To test, or not to test?

February 21st, 2018

For a breakout panel at the 2018 Lown Conference, clinicians and researchers in primary care, emergency medicine, and dermatology are teaming up to discuss the harms of overdiagnosis and overtesting.

Check out our full program and schedule for the Lown Conference on our website!


Turtles and bears and grenades, Oh my!

Dr. Ronald Adler is associate professor of family medicine & community health at the University of Massachusetts Medical School and the author of Cancer Screening Decisions: A Patient-Centered Approach. At last year’s Lown Conference, he co-authored a winning abstract evaluating the quality measures for primary care doctors.

This year, Adler is challenging the popular idea that cancer screening is always beneficial. He explains that the enthusiasm for cancer screening is based on the belief that all cancers are slow-growing and treatable, so finding cancer early lowers the likelihood of harm from cancer. For some cancers, such as cervical cancer, the disease does follow this pattern. Unfortunately, all cancers are not the same and they’re not all prevented by early detection. 

Adler uses the metaphors of Bears, Turtles, and Grenades to distinguish between different types of cancers. Bears are the type of cancer we often think of, potentially lethal but treatable. Like a bear, they start small (as cubs) but can become dangerous as they grow larger. For these cancers, early detection can prevent harm. Grenades are cancers that are very aggressive and usually lethal, even when found early, such as pancreatic cancer. Turtles are indolent cancers, that move slowly and are non-threatening – and are much more common than people think. 

The problem with too much cancer screening, says Adler, is that when we treat too many of the Turtle-type cancers, we take a healthy person and make them endure difficult and potentially harmful cancer treatment. On the panel, Adler will present a framework and useful tips for having conversations about the benefits and risks of cancer screening.  

Dr. David Elpern, a dermatologist in Williamstown, MA, will talk about the specific challenges with over-screening in dermatology. Screening for melanoma has led to a rising incidence of skin cancer but no corresponding decline in mortality, indicating an epidemic of the “Turtle-type” cancer.

Unfortunately, screening for cancer and treating Turtle-type cancers have become a “perpetual income machine” for some dermatologists, who are paid fee-for-service. On the panel, Elpern will talk about how we got here, and ways we can push back against the culture of over-testing in dermatology. 

When fear of radiation overshadows overtreatment

Dr. Joe Fraiman is an Emergency Medicine doctor in New York. He’s been studying a unique issue in overuse – how the fear of radiation from CT scans can lead doctors to overlook other harms of overtreatment. Fraiman gives the example of scanning for pulmonary embolism. Doctors are less likely to give a young woman a CT scan because of the potential for radiation, but they don’t have the same concern when scanning older people.

“Doctors think, ‘They’re old, they’re not going to get cancer.’ But there are harms of overtreatment from CT scans besides just radiation” says Fraiman. For example, elderly patients are more at risk from taking anti-coagulants than young patients. 

In another case, doctors’ concern about radiation has led to other types of overtreatment for appendicitis patients. Doctors have worked to reduce radiation in children thought to have appendicitis by switching from CT scans to ultrasound scans. Unfortunately, ultrasound scans are less accurate than CTs, so more children are likely to have an unnecessary appendectomy when they all have ultrasounds instead of CTs. This issue is a tricky one, and Fraiman is looking forward to discussing this case with the other panelists and audience to brainstorm solutions.