JAMA hides its review of Overdiagnosed

I wonder if the people at JAMA are ever going to understand that the journal would have even more influence if they made articles of a general nature free and available for all to read. Especially when the article makes a recommendation to the general public.

Here is one example, a thoughtful book review in the April 6 edition written by Dr. Leonard Berlin. The topic is Overdiagnosed: Making People Sick in Pursuit of Health, by H. Gilbert Welch, Lisa M. Schwartz, and Steven Woloshin.

Here is the part of the review that JAMA lets you see:

A little-noticed but nonetheless profound evolution in medical practice took place in the latter half of the 20th century. Until that time, individuals visited their physicians only when they experienced symptoms and worried they were ill. Now they began to visit their physicians to undergo testing to detect occult disease, even if they felt healthy and were asymptomatic. A new mantra worked its way into medicine in the United States and was quickly adopted by the public: get tested, diagnose disease early, and be treated while the problem is “small” before it becomes “big” or, even better, before a potential disease becomes a reality. This was, and still is, the right thing to do—correct? Well, maybe not, claim [the authors]. Such testing of healthy individuals all too often results in overdiagnosis and overtreatment, because in reality there is “nothing to fix.”

The next sentences are: As a result, contend the authors, although a few will be helped, many will be overdiagnosed, and some will be harmed. This theme permeates the book.

This is very important stuff. A scientist friend reminds me that, as a general matter, the predictive value of a screening test is mathematically related to the prevalence of the disease in the screened population; so the less prevalent, the tougher it is to have a high predictive value.

You can get a good sense of the book itself from these excerpts published in the New York Times. (Hey JAMA, please note: They include way more than 150 words!) But, let me give you some more excerpts from the book review:

That the prevalence of overdiagnosis has reached epidemic proportions, according to the authors, is attributable to the changing guidelines regarding numerical values of what is considered normal and abnormal as well as to technological advances in radiologic imaging.

According to data documented in the book incidentalomas are found in the lungs of 50% of otherwise “healthy” persons undergoing computed tomography of the chest; in the kidneys and livers of 23% and 15%, respectively, of those undergoing computed tomography of the abdomen; and in the thyroid glands of 67% of those undergoing ultrasound examinations of the neck. The chance that the incidentaloma could represent a lethal cancer is considerably less than 1%.

In all of these areas, the authors argue that the quest to find potential disease which may not exist or, if it does, will never harm the patient often leads to unnecessary surgery and medication that may cause serious adverse effects as well as patient anxiety and ever-increasing costs.

And the important conclusion:

Overdiagnosed is a provocative, intellectually stimulating work. As such, all who are involved in health care, including physicians, allied health professionals, and all current or future patients, will be well served by reading and giving serious thought to the material presented.