Authors McCaffery KJ, Jansen J, Scherer LD, et al.
Review Date February 2016
Citation BMJ 2016;352:i348 doi: 10.1136
Over-diagnosis and over treatment (relevant to prostate cancer screening and screening for other cancers) have serious implications for individuals, healthcare systems, and society, and effective strategies are needed to help the public, clinicians, and policy makers address this problem. There are several challenges to communicating balanced information about over-diagnosis including the potential to confuse the public, undermine trust in the healthcare system, and adversely affecting people who already have a diagnosis. However, there are some strategies that can potentially manage these challenges.
To describe what is known and what we need to know to communicate effectively and safely about over-diagnosis and overtreatment.
The authors have reviewed the literature to describe what is known about effective communication about over-diagnosis and over-treatment and argue the case for a greater understanding of the gaps in our knowledge of effective communication strategies and the importance of helping patients, healthcare providers and others to understand the issues and make informed decisions about undergoing healthcare tests or treatments.
Key Messages to be communicated:
• 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.
1. Communication-based strategies for individuals:
• 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.
2. Strategies for communities:
• 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.
3. Strategies for policy:
• 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.
Challenges to effective communication:
• 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.
The review showed that more studies are needed about the current understanding of over-diagnosis by patients, doctors and the public and attitudes and choices when presented with such information. We also need to understand how best to implement effective communication strategies and how to avoid potential harms of such communication such as confusing the public, creating distrust and adversely affecting individuals already diagnosed and treated.
The authors argue that we have some tools to move forward with an evidence-based approach but it will take time to achieve widespread understanding of over-diagnosis.
Points to Note
- 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.