Walking the tightrope: Communicating overdiagnosis in modern healthcare

McCaffery KJ, Jansen J, Scherer LD, et al.

February 2016

BMJ 2016;352:i348 doi: 10.1136

Understanding of over-diagnosis and over-treatment is limited so effective communication is essential

Individuals need to know the nature, likelihood and duration of harms of over-diagnosis

At society level need to understand resources wasted on unnecessary tests/treatments

It is difficult to know if an individual has been over-diagnosed – only observable at population level.

Shared decision making can help and should be enhanced by including discussions about over-diagnosis

Decision aids shown to improve patient’s knowledge and understanding of risk and benefits of options and increase consistency between patient’s values and choices.

However, information on the harms of over-diagnosis not often presented to patients and shard decision making not often implemented.

Mass media campaigns can change behavior e.g. back pain campaign reduced imaging and health care usage.

Can change both community and health practitioner attitudes.

Deliberative democratic methods such as community juries gather informed public responses on a disputed issue and can lead to better informed citizens and more transparent decision making by policymakers.

Changing terminology can change attitudes towards tests/treatments such as not using the word ‘cancer’ for early lesions can lead to greater acceptance of less intervention such as active surveillance.

Low levels of awareness of over-diagnosis, particularly in breast and prostate cancer screening, amongst both the public and health practitioners.

Counterintuitive messages – public health messages of benefits of early detection seem to contradict messages about over-diagnosis.

Suggesting reductions in use of tests popular with the public can cause hostile responses.

Intolerance of uncertainty and anxiety about missing rare cases underpins much over testing. Communicating uncertainty may lead to confusion and distrust. However, distrust can arise if patients not told about risks of over-diagnosis.

Vested interests will often overstate the benefits of tests/treatments.

This review examines the research around understanding of over-diagnosis and over-treatment and effective communication strategies that can help improve understanding of patients, clinicians and the community.

There is evidence that some strategies can improve patients decision-making such as shared decision making and the use of decision aids.

There are some potential harms of communicating about over-diagnosis that need to be considered when developing communication strategies.

Potential harms include confusing the public, creating distrust and adversely affecting individuals already diagnosed and treated.

Despite the challenges, it can benefit patients and the healthcare system as a whole if there is greater understanding of the concept and risk involved in over-diagnosis and it is time to improve our understanding and use of effective strategies to achieve this.