From the Annals of Overdiagnosis

Perspective article

Income and Cancer Overdiagnosis — When Too Much Care Is Harmful

H. Gilbert Welch, M.D., M.P.H., and Elliott S. Fisher, M.D., M.P.H.

N Engl J Med 2017; 376:2208-2209

There are scores of articles on over-medicalization, over-diagnosis and over treatment.  This short Perspective piece in the New England Journal of Medicine by H.G. Welch and Elliott Fisher is a great introduction to this topic.

Link to PDF.

“Although higher-income people live longer than poorer individuals, there is little evidence that people with higher incomes live longer because they receive more medical care.  In fact, there are reasons to wonder whether wealthier people receive too much care.

We used data from the SEER program to examine incidence and mortality trends for four types of cancer whose reported incidence is known to be sensitive to observational intensity: breast cancer, prostate cancer, thyroid cancer, and melanoma. The combined incidence of these cancers has been rising in all U.S. counties, but there hasn’t been a parallel increase in cancer-specific mortality — which suggests that considerable over-diagnosis may be occurring.

We found that high-income counties have experienced markedly greater increases in incidence than low-income counties since 1975; but mortality rates are similar in high and low income counties.  The graph also shows that combined mortality from the four cancers is similar in high- and low-income counties, suggesting that the underlying disease burden is similar. What’s more, mortality hasn’t been increasing — as one might expect given the increasing incidence in some areas — but rather decreasing, reflecting decreasing mortality from breast and prostate cancer in particular.

Excessive screening is responsible for the increasing rates and this has had no impact on overall morality.  Excessive testing of low-risk people produces real harm, leading to treatments that have no benefit (because there is nothing to fix) but can nonetheless result in medication side effects, surgical complications, and occasionally even death.

Physicians have overstated medicine’s role in promoting health. In so doing, we may have unintentionally devalued the role of more important determinants of health for people at every income level — healthy food, regular movement, and finding purpose in life.”