www.bmj.com/content/367/bmj.l6576">BMJ Analysis</a>, there are signs of change.</p>
<p>In Norway, industry-supported education can no longer be used formally by doctors, and the government funds independent drug information. </p>
<p>Some medical journals no longer accept drug company advertising. Citizen groups like the US <a href="https://www.nwhn.org/">National Women’s Health Network</a> accept no funds from companies selling healthcare products. </p>
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<img alt="" src="https://images.theconversation.com/files/304847/original/file-20191203-67023-wq4lne.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/304847/original/file-20191203-67023-wq4lne.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/304847/original/file-20191203-67023-wq4lne.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/304847/original/file-20191203-67023-wq4lne.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/304847/original/file-20191203-67023-wq4lne.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/304847/original/file-20191203-67023-wq4lne.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/304847/original/file-20191203-67023-wq4lne.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Some change is underway.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1033147024?src=29445d3d-d86b-4e65-b92f-5f659c7bf18c-1-0&size=huge_jpg">Brian A Jackson/Shutterstock</a></span>
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<p>The biggest challenge is working out ways to evaluate tests and treatments, free from the influence of companies developing them. But radical reform is in the wind in many places.</p>
<p>In <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2362.2009.02226.x">Italy</a>, the promotional budgets of drug companies are taxed to create a pool for independent research.</p>
<p>In Britain, <a href="https://cancerunion.org/wp-content/uploads/2019/09/Medicines-For-The-Many.pdf">Labour</a> is proposing the government funds clinical trials and creates <a href="https://www.theguardian.com/politics/2019/sep/24/labour-pledges-to-break-patents-and-offer-latest-drugs-on-nhs">state-owned pharmaceutical makers</a>.</p>
<h2>More needs to be done</h2>
<p>Our <a href="https://www.bmj.com/content/367/bmj.l6576">proposals</a> are from a team with expertise across medicine, law, and philosophy and includes people from The BMJ and the World Organisation of Family Doctors. </p>
<p>We argue the pathway to independence includes three key reforms: </p>
<ul>
<li><p>government policies ensuring the evaluation of tests, treatments and technologies is free from sponsor influence</p></li>
<li><p>reforms to ensure medical education is free from industry support and on-going professional accreditation can’t be gained from company-sponsored events</p></li>
<li><p>new rules to end marketing interactions between industry and prescribing doctors, such as sales representatives’ visits.</p></li>
</ul>
<p>In our view, tackling the current epidemic of medical excess can only work if decision-makers within health care seek much more independence from those profiting from that excess. And if you want to help develop more detailed recommendations for reform, and support the campaign launched in BMJ today, you can do so <a href="https://www.bmj.com/commercial-influence">here</a>.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/we-need-new-rules-for-defining-who-is-sick-step-1-remove-vested-interests-114621">We need new rules for defining who is sick. Step 1: remove vested interests</a>
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<img src="https://counter.theconversation.com/content/127495/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ray Moynihan receives research funding from the National Health and Medical Research Council. He is co-chair of the scientific committee for the Preventing Overdiagnosis international scientific conference, co-sponsored by the World Health Organization, Sydney, December 5-7. </span></em></p>Too often, pharmaceutical companies and device manufacturers exert influence in how their products are tested in the research phase and recommended in the clinic.Ray Moynihan, Assistant Professor, Bond UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1249942019-10-15T18:58:41Z2019-10-15T18:58:41ZThese 3 factors predict a child’s chance of obesity in adolescence (and no, it’s not just their weight)<figure><img src="https://images.theconversation.com/files/296995/original/file-20191015-98674-gln5an.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The mother's education level is also a factor.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/happy-mother-boy-portrait-578217337?src=dCwqXkU4i5Hc2wqArE3FgQ-1-51">Brainsil/Shutterstock</a></span></figcaption></figure><p>Three simple factors can predict whether a child is likely to be overweight or obese by the time they reach adolescence: the child’s body mass index (BMI), the mother’s BMI and the mother’s education level, according to our new research. </p>
<p>The study, published in the <a href="https://www.nature.com/articles/s41366-019-0457-2">International Journal of Obesity</a>, found these three factors predicted whether children of all sizes either developed weight problems or resolved them by age 14-15, with around 70% accuracy. </p>
<p>One in four Australian adolescents is overweight or obese. This means they’re <a href="https://www.nature.com/articles/s41366-019-0461-6">likely to be obese in adulthood</a>, placing them at <a href="https://www.who.int/gho/ncd/en/">higher risk</a> of heart disease, diabetes, Alzheimer’s and cancer. </p>
<p>Combining these three factors may help clinicians target care to those most at risk of becoming obese in adolescence.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/more-than-one-in-four-aussie-kids-are-overweight-or-obese-were-failing-them-and-we-need-a-plan-114005">More than one in four Aussie kids are overweight or obese: we're failing them, and we need a plan</a>
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<h2>Targeting care to those who need it</h2>
<p>GPs are <a href="https://www.ncbi.nlm.nih.gov/pubmed/18953227">well placed to both prevent and treat</a> excess weight and obesity. But time constraints make it difficult. Few parents make appointments to address concerns about weight, so most counselling occurs in the context of a visit for something else.</p>
<p>It’s also difficult for GPs to know which children might need this counselling. GPs don’t want to offer treatment to the overweight or obese child who is going to <a href="https://pediatrics.aappublications.org/content/135/2/e292">grow out it</a>. Nor do they want to raise the topic of excess weight to a child who is in the normal weight range, without good reason. </p>
<p>Targeting care, whether treatment or prevention, to those who really need it avoids wasting resources and harm from over-treating children who will grow out of their weight issues. But until now, we haven’t been able to predict on the spot who these children are.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/weighing-kids-at-school-has-more-pros-than-cons-but-the-reasons-may-surprise-you-100387">Weighing kids at school has more pros than cons but the reasons may surprise you</a>
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<h2>Our study</h2>
<p>We set out to determine whether simple factors, such as those available to GPs in a standard appointment, could accurately predict which normal-weight children were likely to become overweight or obese, and which heavy children were likely to resolve to a normal weight by adolescence. </p>
<p>By drawing on the <a href="https://growingupinaustralia.gov.au/sites/default/files/tp1.pdf">Longitudinal Study of Australian Children</a>, we considered this question in close to 7,000 children. Children were recruited in 2004 at 0-12 months or four to five years of age and followed up every two years, across six time points, to age 10-11 and 14-15 years respectively.</p>
<p>At each time point, interviewers measured children’s height and weight (except 0-12 months), and parents reported their height and weight, allowing us to calculate their BMI.</p>
<p>We also selected 23 other obesity-related factors clinicians could readily ask in a routine appointment. These included historical factors – such as the child’s birth weight, duration of breastfeeding, mode of delivery and the mother’s education levels – and questions about how often they ate high-fat foods and sugary drinks, their enjoyment of physical activity, and levels of disadvantage in their neighbourhood. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/297017/original/file-20191015-98653-cq4opd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/297017/original/file-20191015-98653-cq4opd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/297017/original/file-20191015-98653-cq4opd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/297017/original/file-20191015-98653-cq4opd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/297017/original/file-20191015-98653-cq4opd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/297017/original/file-20191015-98653-cq4opd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/297017/original/file-20191015-98653-cq4opd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The researchers also looked at how often the children ate high-fat food.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/two-years-old-boy-eating-french-143265838?src=iWBJf5n4eZ_ujohkR_vV6A-1-13">Romrodphoto/Shutterstock</a></span>
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<p>Other studies have tended to look at these factors in isolation or to examine predictive factors at a single time point. We were able to look at the combined effects of all the questions across all the time points throughout childhood.</p>
<h2>What did we find?</h2>
<p>Three consistent factors in both age groups predicted the development or resolution of weight problems by adolescence: the mother’s BMI, the child’s BMI and the mother’s level of education. </p>
<p>For every one unit increase in the child’s BMI at age six to seven, the odds of developing weight problems at 14-15 rose three-fold. It also halved the odds of the weight issues resolving. </p>
<p>Similarly, for every one unit increase of the mother’s BMI when the child was aged six to seven, the chance of the child developing weight problems by 14-15 increased by 5%. The odds of weight issues resolving decreased by 10%. </p>
<p>In addition, at two to five years of age, children whose mothers had a university degree had lower odds of being overweight or obese. For children who were already overweight or obese at two to five, those whose mothers had a university degree were more likely to have their weight issues resolved by adolescence.</p>
<p>Together, these three factors were around 70% accurate in predicting both the development and resolution of weight problems. </p>
<p>Only 13% of normal-weight six to seven year olds, with none of these three risk factors, became overweight or obese by age 14-15. </p>
<p>In contrast, 71% of those with all three risk factors became overweight or obese. </p>
<h2>How could these findings improve care?</h2>
<p>Unlike genetic information or blood tests, these three factors are available on the spot. And despite their apparent simplicity, they include a complex mix of genetic, environmental and lifestyle information about our health. This data is impossible to measure accurately in a brief – or even long – doctor’s appointment. </p>
<p>These three questions may help health practitioners target treatment to high-risk children.</p>
<p>Of course, even if we can accurately identify children at risk of becoming overweight or obese, we still lack effective prevention methods. Lifestyle interventions, such as counselling to improve the quality of their diet and increase physical activity, remain the first choices. However, the <a href="https://www.ncbi.nlm.nih.gov/pubmed/27621413">effectiveness of these interventions is limited</a>. We urgently need more effective tools to prevent and manage excess weight and obesity in children. </p>
<p>If you’re concerned about your child’s weight, <a href="https://www.rch.org.au/weight-management/management/#children-familes">speak to a professional</a> such as a dietitian, GP or paediatrician. They can also help manage other conditions that can accompany obesity, such as anxiety and high blood pressure.</p>
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Read more:
<a href="https://theconversation.com/five-things-parents-can-do-to-improve-their-childrens-eating-patterns-95370">Five things parents can do to improve their children's eating patterns</a>
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<img src="https://counter.theconversation.com/content/124994/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kate Lycett receives funding from the National Health and Medical Research Council and the National Heart Foundation. </span></em></p><p class="fine-print"><em><span>Anneke Grobler receives funding from the Thrasher Research Fund, MRFF and RCH foundation. </span></em></p><p class="fine-print"><em><span>Markus Juonala and Melissa Wake do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>One in four Australians is overweight or obese by the time they reach adolescence, but it’s difficult to predict who is at risk. These three questions can help.Kate Lycett, Senior Research Officer, Deakin University; Honorary Fellow, The University of Melbourne, Murdoch Children's Research InstituteAnneke Grobler, Statistician, Murdoch Children's Research InstituteMarkus Juonala, Professor of Internal Medicine, University of TurkuMelissa Wake, Paediatrician and Director of Generation Victoria (GenV) , Murdoch Children's Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1168142019-05-28T19:47:31Z2019-05-28T19:47:31ZSurgery rates are rising in over-85s but the decision to operate isn’t always easy<figure><img src="https://images.theconversation.com/files/276679/original/file-20190528-193518-nwxvjs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The decision about whether to operate can't just be based on age, though age-related decline is certainly a consideration. </span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/Y5VBtBgswLQ">Philippe Leone</a></span></figcaption></figure><p>In January, <a href="https://www.sbs.com.au/news/hip-replacement-for-107-year-old-a-success">107-year-old Daphne Keith</a> broke her hip and became the oldest Australian to have a partial hip replacement. This isn’t something you would have heard of two or three decades ago. </p>
<p>For Daphne, the decision was fairly clear-cut. Surgery, with all its risks, was a better option than the alternative: to be stuck in bed for the rest of her life. As she summed it up, “What do I have to lose?” </p>
<p>But in many cases the balance between benefits and harms of surgery for older people is not as clear-cut.</p>
<p>Advances in anaesthetic and surgical techniques (especially keyhole surgery) now allow older adults to undergo operations and procedures that were previously not possible.</p>
<p>As the population <a href="https://www.who.int/news-room/fact-sheets/detail/ageing-and-health">ages</a>, we’re operating on older and <a href="https://onlinelibrary.wiley.com/doi/pdf/10.1002/bjs.11148">older people</a>. <a href="https://www.aihw.gov.au/getmedia/0b26353f-94fb-4349-b950-7948ace76960/ah16-6-17-health-care-use-older-australians.pdf.aspx">Rates for elective surgery</a> in Australia are increasing the most among those aged over 85.</p>
<p>So how do we decide who should and shouldn’t undergo surgery?</p>
<h2>Age is a factor, but not the only one</h2>
<p>As we age there are increasing differences between individuals in terms of how our minds and bodies function. Younger people – whether they’re aged five, 20 or even 40 – are generally very similar to their age-matched peers, in terms of their cognitive and physical abilities. </p>
<p>But if we compare older adults, there are marked differences in their function. Some 70-year-olds are fit, healthy and still working full-time. Other 70-year-olds have multiple medical conditions, are frail and living in nursing homes. </p>
<p>So decisions about surgery shouldn’t be based on age alone. </p>
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Read more:
<a href="https://theconversation.com/whats-happening-in-our-bodies-as-we-age-67931">What's happening in our bodies as we age?</a>
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<p>However, we can’t ignore the changes associated with ageing, which means sometimes the potential harms of surgery will outweigh the benefits.</p>
<p>The harms associated with surgery and anaesthesia include death, surgical complications, longer hospital stays and poorer long-term outcomes. This might mean not being able to return to the same physical or cognitive level of function or needing to go into a nursing home. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/276682/original/file-20190528-193514-y3mgrq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/276682/original/file-20190528-193514-y3mgrq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/276682/original/file-20190528-193514-y3mgrq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/276682/original/file-20190528-193514-y3mgrq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/276682/original/file-20190528-193514-y3mgrq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/276682/original/file-20190528-193514-y3mgrq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/276682/original/file-20190528-193514-y3mgrq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Two 70-year-olds can be in very different health and have vastly different preferences for what they want out of their health care.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1020771727?src=ECccqepuMQx8KTk8mGnOFA-1-89&size=huge_jpg">Rawpixel.com/Shutterstock</a></span>
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<p>The changes in our body as we age, as well as an increase in the number of diseases, and therefore medications we take, can increase the risks associated with surgery and anaesthesia. </p>
<p>Frailty is the strongest predictor of poor outcomes after surgery. Frailty is a decrease in our body’s reserves and our ability to recover from stressful events such as surgery. Frailty is usually associated with increasing age, but not all older people are frail, and you can be frail and still relatively young. </p>
<h2>Consider the patient’s preferences</h2>
<p>Patients <a href="https://www.ncbi.nlm.nih.gov/pubmed/25531451">tend to overestimate the benefits</a> of surgery and underestimate the harms. This highlights the importance of shared decision-making between patients and clinicians.</p>
<p><a href="https://jamanetwork.com/journals/jama/article-abstract/1910118">Shared decision-making</a> means the patient and clinicians come to a decision together, after discussing the options, benefits and harms, and after considering the patient’s values, preferences and circumstances. </p>
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Read more:
<a href="https://theconversation.com/surgery-isnt-always-the-best-option-and-the-decision-shouldnt-just-lie-with-the-doctor-64228">Surgery isn't always the best option, and the decision shouldn't just lie with the doctor</a>
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<p>Research shows that <a href="https://www.nejm.org/doi/full/10.1056/NEJMsa012528">as we age</a> many of us become less focused on longevity and prolonging life at all costs and much more focused on what that life is like, or our quality of life. </p>
<p>Outcomes such as living independently, staying in our own home, the ability to move around, and being mentally alert often become increasingly important in the decision-making process. This information about a person’s values is critical for shared decision-making conversations.</p>
<p>When considering these preferences, the discussion becomes more than just “could” we do this operation – it’s about “should” we do this operation? Someone living at home with early dementia may decide the risk of this worsening, and the possible need to move to a nursing home, is not worth any benefits of surgery.</p>
<p>It’s also important to note that, in some cases, cognitive impairment and dementia associated with ageing mean it’s not the patient (but <a href="https://www.publicadvocate.vic.gov.au/medical-consent">their appointee</a>) making decisions about surgery.</p>
<h2>Not everyone should be offered surgery</h2>
<p>The ageing of our population raises challenges for policymakers. More surgeries means greater pressure on the health budget. We don’t have a bottomless pit of health funding, so how do we decide who is eligible, based on fair and equitable resource allocation?</p>
<p>Given the marked variability between individuals as we age, decisions and policies about access to medical care (including surgery) should not be based on age alone. There should not be policies that say “no” to surgery based on age. </p>
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<img alt="" src="https://images.theconversation.com/files/276684/original/file-20190528-193540-s5cf6p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/276684/original/file-20190528-193540-s5cf6p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/276684/original/file-20190528-193540-s5cf6p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/276684/original/file-20190528-193540-s5cf6p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/276684/original/file-20190528-193540-s5cf6p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/276684/original/file-20190528-193540-s5cf6p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/276684/original/file-20190528-193540-s5cf6p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">More surgery means greater expenditure.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1023401932?src=6ueJ6xpFUHjwAWifoJ9AqA-1-33&size=huge_jpg">MAD.vertise/Shutterstock</a></span>
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<p>Equally, when considering resource allocation, it should not just be about how many years a person has to live, or blunt assessments based on how much their operation might cost the health system.</p>
<p>Take a decision about performing a hip replacement on a 90-year-old with arthritis, for example. A patient who has an elective hip replacement for arthritis and is able to remain living at home will probably “cost less” overall than if that same person would otherwise have had to live in a nursing home.</p>
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Read more:
<a href="https://theconversation.com/who-gets-a-piece-of-the-pie-spending-the-health-budget-fairly-13997">Who gets a piece of the pie? Spending the health budget fairly</a>
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<p>However, this also does not mean we can, or should, offer surgery to everyone. </p>
<p>The practice of medicine, especially when considering older adults, needs to remain focused on individualised patient care. Decisions should be based on medical appropriateness of treatment combined with a patient’s goals and values.</p>
<p>To do this we need to train clinicians in shared decision-making and how to have these often difficult discussions. The goal is to have clinicians who are able to explore a patient’s values and preferences around outcomes, effectively communicate individualised information about options, benefits and harms, and then come to a decision together.</p><img src="https://counter.theconversation.com/content/116814/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Claire McKie does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Rates of elective surgery are rising most among those aged over 85, due to advances in anaesthesia and techniques such as keyhole surgery. But it’s also much riskier.Claire McKie, Senior Lecturer, Clinical and Communication Skills, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1108952019-02-05T00:10:17Z2019-02-05T00:10:17ZFive warning signs of overdiagnosis<figure><img src="https://images.theconversation.com/files/256981/original/file-20190204-193220-1z1kfm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Being labelled with a serious illness can cause psychological distress.</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/fGx-b0r4Qx8">rawpixel</a></span></figcaption></figure><p>We’ve had it drummed into us over decades that early detection is key to treating diseases early, before they have a chance to turn into something really nasty. </p>
<p>But we’ve since learnt the flip-side of this is <a href="https://annals.org/aim/article-abstract/2597574/accepting-existence-breast-cancer-overdiagnosis">overdiagnosis</a>, where people are diagnosed with diseases that won’t harm them. Overdiagnosis is often followed by overtreatment, where procedures or other therapies are offered that won’t benefit the patient and may cause harm. </p>
<p>The chance discovery of a small thyroid cancer in someone’s neck, for instance, is likely to result in a total thyroidectomy (removal) and lifelong thyroid hormone replacement. But this cancer is <a href="https://www.ncbi.nlm.nih.gov/pubmed/26744340">very unlikely</a> to have caused harm had it been left alone. And studies have found <a href="https://www.nejm.org/doi/10.1056/NEJMp1604412">dramatic increases</a> in thyroid cancer worldwide, without changes in death rates.</p>
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Read more:
<a href="https://theconversation.com/is-it-time-to-remove-the-cancer-label-from-low-risk-conditions-101331">Is it time to remove the cancer label from low-risk conditions?</a>
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<p>Overdiagnosis may also begin with a new, more sensitive test. <a href="https://www.ncbi.nlm.nih.gov/pubmed/28505266">Such tests</a> can expand the number of people who are classified as “diseased” and send them down a path of additional invasive tests such as biopsies, as well as surgery and medication. </p>
<p>After the introduction of a new test for <a href="https://www.mayoclinic.org/diseases-conditions/pulmonary-embolism/symptoms-causes/syc-20354647">pulmonary embolism</a>, for instance, more people were diagnosed with these lung blood clots and started on blood thinning drugs. Some suffered complications such as gut and brain haemorrhages. And despite more people being diagnosed and treated for pulmonary embolism, there was <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/227272">no impact</a> on how many people died from them.</p>
<p>But overdiagnosis is difficult to detect. It can take years for the data to be collected to prove there’s a problem with the new way of diagnosing a disease, based on the new test, compared to the old way.</p>
<p>To speed up the detection process, we have collated a list of <a href="http://annals.org/aim/article/doi/10.7326/M18-2645">five markers</a> to indicate overdiagnosis may be occurring. The markers, published today in the journal <a href="http://annals.org/aim/article/doi/10.7326/M18-2645">Annals of Internal Medicine</a>, can help researchers, health authorities, clinicians and even patients determine whether new tests are candidates for overdiangosis. Here they are as a set of questions:</p>
<ol>
<li> is there potential for more diagnoses with the new test?</li>
<li> are more people actually being diagnosed by the new test?</li>
<li> do the additional people diagnosed have milder or harmless forms of the disease? </li>
<li> are more people being treated?</li>
<li> might the harms of being treated outweigh the benefits?</li>
</ol>
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Read more:
<a href="https://theconversation.com/less-is-the-new-more-choosing-medical-tests-and-treatments-wisely-40756">Less is the new more: choosing medical tests and treatments wisely</a>
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<h2>A better way to detect heart disease? Not quite</h2>
<p>When we applied these questions to a new blood test for acute heart disease – <a href="https://www.ahajournals.org/doi/full/10.1161/CIRCOUTCOMES.117.004468">highly sensitive cardiac troponin</a> (HS-cTn) – we found we answered yes to most of them.</p>
<p>This new test was evaluated in a <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31923-8/fulltext">large trial in Scotland</a>. The trial found that among patients presenting to hospital with a possible heart attack, the new test (HS-cTn) led to more people being told they had suffered injury to their heart muscle. </p>
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<img alt="" src="https://images.theconversation.com/files/256979/original/file-20190204-193206-mmfdv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/256979/original/file-20190204-193206-mmfdv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/256979/original/file-20190204-193206-mmfdv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/256979/original/file-20190204-193206-mmfdv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/256979/original/file-20190204-193206-mmfdv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/256979/original/file-20190204-193206-mmfdv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/256979/original/file-20190204-193206-mmfdv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">New tests aren’t generally subject to the same standards of proof of benefit as medications.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/521751805?src=YyMFtMJUoJy-6i72m0aOog-1-0&size=huge_jpg">Ronald Rampsch/Shutterstock</a></span>
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<p>It also led to more people being given additional tests, such as coronary angiogram (a type of X-ray imaging), and prescribed anti-platelet (blood-thinning) and other drugs to prevent heart disease. The risks of coronary angiogram are rare but include heart attack, stroke, arrhythmia, infection and bleeding. A major side effect of anti-platelet medication is bleeding. </p>
<p>Surprisingly, the new test didn’t mean fewer people died of a heart attack over the following year as was expected, despite the additional people being treated. That possibility, or other more long-term benefits, weren’t ruled out by the trial though, so we were unable to answer the last question with confidence. </p>
<p>The new test, HS-cTn, was <a href="https://www.ahajournals.org/doi/full/10.1161/CIRCOUTCOMES.117.004468">introduced into Australia in 2010</a> and is now <a href="https://www.tctmd.com/news/first-high-sensitivity-troponin-assay-finally-comes-united-states">widely used in Australia, Europe, and the United States</a>. But we still don’t know whether using it improves patients’ lives. </p>
<p>We can’t say for sure whether overdiagnosis is occurring as a result of this new test, but there are enough red flags to identify that it could be a problem. We need to evaluate the new test further.</p>
<h2>More scrutiny of new tests needed</h2>
<p>While we used the example of HS-cTn, the same reservations and uncertainties apply to the <a href="https://www.bmj.com/content/bmj/350/bmj.h705.full.pdf">introduction of many new tests</a>.</p>
<p>New tests aren’t generally subject to the same standards of proof of benefit as medications, before being allowed (and often promoted) on the market. It’s time to change the rules. </p>
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Read more:
<a href="https://theconversation.com/five-commonly-over-diagnosed-conditions-and-what-we-can-do-about-them-82319">Five commonly over-diagnosed conditions and what we can do about them</a>
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<p>Potential harms, as well as benefits, need to be considered before new tests are used in routine clinical practice. At a minimum, processes should be set up to collect and monitor the data needed to answer the five questions. </p>
<p>Regulators should only allow the provisional use of the test in the years immediately after it becomes available; for a limited time period, for instance, or in research contexts. </p>
<p>Further funding would be dependent on proof the test is overall beneficial rather than harmful for patients once both benefits and harms are established.</p>
<p>Without these safeguards, the introduction of new tests will continue to put patients at risk of harm from the very tests and treatments they expect will help them.</p><img src="https://counter.theconversation.com/content/110895/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alexandra Barratt receives funding from National Health and Medical Research Council, and is co-chair of the Preventing Overdiagnosis Scientific Conference 2019. </span></em></p><p class="fine-print"><em><span>Katy Bell receives funding from the Australian National Health and Medical Research Council (Centres of Research Excellence grant No.1104136: Creating sustainable health care: ensuring new diagnostics avoid harms, improve outcomes and direct resources wisely).</span></em></p>New tests may mean more people are diagnosed, but that doesn’t mean they’ll be helped by the label or the treatment. Here are five markers that overdiagnosis may be occuring.Alexandra Barratt, Professor of Public Health, University of SydneyKaty Bell, Senior Lecturer in Clinical Epidemiology and Senior Research Fellow in the School of Public Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1013312018-08-12T20:13:28Z2018-08-12T20:13:28ZIs it time to remove the cancer label from low-risk conditions?<figure><img src="https://images.theconversation.com/files/231570/original/file-20180812-2900-19rz7m6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many people associate the word cancer with major illness or death.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/599606216?src=EkdSPfaYPe_mqU4kw8kIAA-1-72&size=huge_jpg">Shutterstock</a></span></figcaption></figure><p>Over the past few decades, our understanding of cancer has changed. We now know some cancers <a href="https://prevention.cancer.gov/news-and-events/infographics/what-cancer-overdiagnosis">don’t grow or grow so slowly</a> that they’ll never cause medical problems. </p>
<p>But the way we label disease can harm. The use of more medicalised labels, including cancer, can <a href="https://bmjopen.bmj.com/content/7/7/e014129">increase levels of anxiety and the desire for more invasive treatments</a>.</p>
<p>Given this growing evidence, my colleagues and I argue in <a href="https://www.bmj.com/content/362/bmj.k3322">The BMJ</a> today that it may be time to stop telling people with very low-risk conditions that they have “cancer” if they’re unlikely to be harmed by it.</p>
<h2>Our understanding of cancer has changed</h2>
<p>Cancer screening for people who have no symptoms and the use of increasingly sensitive technologies can lead to <a href="https://www.bmj.com/content/350/bmj.h869">overdiagnosis</a> – a diagnosis that causes more harm than good. Overdiagnosis is most common in breast, prostate and thyroid cancer. </p>
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Read more:
<a href="https://theconversation.com/most-people-want-to-know-risk-of-overdiagnosis-but-arent-told-41889">Most people want to know risk of overdiagnosis, but aren't told</a>
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</p>
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<p>Thyroid cancer diagnoses, for example, have <a href="https://www.nejm.org/doi/full/10.1056/NEJMp1604412">dramatically increased</a> in developing countries. This has mainly been driven by an increase in the detection of papillary thyroid cancers. These are a sub-type of thyroid cancer which are often small (less than 2cm in size) and slow-growing.</p>
<p>But death rates from thyroid cancer remain largely unchanged. And tumour growth and spread in patients with small papillary thyroid cancer who choose surgery are <a href="https://www.sciencedirect.com/science/article/pii/S0748798317303700?via%3Dihub">similar to those</a> who just monitor their condition. </p>
<p>In fact, <a href="http://ascopubs.org/doi/abs/10.1200/JCO.2016.67.7419?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed&">autopsy studies spanning over 60 years</a> show thyroid “cancers” have always been common but often went undetected and didn’t cause harm. </p>
<h2>Impact of the cancer label</h2>
<p>Many people associate the word cancer with major illness or death. It can be frightening to hear. This association has been ingrained by public health messaging that cancer screening saves lives. </p>
<p>Although this promotion has had the best of intentions, it has also <a href="https://www.nejm.org/doi/full/10.1056/nejmp1209407">induced feelings of fear and vulnerability</a> in the population. It has then offered hope, through screening. </p>
<p>After decades, this messaging has resulted in <a href="https://jamanetwork.com/journals/jama/fullarticle/197942">highly positive attitudes towards cancer screening</a> and early treatment. It has also led to an increased, sometimes unwarranted, <a href="http://journals.sagepub.com/doi/abs/10.1177/0272989X05282639?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed&">desire for surgery</a>. </p>
<p><a href="https://bmjopen.bmj.com/content/7/7/e014129">Several studies</a> show the cancer label, and the use of medicalised labels in various other conditions, leads to higher levels of anxiety and perceived severity of the condition, as well as a greater preference for invasive treatments.</p>
<p>The increased desire for more aggressive treatments has been shown clinically in ductal carcinoma in situ (DCIS) of the breast (sometimes known as stage O breast cancer). Women are <a href="https://link.springer.com/article/10.1245%2Fs10434-014-4334-x">increasingly choosing</a> mastectomy and bilateral mastectomy (removal of one or both breasts) rather than lumpectomy (removal of the lump), even though these <a href="https://www.nytimes.com/2015/08/21/health/breast-cancer-ductal-carcinoma-in-situ-study.html">treatments do not change their odds</a> of dying of breast cancer. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/treating-stage-0-breast-cancer-doesnt-always-save-womens-lives-so-should-we-screen-for-it-46624">Treating 'stage 0' breast cancer doesn't always save women's lives so should we screen for it?</a>
</strong>
</em>
</p>
<hr>
<p>Similarly, in localised prostate cancer, active surveillance has been a recommended management option for a number of years, which means monitoring the condition and not providing immediate treatment. But men are <a href="https://www.nytimes.com/2016/05/25/health/prostate-cancer-active-surveillance-surgery-radiation.html">only beginning to avoid immediate treatment</a> and follow active surveillance at similar rates to men who choose surgery or radiation. </p>
<p>There is also evidence and informed speculation that melanoma in situ (also called stage 0 melanoma), small lung cancers, and some small kidney cancers may similarly be considered low risk and subject to overdiagnosis and overtreatment.</p>
<h2>A strategy to reduce overdiagnosis and overtreatment</h2>
<p>Removing the cancer label is <a href="https://www.sciencedirect.com/science/article/pii/S1470204513705989?via%3Dihub">one strategy</a> that has been proposed in recent years by international cancer experts to reduce overdiagnosis and overtreatment in some low-risk conditions. </p>
<p>The cancer label has previously been removed when there was clear evidence the condition was low-risk and very unlikely to cause harm. In 1998, “papilloma and grade 1 carcinoma of the bladder” was <a href="https://insights.ovid.com/pubmed?pmid=9850170">re-labelled</a> to “papillary urothelial neoplasia of low malignant potential”. The word carcinoma, which is another way of saying cancer, was dropped.</p>
<p>More recently, reference to “cancer” <a href="https://jamanetwork.com/journals/jamaoncology/fullarticle/2513250">was removed from a sub-type of papillary thyroid cancer</a>, which is identified after surgery. This was done to eliminate the need for ongoing follow-up and reduce any potential patient anxiety. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/informed-aussies-less-likely-to-want-a-prostate-cancer-test-36880">Informed Aussies less likely to want a prostate cancer test</a>
</strong>
</em>
</p>
<hr>
<p>It’s vital we learn from these past examples. We also need to establish a formal evaluation of the impact that removing the cancer label will have on clinical practice and patient outcomes, to drive effective reform. </p>
<p>Ultimately, removing the cancer label will create controversy and take time. But the end result should better support appropriate evidence-based care for both future and current patients.</p><img src="https://counter.theconversation.com/content/101331/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Brooke Nickel receives funding from Sydney Catalyst and a National Health and Medical Research Council grant. </span></em></p>Labelling very low-risk conditions as cancers can cause unnecessary anxiety and lead to overtreatment.Brooke Nickel, PhD Candidate, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/575162016-04-20T04:36:40Z2016-04-20T04:36:40ZWhy over-treating malaria in Africa is a problem, and how it can be stopped<figure><img src="https://images.theconversation.com/files/119236/original/image-20160419-13898-h2wcv4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">In Africa, over-treatment happens when a person who has malaria symptoms gets medication without a test.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/worldbank/7826340142/">Arne Hoel/World Bank</a></span></figcaption></figure><p>Malaria policymakers and clinicians are concerned about the clinical, financial and public health harms associated with over-treating malaria. </p>
<p>Over-treatment happens when a person who doesn’t have malaria is given antimalarial drugs unnecessarily. This could be a person who has malaria-like symptoms such as fever. </p>
<p>About 88% of the world’s malaria cases are found <a href="http://www.who.int/malaria/publications/world-malaria-report-2015/report/en/">in Africa</a>. As a result, over-treatment of malaria is most common on the continent. </p>
<p>There are three main issues with over-treatment. </p>
<ul>
<li><p>The first is that because malaria has been so prevalent there is a danger that all fevers are diagnosed as being caused by the disease. This means that other serious infections could be missed. This is particularly true as the number of malaria cases has <a href="http://www.afro.who.int/en/downloads/cat_view/1501-english/1235-clusters-and-programmes/795-malaria-mal.html?start=15">dropped</a> in many countries. </p></li>
<li><p>Second, the <a href="http://www.who.int/malaria/publications/world-malaria-report-2015/report/en/">currently recommended</a> first-line antimalarial drugs – artemisinin-based combination therapies – are not cheap. Their unnecessary use leads to a waste of resources.</p></li>
<li><p>And third, in some countries, resistance against these drugs has emerged. They therefore need to be used sparingly.</p></li>
</ul>
<p>To help overcome this problem the use of rapid diagnostic tests should be expanded. The tests have been around for at least six years and have changed the way that malaria is diagnosed. They can detect the presence of malaria within minutes and can be used in basic health care services in remote places. </p>
<p>In 2010 the World Health Organisation <a href="http://www.afro.who.int/en/downloads/cat_view/1501-english/1235-clusters-and-programmes/795-malaria-mal.html?start=15">recommended</a> that countries switch to this method of universal testing before treatment can begin. </p>
<p>There has been a rapid scaling up of the use of the tests in recent years. Nevertheless, over-treatment of malaria remains a problem.</p>
<h2>Why over-treatment happens</h2>
<p>Up until about 15 years ago, policymakers such as the World Health Organisation promoted a strategy known as <a href="http://www.afro.who.int/en/downloads/cat_view/1501-english/1235-clusters-and-programmes/795-malaria-mal.html?start=15">“presumptive treatment of malaria”</a>. This meant that in areas where diagnostic testing was unavailable, patients with fever were treated with antimalarials. </p>
<p>This happened whether or not there were signs of any other illnesses. As a result, there was a substantial <a href="http://malariajournal.biomedcentral.com/articles/10.1186/1475-2875-10-107">overuse of chloroquine</a>, the drug used to treat malaria before artemisinin. Chloroquine was <a href="http://www.afro.who.int/en/downloads/cat_view/1501-english/1235-clusters-and-programmes/795-malaria-mal.html?start=15">cheap and well tolerated</a> by the body.</p>
<p>Previous health worker training emphasised the danger of missing a case of malaria and sending a child home <a href="http://www.afro.who.int/en/downloads/cat_view/1501-english/1235-clusters-and-programmes/795-malaria-mal.html?start=15">without treatment</a>. This ingrained a belief in health workers and is likely to take time to change. They will require evidence based reassurance that the new policy of testing before treating is safe.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/119238/original/image-20160419-13923-1v6lkn6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/119238/original/image-20160419-13923-1v6lkn6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=402&fit=crop&dpr=1 600w, https://images.theconversation.com/files/119238/original/image-20160419-13923-1v6lkn6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=402&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/119238/original/image-20160419-13923-1v6lkn6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=402&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/119238/original/image-20160419-13923-1v6lkn6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=505&fit=crop&dpr=1 754w, https://images.theconversation.com/files/119238/original/image-20160419-13923-1v6lkn6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=505&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/119238/original/image-20160419-13923-1v6lkn6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=505&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Antimalarial medication.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/worldbank/7826321350/">Arne Hoel/World Bank</a></span>
</figcaption>
</figure>
<p>In our <a href="http://www.bmj.com/content/352/bmj.i107">paper</a> we analysed three scenarios that can lead to over-treatment. When:</p>
<ul>
<li><p>treatment is based on symptoms and no tests done;</p></li>
<li><p>negative test results are ignored and treatment is administered; or</p></li>
<li><p>tests erroneously give positive results and treatment is administered.</p></li>
</ul>
<p>Studies have highlighted how these scenarios play out. In Uganda, around two-thirds of people seek malaria treatment from retail drug stores, where testing is rarely <a href="http://www.sciencedirect.com/science/article/pii/S0277953611000517">done</a>. This seems to be <a href="http://www.sciencedirect.com/science/article/pii/S1471492213000184">true</a> in other African countries.</p>
<p>In <a href="http://malariajournal.biomedcentral.com/articles/10.1186/1475-2875-6-57">Kenya</a>, over-the-counter malaria medicines are the most-popular first response to fever in children and adults with acute illnesses.</p>
<p>Another reason for not testing is a shortage of rapid tests. Surveys of facilities in <a href="http://malariajournal.biomedcentral.com/articles/10.1186/1475-2875-12-293">Tanzania</a>, <a href="http://malariajournal.biomedcentral.com/articles/10.1186/1475-2875-13-295">Mozambique</a> and the <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0071442">Democratic Republic of Congo</a> estimated that between 50% and 62% did not have rapid diagnostic tests in stock. </p>
<p>Even when the tests are available, in some instances they are not universally used. In one <a href="http://malariajournal.biomedcentral.com/articles/10.1186/1475-2875-12-293">Tanzanian study</a> staff reverted to presumptive treatment when the patient workload was high or there were staff shortages.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/119237/original/image-20160419-13919-yrrlyy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/119237/original/image-20160419-13919-yrrlyy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/119237/original/image-20160419-13919-yrrlyy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/119237/original/image-20160419-13919-yrrlyy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/119237/original/image-20160419-13919-yrrlyy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/119237/original/image-20160419-13919-yrrlyy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/119237/original/image-20160419-13919-yrrlyy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A boy in Busia, Western Kenya, has a rapid diagnostic malaria test.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/livinggoods/20447469773/in/photolist-bLePu2-x9SCoi-xPf6gH-xPfiGK-y7rbWD-x9SHZP/">Living Goods Kenya/flickr</a></span>
</figcaption>
</figure>
<h2>Why rapid diagnostic tests are the answer</h2>
<p>Rapid diagnostic tests are accurate and can reduce over-treatment by 95% if they are available and used correctly. They are conducted next to the patient and the results are made available within minutes. There is no need to send blood samples to a laboratory, which can take several days and delay treatment. </p>
<p>But successful universal use of the test will need different interventions across public, private and retail sectors. The latest <a href="http://www.who.int/malaria/publications/world-malaria-report-%202015/report/en/">World Health Organisation data</a> shows that the use of diagnostic testing across the continent increased from 41% in 2010 to 65% in 2014. But this only reflects use in the public-sector health facilities. Many people still seek anti-malarial treatment from retail drug stores as a first response to fever.</p>
<p>There are three processes that can improve the use of these tests. </p>
<ul>
<li><p>First, improving the management at healthcare centres would mean they don’t run out of rapid diagnostic tests. </p></li>
<li><p>Second, technology can help. This was evaluated in rural districts in <a href="http://malariajournal.biomedcentral.com/articles/10.1186/1475-2875-9-298">Tanzania</a> and <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0054066">Kenya</a>. The use of mobile phones, particularly <a href="http://malariajournal.biomedcentral.com/articles/10.1186/1475-2875-9-298">SMS services</a>, and the internet means that health low stocks can be notified. The quality assurance of the tests can also be improved. </p></li>
<li><p>Third, the rapid diagnostic tests should be subsidised. Previously, a <a href="https://heapol.oxfordjournals.org/content/early/2015/04/09/heapol.czv028.full">subsidy</a>for artemisinin successfully increased its availability in the private sector. <a href="http://www.bmj.com/content/350/bmj.h1019.short">Research</a> has proposed that a similar approach could improve the use of rapid diagnostic tests.</p></li>
</ul><img src="https://counter.theconversation.com/content/57516/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Eleanor Ochodo does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Despite tests which rapidly test for malaria being around for several years, overtreatment of malarial drugs still takes place in Africa.Eleanor Ochodo, Senior Researcher and Lecturer, Centre for Evidence-Based Health Care, Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/569242016-03-31T19:20:35Z2016-03-31T19:20:35ZResisting expanding disease empires: why we shouldn’t label healthy people as sick<figure><img src="https://images.theconversation.com/files/116871/original/image-20160331-28472-11ghdvy.jpg?ixlib=rb-1.1.0&rect=0%2C95%2C1600%2C970&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Expanding the definitions of disease can cause a cascade of overtesting and overtreatment.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/ftmeade/7349088852/">Fort George G. Meade Public Affairs Office/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>You might have heard the frightening news last year suggesting half of all Americans had some form of diabetes. A <a href="http://jama.jamanetwork.com/article.aspx?articleid=2434682">survey in the journal JAMA</a> was covered extensively, including by <a href="http://www.nbcnews.com/health/diabetes/half-americans-have-diabetes-or-high-blood-sugar-survey-finds-n423491">NBC</a>, <a href="http://www.webmd.com/diabetes/news/20150908/diabetes-prediabetes-americans">WebMD</a> and the <a href="http://www.latimes.com/science/la-sci-sn-diabetes-study-20150908-story.html">Los Angeles Times</a>. </p>
<p>But as the <a href="http://www.healthnewsreview.org/2015/09/half-of-americans-have-diabetes-or-pre-diabetes-really-what-does-that-mean/">HealthNewsReview blog</a> later pointed out, almost none of the media coverage raised questions about the expanding definition of diabetes or the controversial new “pre-diabetes”, <a href="https://content.govdelivery.com/accounts/USCDC/bulletins/13b4f85">claimed to afflict</a> close to 90 million Americans. </p>
<p>Part of the expanding empires of disease, the creation of new “pre-conditions” is turning millions of people into patients across the globe. We now have pre-osteoporosis, pre-hypertension and pre-dementia – and, like pre-diabetes, all of them are controversial. </p>
<p>An <a href="http://www.bmj.com/content/349/bmj.g4485">article in The BMJ</a> (British Medical Journal) in 2014 asked bluntly “whether it is worth having the category of pre-diabetes at all”. It suggested the term go into cold storage until it was clear that the millions of people being labelled with it would actually benefit. </p>
<p>“Rather than turning healthy people into patients with pre-diabetes,” argued two distinguished professors in The BMJ, “we should use available resources to change the food, education, health and economic policies that have driven this epidemic.” </p>
<h2>Diagnosis creep</h2>
<p>As I explain in an editorial on this problem of “diagnosis creep” in <a href="http://www.australianprescriber.com/">the journal Australian Prescriber</a> today, there is an urgent need for much greater scepticism about the expanding empires of disease – and we’re not just talking about pre-diseases. </p>
<p>A dramatically expanded definition of “chronic kidney disease” gives a label to around one in ten adults, and almost half of the elderly, many of whom will never suffer any kidney disease, chronic or otherwise. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/116873/original/image-20160331-6126-1afmtu8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/116873/original/image-20160331-6126-1afmtu8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/116873/original/image-20160331-6126-1afmtu8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/116873/original/image-20160331-6126-1afmtu8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/116873/original/image-20160331-6126-1afmtu8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/116873/original/image-20160331-6126-1afmtu8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/116873/original/image-20160331-6126-1afmtu8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The creation of new</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/dfid/15834977505/">DFID - UK Department for International Development/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>New diagnostic criteria will almost triple the numbers of pregnant women who are labelled as having gestational diabetes – without good evidence that the newly labelled women or their babies will benefit. </p>
<p>And thresholds that define attention-deficit hyperactivity disorder (ADHD) continue to fall, which means even more children and now adults will be diagnosed.</p>
<h2>Early diagnosis is a double-edged sword</h2>
<p>Medicine is transforming more and more formerly healthy people into patients and building ever bigger potential markets for the industries that sell treatments. </p>
<p>Some of the newly labelled patients will benefit – early detection can mean deadly disease is stopped in its tracks. </p>
<p>But early diagnosis is a double-edged sword. For other people with mild problems or at very low risk of future illness, a diagnosis can bring more harm than good. It can cause a cascade of overtesting and overtreatment and waste precious resources better spent on those in greatest need. </p>
<p>A few years ago, colleagues and I analysed changes made by expert panels of doctors to the definitions of 14 common conditions, including high-blood pressure, depression, arthritis and Alzheimer’s disease. Our study was published in the international journal <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001500">PLOS Medicine</a> and was covered on <a href="https://theconversation.com/how-diseases-get-defined-and-what-that-means-for-you-16965">The Conversation</a>. </p>
<p>In summary, most conditions were expanded – including high blood pressure, Alzheimer’s disease, high cholesterol, depression, rheumatoid arthritis, multiple sclerosis and myocardial infarction or heart attack. Pre-diseases were created, thresholds for diagnosis were lowered, or the processes used to diagnose were changed so that people would be diagnosed and labelled earlier. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/116874/original/image-20160331-28443-q29qmn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/116874/original/image-20160331-28443-q29qmn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/116874/original/image-20160331-28443-q29qmn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/116874/original/image-20160331-28443-q29qmn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/116874/original/image-20160331-28443-q29qmn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/116874/original/image-20160331-28443-q29qmn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/116874/original/image-20160331-28443-q29qmn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">There’s no evidence to suggest patients benefit from expanded definitions.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-133606469/stock-photo-man-reading-prescription-bottle.html?src=EEiSdHN_5TmJiOIks_-e0g-3-11">Burlingham/Shutterstock</a></span>
</figcaption>
</figure>
<p>No panel rigorously investigated and reported on the potential downside of their decision to expand – the danger that some people might be caught unnecessarily by the newly widened definitions. </p>
<p>No panels reported on the possibility that the new patients created by the new definitions might be “<a href="https://theconversation.com/preventing-over-diagnosis-how-to-stop-harming-the-healthy-8569">overdiagnosed</a>” – they might be labelled with a disease that would never harm them, or be given a diagnosis and treatment that would do them more harm than good. </p>
<h2>An epidemic of conflicts of interest</h2>
<p>Perhaps most disturbingly, among the panels of experts who included disclosure sections in their publications, 75% revealed multiple financial ties to around seven drug companies each. </p>
<p>These influential doctors – who were deciding whether millions of people around the world would be defined as healthy or sick – were being paid directly by pharmaceutical companies for activities like speaking, consulting, advising or researching. </p>
<p>This epidemic of conflicts of interest is in direct contrast to recommendations from organisations like the prestigious <a href="http://www.nationalacademies.org/hmd/Reports/2009/Conflict-of-Interest-in-Medical-Research-Education-and-Practice.aspx">US Institute of Medicine</a>, which is calling for much greater independence among those who write influential medical guidelines. </p>
<p>Some of the conflicts are unbelievable. Among the expert guideline panel that in 2003 created a diagnostic category called “pre-hypertension” or pre-high blood pressure, <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001500">80% of members disclosed ties</a> to an average of around 12 companies each, including companies selling drugs for high blood pressure. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/116877/original/image-20160331-28476-14ttq53.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/116877/original/image-20160331-28476-14ttq53.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/116877/original/image-20160331-28476-14ttq53.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/116877/original/image-20160331-28476-14ttq53.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/116877/original/image-20160331-28476-14ttq53.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=425&fit=crop&dpr=1 754w, https://images.theconversation.com/files/116877/original/image-20160331-28476-14ttq53.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=425&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/116877/original/image-20160331-28476-14ttq53.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=425&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Exercise a healthy scepticism about how new diseases are defined.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-328829339/stock-photo-blurred-image-people-sitting-in-hospital-room.html?src=7cShDS-DUX7sE_FJiZOZLQ-1-58">NanD_PhanuwatTH/Flickr</a></span>
</figcaption>
</figure>
<p>More than half of the members of the 2011 panel that described “pre-dementia” and defined “pre-clinical” Alzheimer’s disease <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001500">had financial ties</a> to around five companies each. </p>
<p>It was a similar situation for the <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001500">2012 psychiatric panels</a> that widened the definitions of depression and attention-deficit hyperactivity disorder. More than half of the experts disclosed links to drug companies, including those that could directly benefit by selling drugs to expanded patient populations.</p>
<h2>Reforming unhealthy disease definitions</h2>
<p>There is a growing unease about these expanding empires of disease and the epidemics of conflicts of interest among those driving the expansion. </p>
<p>A series in The BMJ is <a href="http://www.bmj.com/content/347/bmj.f4247">examining expanding disease definitions</a> and the risk of overdiagnosis. It has already included articles on the controversy over gestational diabetes, attention-deficit hyperactivity disorder, chronic kidney disease, pre-dementia, mild hypertension, osteoporosis and pulmonary embolism. </p>
<p>A group of GPs in the UK have successfully lobbied the Royal College of General Practitioners to set up a standing committee to address overdiagnosis. <a href="http://bjgp.org/content/66/644/116.long">Some of them last month called for</a> a “grassroots revolution” to tackle this problem. </p>
<p>Across Europe, the new “quaternary prevention” movement is also gathering strength. This doctor-led movement is aimed at preventing people receiving diagnoses that may do them more harm than good. </p>
<p>Globally, the Guidelines International Network – an umbrella group for all medical guidelines – has <a href="http://www.g-i-n.net/working-groups/overdiagnosis">just created an overdiagnosis working group</a> to push the process of reform. </p>
<p>At the same time, many global initiatives are addressing the problem of too much medicine, including <a href="http://www.choosingwisely.org.au/home">Choosing Wisely</a>, <a href="http://lowninstitute.org/">The Right Care campaign</a> and the international <a href="http://www.preventingoverdiagnosis.net">Preventing Overdiagnosis conferences</a>, the fourth being held in Barcelona this September. </p>
<p>But until we see genuine reform of the conflicted panels that define diseases – greater independence, more broadly representative and much more interested in both the benefits and harms of their decisions – a healthy scepticism about expanding definitions is highly recommended. </p>
<p><em>This ideas in this article are based on a piece published today in the peer-reviewed journal <a href="http://www.australianprescriber.com/">Australian Prescriber</a>.</em></p><img src="https://counter.theconversation.com/content/56924/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr Ray Moynihan and colleagues have recently received funding from the NHMRC to investigate the problems of overdiagnosis and overtreatment. Ray is a Senior Research Fellow at Bond University, and an honorary Senior Research Fellow at the Sydney Medical School - Public Health. He is also co-chair of the scientific committee for the Preventing Overdiagnosis international conference, taking place in September 2016. </span></em></p>The creation of new “pre-conditions” is turning millions of people into patients across the globe.Ray Moynihan, Senior Research Fellow, Bond UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/560072016-03-15T19:08:01Z2016-03-15T19:08:01ZAntibiotics for colds, x-rays for bronchitis, internal exams with pap tests – the latest list of tests to question<figure><img src="https://images.theconversation.com/files/115059/original/image-20160315-17766-1oucbfb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Among the 61 recommendations is: 'Don’t order chest x-rays in patients with uncomplicated acute bronchitis'.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/">Monkey Business Images/Shutterstock</a></span></figcaption></figure><p>The problem of questionable treatment and tests which may provide little or no benefit, yet may cause harm, is ubiquitous across all areas of health care. </p>
<p>Harm doesn’t just come in the form of side-effects or further testing. The “cons” of any treatment or test also include the costs, which can be financial, emotional, and the costs of the individual’s time. </p>
<p>The <a href="https://theconversation.com/less-is-the-new-more-choosing-medical-tests-and-treatments-wisely-40756">Choosing Wisely campaign</a> encourages patients and clinicians to question unnecessary treatments. First launched in America in 2012 and in Australia last year, the clinician-led initiative collates lists of tests, treatments and procedures that provide little or no value, and which may cause harm. </p>
<p>Today the Australian organisers, NPS MedicineWise, will release an additional 61 recommendations. These include:</p>
<ul>
<li><p>Don’t order chest x-rays in patients with uncomplicated acute bronchitis (<em>Routine chest x-rays don’t improve outcomes and may lead to false positives, further investigations and unnecessary radiation</em>)</p></li>
<li><p>Avoid prescribing antibiotics for upper respiratory tract infections, also known as the common cold (<em>Most uncomplicated upper respiratory infections are viral and antibiotic therapy isn’t suitable</em>)</p></li>
<li><p>Don’t initiate medicines to prevent disease in patients who have a limited life expectancy (<em>There is limited evidence to support the use of many medicines in frail, elderly patients who are more susceptible to the side-effects of medicines</em>) </p></li>
<li><p>Don’t routinely do a pelvic examination with a pap smear (<em>The procedure can cause pain, fear, anxiety and embarrassment and can lead to unnecessary, invasive and potentially harmful diagnostic procedures</em>)</p></li>
<li><p>Don’t request imaging for patients with non-specific low back pain (<em>Trials have consistently shown there is no advantage from routine imaging of non-specific low back pain and there are potential harms</em>).</p></li>
</ul>
<p>The need for informed conversations about potentially unnecessary treatments, tests and procedures is certainly not restricted to only the medical professions.</p>
<p>As well as the medical colleges and societies involved, it is encouraging that in this second release, organisations which represent nurses and allied health professionals such as physiotherapists and hospital pharmacists have participated. Hopefully in future releases, we will see more of Australia’s allied health organisations becoming involved in Choosing Wisely. </p>
<p>As with the <a href="https://theconversation.com/less-is-the-new-more-choosing-medical-tests-and-treatments-wisely-40756">2015 lists</a>, most of the recommendations are about doing less. Only a few are about encouraging a particular action to be done. An example is having an earlier conversation about prognosis, wishes, values and end of life in patients with advanced disease. </p>
<p>This may be because we clinicians are guilty more often of doing too much than too little. </p>
<p>This is counter-intuitive to most of us. Somehow, the thought that a clinician might have not done enough feels more reprehensible than their having done too much. And this is not just what patients might think – it’s probably true of many clinicians as well. </p>
<p>The memories of many junior hospital doctors probably include over-ordering tests (“just in case”, but also to demonstrate their knowledge of rare diagnostic possibilities) to avoid their seniors criticising them during an upcoming ward round. </p>
<p>The realisation that patients can actually be harmed more by receiving unnecessary tests, procedures, and treatments, than by not having received them has been painfully slow. </p>
<p>The Choosing Wisely campaign helps to signal a very important departure from normal business for clinicians and their organisations – thinking about <em>not</em> doing things. </p>
<p>While one of the drivers behind the Choosing Wisely campaign is reducing the tests and treatments people receive that provide little or no benefit, another is minimising the harm that can result from them. </p>
<p>For many of the recommendations, the harm is one that affects the individual. Quite a few of the recommendations are about not doing medical imaging and screening (such as not requesting imaging for non-specific low back pain). These typify individual harm – for example, unnecessary radiation exposure increases the risk of cancer. </p>
<p>Then there is a cluster of recommendations about the wise use of antibiotics. Antibiotic use has the interesting peculiarity of potentially causing harm to both individual patients and the community. We know that antibiotics – which can be life-saving for some serious infections such as meningitis and pneumonia – have little benefits to the common coughs and colds that make up a huge proportion of general practitioner visits. On balance, these benefits are of the same order as the common harms they cause (such as vaginal or oral thrush, diarrhoea, rashes, and so on). </p>
<p>But another important harm is the risk of inducing resistance. Antibiotic resistance – when bacteria adapt and antibiotics fail – is a deepening crisis that is <a href="https://theconversation.com/antibiotic-resistance-sorry-not-my-problem-44011">already killing thousands directly</a> and may soon disrupt many routine clinical procedures. </p>
<p>Antibiotic resistance is a direct result of antibiotic use. The more antibiotics are used when they are not needed, the less likely they are to be effective when needed for a bacterial infection. </p>
<p>So while the unnecessary use of antibiotics has potential harms to the individual, it can also contribute to the restricted use of antibiotics by others in the community who do need it. </p>
<p>For all of the recommendations, there is the harm to society that occurs from the wasted resources and cost of providing unnecessary tests and treatments, often at the expense of more effective uses of precious health care dollars. </p>
<p>But the premise behind Choosing Wisely is not about cost-cutting. It is one of the few existing processes for dealing with the one-way ratchet caused by more treatments and tests being generated every year, all of which increases the amount of things that can – but not necessarily should – be provided to patients. </p>
<p>No test or treatment should be provided to a patient <a href="https://www.mja.com.au/journal/2014/201/1/shared-decision-making-what-do-clinicians-need-know-and-why-should-they-bother">without a conversation</a> between the patient and clinician, during which the options (including the option of doing nothing), their benefits and harms, and the patient’s preferences and values <a href="http://www.choosingwisely.org.au/5-questions-to-ask-your-doctor">are discussed</a>.</p><img src="https://counter.theconversation.com/content/56007/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tammy Hoffmann has received funding from the NHMRC and ACSQHC for research about shared decision making.</span></em></p><p class="fine-print"><em><span>Chris Del Mar receives funding from the NHMRC and ACSQHC for related research </span></em></p>Harm doesn’t just come in the form of side-effects or further testing. The “cons” of any treatment also include the costs, which can be financial, emotional, and the costs of the individual’s time.Tammy Hoffmann, Professor of Clinical Epidemiology, Bond UniversityChris Del Mar, Professor of Public Health, Bond UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/482392015-09-29T02:27:34Z2015-09-29T02:27:34ZCostly and harmful: we need to tame the tsunami of too much medicine<figure><img src="https://images.theconversation.com/files/96562/original/image-20150929-30976-vga2ax.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">GPs have increased their test ordering by more than 50%. Imaging for back pain is one of the key culprits.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/white_ribbons/6090449846/">lauren rushing/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span></figcaption></figure><p>ABC’s Four Corners program on <a href="http://www.abc.net.au/4corners/stories/2015/09/28/4318883.htm">waste in health care</a> didn’t pull any punches. “Many common treatments are often unnecessary, ineffective, or worse still harmful,” said presenter Kerry O’Brien, introducing a special investigation narrated by long-time ABC health reporter Dr Norman Swan. “Waste runs into tens of billions of dollars a year – much of it due to overdiagnosis and the ill-advised treatments that follow.” </p>
<p>For those who missed it, last night’s program focused on several high-cost areas of health care where the evidence suggests that too much medicine is doing us more harm than good: knee pain, back pain, chest pain and PSA (prostate specific antigen) screening for prostate cancer. </p>
<p>The program’s key targets were sophisticated and expensive medical tests – such as <a href="http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/ct_scan">computed tomography</a> (CT) scans and magnetic resonance imaging (MRIs) – being ordered in ever greater numbers, often unnecessarily. In the past ten years for example, GPs have increased their test ordering by more than 50%. This equates to around four million extra tests a year. </p>
<p>While it might seem like common sense to want to take a test to see what’s wrong, the problem is that test results can often be misleading and unhelpful – and can start a cascade of further unnecessary tests and treatments. </p>
<h2>‘Fixing’ ageing knees</h2>
<p>Take knee pain, for example. In the Four Corners program, Professor Rachelle Buchbinder explained that if you give MRIs to healthy people who have no knee pain, you will still find “abnormalities” in their MRI results. This is partly because of the normal wear and tear associated with ageing.</p>
<p>“A picture in medicine does not always tell a story – a positive test may not mean a thing,” said Swan. “We’re getting a whole lot of knee scans that we don’t need and which cause us risk and expense.” </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/96567/original/image-20150929-30970-1b3jq1t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/96567/original/image-20150929-30970-1b3jq1t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/96567/original/image-20150929-30970-1b3jq1t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/96567/original/image-20150929-30970-1b3jq1t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/96567/original/image-20150929-30970-1b3jq1t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/96567/original/image-20150929-30970-1b3jq1t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/96567/original/image-20150929-30970-1b3jq1t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Arthroscopies are needlessly performed for osteoarthritis of the knee.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/21072575@N00/3567686583/">Laundry Broad/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p>The knee example gets worse. </p>
<p>The unnecessary MRI might show some “abnormality” with the knee which has nothing to do with your pain, but is worrying enough to land you with an orthopedic surgeon who recommends and performs an arthroscopy. </p>
<p>But as Buchbinder pointed out, there is evidence, from the <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa013259">New England Journal of Medicine</a> no less, suggesting arthroscopy for osteoarthritis of the knee is no better than sham surgery or placebo. More recent evidence, again from the <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1305189">NEJM</a>, suggests arthroscopy to clean up a tear to the meniscus is also no better than sham surgery. </p>
<h2>Too much agreement</h2>
<p>One criticism of the Four Corners program is that almost all the interviewees shared the view Australia is doing too many tests and treatments, and urgently needs to wind them back. We didn’t hear anyone take the view we need <em>more</em> medicine not less. </p>
<p>To counter that criticism, and in defence of the program, one of the important roles of investigative media is sometimes to take a perspective and run an argument. There’s undeniably mounting evidence of <a href="https://theconversation.com/au/topics/overdiagnosis">overuse and overdiagnosis</a>, and the scientific credibility of those interviewed was impeccable. </p>
<p>Take Dr Robyn Ward, a cancer specialist and chair of Australia’s Medical Services Advisory Committee, which uses an evidence-based approach to assess new tests and procedures. “Often the best medicine is no medicine at all, or the best intervention is no intervention at all,” said Ward, who sees Australia’s fee-for-service system, which largely rewards doctors for throughput, as one of the drivers of excess. </p>
<p>Other drivers covered in the program included professional interests, commercial forces, technological change, expanding disease definitions, patient demand and cultural faith in early detection.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/96568/original/image-20150929-30984-tdwmmw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/96568/original/image-20150929-30984-tdwmmw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/96568/original/image-20150929-30984-tdwmmw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/96568/original/image-20150929-30984-tdwmmw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/96568/original/image-20150929-30984-tdwmmw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/96568/original/image-20150929-30984-tdwmmw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/96568/original/image-20150929-30984-tdwmmw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Professional interests and expanding disease definition can drive overdiagnosis.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/proimos/6870109454/">Alex Proimos/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span>
</figcaption>
</figure>
<p>Another interviewee was Associate Professor Adam Elshaug, who has produced internationally respected work on what’s called “low-value care”. His landmark article, published in the <a href="https://www.mja.com.au/journal/2012/197/10/over-150-potentially-low-value-health-care-practices-australian-study">Medical Journal of Australia</a> in 2012, listed scores of tests and treatments that are being overused or misused. </p>
<h2>A third of health-care costs squandered</h2>
<p>One of the key claims in the Four Corners program was that almost a third of the money being spent on health care is “squandered”. If you include everything we spend, that’s potentially A$46 billion a year wasted. </p>
<p>While this may well be the case in Australia, it’s perhaps worth pointing out that this estimate arises from studies in the United States. </p>
<p>A key paper in the <a href="http://jama.jamanetwork.com/article.aspx?articleid=1148376">Journal of the American Medical Association</a> in 2012 estimated that total health-care waste in the US – including overtreatment, fraud, administrative complexity and other flaws – accounted for between 20% and 50% of the total cost of health care – with the midpoint estimate being 34%. Hence the one-third figure. </p>
<p>To my knowledge, there are as yet no similarly rigorous estimates of waste in Australian health care. </p>
<h2>Where to from here?</h2>
<p>The federal government is running a major review of all tests and treatments covered by Medicare, with <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/consultation-mbsreviewtaskforce">consultation papers</a> released on the weekend. </p>
<p>According to those documents, a key objective of the review “is to eliminate the funding of low-value or inappropriate health services — that is, treatments, procedures and tests which are of little or no clinical benefit, through overuse or misuse, and which in some cases might actually cause harm to patients”. </p>
<p>Apart from the harms, there is also the tsunami of rapidly rising costs of health care, due in part to ageing, in part to more expensive pills and technology, and in part to overdiagnosis and overtreatment. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/96557/original/image-20150929-30976-1c2bv3t.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/96557/original/image-20150929-30976-1c2bv3t.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/96557/original/image-20150929-30976-1c2bv3t.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=404&fit=crop&dpr=1 600w, https://images.theconversation.com/files/96557/original/image-20150929-30976-1c2bv3t.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=404&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/96557/original/image-20150929-30976-1c2bv3t.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=404&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/96557/original/image-20150929-30976-1c2bv3t.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=507&fit=crop&dpr=1 754w, https://images.theconversation.com/files/96557/original/image-20150929-30976-1c2bv3t.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=507&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/96557/original/image-20150929-30976-1c2bv3t.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=507&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Growth in Medicare benefits; 1983–84 to 2014–15.</span>
<span class="attribution"><a class="source" href="http://www.health.gov.au/internet/main/publishing.nsf/Content/922CB2933B0F1645CA257EC1001D5C12/$File/MBS%20Review_Consultation%20paper_Overview_FINAL.pdf">MBS Review Consultation Paper Overview, September 2015</a></span>
</figcaption>
</figure>
<p>The national review is expected to report in coming years – though likely only after complex horse-trading over many of the 5,700 items on the Medicare schedule, as doctors debate exactly what is appropriate and what’s not. </p>
<p>In the meantime the best approach is a healthy scepticism and as many questions to your doctor as you can squeeze in. Do I really need that test or treatment? Do I really need that diagnosis? Where’s the evidence? And, perhaps most importantly, what happens if I do nothing? </p>
<p>Believe it or not, doing nothing is often the best medical care you could get.</p>
<p>Who knows, maybe the tide of too much medicine is turning. But can a tsunami can be tamed?</p><img src="https://counter.theconversation.com/content/48239/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr Ray Moynihan has received funding from Bond University for studies on overdiagnosis. He has written widely on the problem of too much medicine, is a colleague to several of the program interviewees, and is a co-organizer of the international Preventing Overdiagnosis scientific conferences and the national Preventing Overdiagnosis and Overuse meeting. </span></em></p>The evidence suggests too much medicine is doing us harm, particularly when treating knee pain, back pain, chest pain and screening for prostate cancer.Ray Moynihan, Senior Research Fellow, Bond UniversityLicensed as Creative Commons – attribution, no derivatives.