MEDICALISATION

bmj.com � BMJ blog: Elizabeth Loder on tackling unnecessary treatment in the US: This time “it feels diff erent” � Des Spence: The psychiatric oligarchs who medicalise normality (BMJ 2012;344:e3135) � Research: Overdiagnosis in publicly organised mammography screening programmes (BMJ 2009;339:b2587) Preventing overdiagnosis: how to stop harming the healthy Evidence is mounting that medicine is harming healthy people through ever earlier detection and ever wider definition of disease. With the announcement of an international conference to improve understanding of the problem of overdiagnosis, Ray Moynihan , Jenny Doust , and David Henry examine its causes and explore solutions

edicine’s much hailed ability to help the sick is fast being challenged by its propensity to harm the healthy. A burgeon- ing scientifi c literature is fuel- M ling public concerns that too many people are being overdosed, 1 overtreated, 2 and overdiag- nosed. 3 Screening programmes are detecting early cancers that will never cause symptoms or death, 4 sensitive diagnostic technologies iden- tify “abnormalities” so tiny they will remain benign, 5 while widening disease defi nitions mean people at ever lower risks receive permanent medical labels and lifelong treatments that will fail to benefit many of them. 3 6 With estimates that more than $200bn (£128bn; €160bn) may be wasted on unnecessary treatment every year in the United States,7 the cumulative burden from overdiagnosis poses a signifi cant threat to human health. Narrowly defined , overdiagnosis occurs when people without symptoms are diagnosed with a disease that ultimately will not cause them to experience symptoms or early death.3 More broadly defi ned, overdiagnosis refers to the related problems of overmedicalisation and subsequent overtreatment, diagnosis creep, shift ing thresholds, and disease mongering, all processes helping to reclassify healthy people with mild problems or at low risk as sick. 8 The downsides of overdiagno- Changing diagnostic criteria sis include the negative effects of for many conditions are unnecessary labelling, the harms of unneeded tests and therapies, and the causing virtually the entire opportunity cost of wasted resources that older adult population to be could be better used to treat or prevent classified as having at least genuine illness. The challenge is to articu- one chronic condition

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5 late the nature and extent of the problem more Thyroid cancer causes. As we will discuss below, there is now  widely, identify the patterns and drivers, and New diagnoses strong evidence from randomised trials and other develop a suite of responses from the clinical to Deaths studies comparing screened and unscreened the cultural.  populations that an important proportion of the At the clinical level, a key aim is to better dis- cancer detected through some popular screening  criminate between benign “abnormalities” and programmes may be pseudodisease.4 12 Evidence

those that will go on to cause harm. In terms of Rate per   people  from autopsy studies suggests a large reservoir education and raising awareness among both the of subclinical disease in the general population, public and professionals, more honest informa-  including prostate, breast, and thyroid cancer, Melanoma 12 tion is needed about the risk of overdiagnosis,  the bulk of which will never harm. Similarly, particularly related to screening. More deeply, screening the hearts of people without symp- mounting evidence that we’re harming healthy  toms or at low risk may also lead to overdiagno-

people may force a questioning of our faith in  sis of coronary atherosclerosis and subsequent ever-earlier detection, a renewal of the process unnecessary interventions.13 Our understanding  of disease definition, and a fundamental shift in of the nature and extent of overdiagnosis and the Rate per   people the systemic incentives driving dangerous excess.  amount of pseudodisease detected by screening Next year, an international scientific confer- remains limited but is evolving, and as Woolfe  ence called Preventing Overdiagnosis aims to and Harris observed recently in JAMA, “concern Kidney cancer deepen understanding and awareness of the  about overdiagnosis is justified.”14

problem and its prevention. The conference  will take place on 10-12 September 2013 in Increasingly sensitive tests the United States, hosted by the Dartmouth  People presenting to doctors with symptoms can Institute for Health Policy and Clinical Practice  also be overdiagnosed because changes in diag-

in partnership with the BMJ, the leading US Rate per   peopl e nostic technologies or methods have enabled the  consumer organisation Consumer Reports, and identification of less severe forms of diseases or Bond University. The conference is timely, as  disorders. It is becoming clearer that a substan- growing concern about overdiagnosis is giving Prostate cancer tial proportion of these earlier “abnormalities”  way to concerted action. The Archives of Internal will never progress, raising awkward questions Medicine’s feature “Less is More” now regularly  about exactly when to use diagnostic labels and 9 augments the evidence base, high level health  therapeutic approaches traditionally deployed policy groups in Europe are debating ways against much more serious forms of disease. to tackle excess,10 and the recently launched  Rate per   people Choosing Wisely campaign warns about dozens  Incidentalomas of potentially unnecessary tests and treatments Diagnostic scanning of the abdomen, pelvis,  across nine specialties.11 chest, head, and neck can reveal “incidental Breast cancer Many factors—including the best of inten-  findings” in up to 40% of individuals being tions—are driving overdiagnosis, but a key con- tested for other reasons.15 Some of these are tributor is advances in technology. The literature  tumours, and most of these “incidentalomas” suggests several broad and related pathways to are benign. A very small number of people will  overdiagnosis: screening detected overdiagno- benefit from early detection of an incidental

sis in people without symptoms; overdiagnosis Rate per   people  malignant tumour, while others will suffer the resulting from use of increasingly sensitive tests anxiety and adverse effects of further investi- in those with symptoms; overdiagnosis made  gation and treatment of an “abnormality” that        incidentally—“incidentalomas”; and overdiag- Year would never have harmed them. As others have nosis resulting from excessively widened disease Rates of new diagnosis and death for five types of shown, the rapidly rising incidence for some can- cancer in the US, 1975-2005. Adapted from Welch definitions. These different pathways are not 12 cers, set against relatively stable death rates, is a mutually exclusive, and a more rigorous classi- and Black phenomenon suggestive of widespread overdiag- fication of the different forms of overdiagnosis nosis, whether from screening or the detection of will be a focus of discussion at the 2013 scien- form that will never cause that person symptoms incidentalomas (figure).12 tific conference. or early death. Sometimes this form of disease is called pseudodisease. Contrary to popular Excessively widened definitions Screening detected overdiagnosis notions that cancers are universally harmful and Another pathway to overdiagnosis is through dis- This pathway to overdiagnosis occurs when a ultimately fatal, some cancers can regress, fail ease boundaries being widened and treatment screening programme detects disease in a per- to progress, or grow so slowly that they will not thresholds lowered to a point where a medical son without symptoms but the disease is in a cause harm before the individual dies from other label and subsequent therapy may cause people

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Arguably the strongest evidence of overdiagnosis comes from studies of screening detected breast cancers

more harm than good. Changing diagnostic cri- Box 1 | Problems of overdiagnosis Gestational diabetes teria for many conditions are routinely increasing A 2010 revision of the criteria defining gesta- 16 Asthma—Canadian study suggests 30% the numbers of people defined as sick, causing of people with diagnosis may not have tional diabetes recommended a dramatic low- virtually the entire older adult population to be asthma, and 66% of those may not require ering of the diagnostic threshold, more than classified as having at least one chronic condi- medications37 doubling the number of pregnant woman clas- tion.17 This widening has happened both with Attention deficit hyperactivity disorder— sified to almost 18%.29 Proponents argue uni- asymptomatic conditions that carry a risk of an Widened definitions have led to concerns versal screening with the new definition will adverse event, such as osteoporosis, where treat- about overdiagnosis; boys born at the end of the reduce health problems, including babies being ments may do more harm than good for those at school year have 30% higher chance of diagnosis “large for gestational age.”29 Critics, however, and 40% higher chance of medication than those very low risk of fracture,18 and for behavioural are calling for an urgent debate before the new born at the beginning of the year46 conditions such as female sexual dysfunction, expanded definition is more widely adopted, Breast cancer—Systematic review suggests up where common difficulties have been reclassi- because they fear many women may be over- 19 to a third of screening detected cancers may be fied as dysfunctions. overdiagnosed4 medicalised and overdiagnosed, that the screen- Such changes in diagnostic criteria are com- Chronic kidney disease—Controversial definition ing test has poor reproducibility for mild cases, monly made by panels of health professionals classifies 1 in 10 as having disease; concerns the evidence of benefit for the newly diagnosed with financial ties to companies that benefit about overdiagnosis of many elderly people 23 pregnant women is weak, and the benefit modest directly from any expansion of the patient pool.20 Gestational diabetes—Expanded definition at best.30 31 As definitions broaden and thresholds fall, peo- classifies almost 1 in 5 pregnant women 31 ple with smaller risks or milder problems are High blood pressure—Systematic review suggests Chronic kidney disease 22 labelled, which means the potential benefits of possibility of substantial overdiagnosis More than 10% of adults in the United States are treatment decline, raising the possibility that High cholesterol—Estimates that up to 80% of now classified as having some form of chronic people with near normal cholesterol treated for life 32 harms will outweigh benefits. As Welch and col- 3 kidney disease. A working definition launched may be overdiagnosed 33 leagues estimated in their 2011 book Overdiag- as part of new clinical guidelines asserts that nosed,3 many people diagnosed and treated long Lung cancer—25% or more of screening detected an estimated glomerular filtration rate (eGFR) lung cancers may be overdiagnosed56 term for near-normal cholesterol concentration below 60 ml/min/1.73 m2 and sustained for Osteoporosis—Expanded definitions may mean or near-normal osteoporosis may be “overdiag- three months or longer is deemed abnormal, a many treated low risk women experience net nosed,” in the sense that they would never have harm18 decision critics argue automatically creates the experienced the events their treatments are Prostate cancer—Risk that a cancer detected by potential for overdiagnosis, particularly among 34 designed to prevent. prostate specific antigen testing is overdiagnosed elderly people. A related form of overdiagnosis occurs when may be over 60%12 According to Winearls and Glassock in an people are diagnosed outside of already widened Pulmonary embolism—Increased diagnostic article last year the new classification system diagnostic criteria, as can occur when inappro- sensitivity leads to detection of small emboli. Many is “like a fishing trawler” and “captures many 39 priate manufacturers’ norms exaggerate the may not require anticoagulant treatment more innocent subjects than it should.”23 They incidence of abnormality,21 when diagnostic Thyroid cancer—Much of the observed increase in estimate that up to one third of people over 65 28 methods wrongly label random or normal fluc- incidence may be overdiagnosis may meet the new criteria, yet of these, fewer tuations in biomarkers as true abnormalities,22 than 1 in 1000 will develop end stage renal or when important qualifiers are left out of the 50s ranged from 1.7% to 54%.24 An Australian disease each year. They also point to major process of diagnosis.23 study estimated the rate was at least 30%,25 problems with the reliability and consistency of while a Norwegian study calculated 15-25%.26 the eGFR test and express concern many older Examples of overdiagnosis A 2009 systematic review in the BMJ concluded people are being labelled on the basis of a single The growing evidence on overdiagnosis sug- up to one third of all screening detected cancers and potentially inaccurate laboratory measure. gests the problem may exist to varying extents may be overdiagnosed.4 However, even with Elsewhere they have argued that “the majority of across many conditions (box 1), including strong evidence from population based studies, those held to have CKD [chronic kidney disease] those for which underdiagnosis may simulta- it is currently impossible to discriminate between have no identifiable kidney disease” and they’ve neously be a feature. For some conditions, the cancers that will harm and those that will not. highlighted attempts by some organisations to evidence remains tentative and speculative, for move away from others it has become much more robust. Thyroid cancer the controversial While the chances of tests detecting a thyroid new definition, Breast cancer “abnormality” are high, the risk it will ever raise the threshold Arguably the strongest evidence of overdiagnosis cause harm is low.3 27 Analysis of rising inci- for diagnosis, and dramati- comes from studies of screening detected breast dence shows many of the newly diagnosed thy- cally reduce prevalence.35 cancers, though estimates of its extent are wide roid cancers are the smaller and less aggressive Responding to criticisms, ranging. A 2007 systematic review in Lancet forms not requiring treatment,28 which itself proponents have defended Oncology found the proportion of overdiagnosis carries the risk of damaged nerves and long the new definition as being of invasive breast cancer among women in their term medication.3 “clear, simple, and useful.”36

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An intuitive belief in early detection, fed by deep faith in medical technology is arguably at the heart of the problem of overdiagnosis

Asthma Box 2 | Drivers of overdiagnosis diagnostic or therapeutic technologies in which Although asthma can be severe and may be Technological changes detecting ever smaller they have a commercial interest may also drive underdiagnosed and undertreated, some stud- “abnormalities” unnecessary diagnosis. ies suggest that there may also be substantial Commercial and professional vested interests Avoidance of litigation and the psychology of overdiagnosis. One large study in 2008 found Conflicted panels producing expanded disease regret is another obvious driver as professionals that almost 30% of people diagnosed as having definitions and writing guidelines can be punished for missing the early signs of dis- asthma did not have the condition, and almost Legal incentives that punish underdiagnosis but not ease yet don’t generally face sanctions for over- overdiagnosis 66% of those did not need drugs or asthma care diagnosing. Quality measures focused on doing 37 Health system incentives favouring more tests and during six months of follow-up. The authors treatments more may also encourage overdiagnosis in order 47 concluded, “A substantial proportion of people Cultural beliefs that more is better; faith in early to meet targets for remuneration incentives. . . . may be overdiagnosed with asthma and may detection unmodified by its risks An intuitive belief in early detection, fed by be prescribed asthma medications unnecessar- deep faith in medical technology is arguably ily.” In the same year a Dutch study found that of children, who have no say in the appro- at the heart of the problem of overdiagnosis. of 1100 patients using inhaled corticosteroids, priateness of a label that can permanently Increasingly we’ve come to regard simply being 30% may have been using the drugs without any change their lives. This is particularly salient “at risk” of future disease as being a disease in its clear indications.38 with attention deficit hyperactivity disorder.45 A own right. Starting with treatment of high blood recent study of almost a million Canadian chil- pressure in the middle of the 20th century,48 Pulmonary embolism dren found boys born in December (typically increasing proportions of the healthy population Doctors think of pulmonary embolism as a the youngest in their year) had a 30% higher have been medicalised and medicated for grow- “not to be missed” diagnosis, because fail- chance of diagnosis and 40% higher chance of ing numbers of symptomless conditions, based ure to detect it can have catastrophic conse- receiving medication than those born in Janu- solely on their estimated risk of future events. quences. Historically it was diagnosed only ary, with the authors concluding their findings Although the approach has reduced suffering when the blockage was large enough to cause “raise concerns about the potential harms of and extended life for many, for those overdiag- infarction of part of the lung or haemodynamic overdiagnosis and overprescribing.”46 nosed it has needlessly turned the experience instability. In such patients, treatment with an of life into a tangled web of chronic conditions. anticoagulant or a thrombolytic agent was con- Drivers of overdiagnosis The cultural norm that “more is better” is con- sidered mandatory. Now, however, computed The forces driving overdiagnosis are embedded firmed by recent evidence suggesting patient tomography (CT) pulmonary angiography can deep within the culture of medicine and wider satisfaction flows from increased access to tests detect smaller clots, and there is uncertainty society, underscoring the challenges facing any and treatments, even though more care may be about whether treatment is always necessary.39 attempt to combat them (box 2). A key driver is associated with greater harm.49 50 Analysing trends before and after the wide- technological change itself. As Black described in spread introduction of CT pulmonary angiog- 1998, the ability to detect smaller abnormalities What can we do about overdiagnosis? raphy, Weiner and colleagues suggested that axiomatically tends to increase the prevalence Building on existing knowledge and activity, the the almost doubling in incidence “reflects an of any given disease.5 In turn this leads to over- 2013 conference on overdiagnosis will provide a epidemic of diagnostic testing that has created estimation of the benefits of therapies, as milder forum for learning more, increasing awareness, overdiagnosis,” with much of the increase con- forms of the disease are treated and improvements and developing ways to prevent the problem sisting of “clinically unimportant” cases that in health are wrongly ascribed to treatment suc- (www.preventingoverdiagnosis.net). Research “would not have been fatal even if left undi- cess, creating a “false feedback” loop fuelling a on overdiagnosis is now recognised as part of the agnosed and untreated.”40 An observational “cycle of increasing testing and treatment, which future scientific direction of the National Cancer study is investigating the safety of not treating may eventually cause more harm than benefit.”5 Institute’s division of cancer prevention in the people with very small blood clots.41 The industries that benefit from expanded United States.51 The 2013 conference hopes to markets for tests and treatments hold wide- provide researchers working in this field with Attention deficit hyperactivity disorder reaching influence within the medical profes- the chance to share and debate methods and fur- Much has been written about expanding diag- sion and wider society, through financial ties ther advance research agendas. As to education, nostic definitions within mental illness and with professional and patient groups and fund- the development of a range of curriculums and concerns about the dangers of overtreatment.42 ing of direct-to-consumer advertising, research information packages could help raise awareness Debate has intensified with suggestions that foundations, disease awareness campaigns, about the risks of overdiagnosis, particularly current processes for defining disease may be and medical education.8 Most importantly, the associated with screening.52 In association with contributing to the widespread overdiagnosis members of panels that write disease defini- the BMJ, a series of articles about the potential of conditions such as bipolar, autistic dis- tions or treatment thresholds often have finan- for overdiagnosis within specific conditions is order, and attention cial ties to companies that stand to gain from being planned. And at the level of clinical prac- deficit hyperactivity expanded markets.20 Similarly, health profes- tice new protocols are being developed to bring disorders.43 44 One sionals and their associations may have an more caution in treating incidentalomas.3 Simi- focus of concern is the interest in maximising the patient pool within larly, some are urging that we consider raising possible overdiagnosis their specialty, and self-referrals by clinicians to the thresholds that define “abnormal”—in breast

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cancer screening, for exam- 1 Abramson J. Overdosed America: the broken promise of 28 Davies L, Welch G. Increasing incidence of thyroid cancer in ple—and evaluate methods American medicine. Harper, 2004. the United States, 1973-2002. JAMA 2006;295:2164-7. 2 Brownlee S. Overtreated: why too much medicine is making 29 International Association of Diabetes and Pregnancy of observing changes to some us sicker and poorer Bloomsbury, 2007. Study Groups. Recommendations on the diagnosis and suspected pathologies over time, 3 Welch G, Schwartz L, Woloshin S. Overdiagnosed: making classification of hyperglycemia in pregnancy. Diabetes Care 53 people sick in pursuit of health. Beacon Press, 2011. 2010;33:676-82. rather than intervening immediately. As 4 Jørgensen K, Gøtzsche P. Overdiagnosis in publicly organised 30 Ryan E. Diagnosing gestational diabetes. Diabetologia we’ve seen, early studies of how to safely undiag- mammography screening programmes: systematic review of 2011;54:480-6. incidence trends. BMJ 2009;339:b2587. 31 Cundy T. Proposed new diagnostic criteria for gestational nose or de-prescribe are starting to emerge. 5 Black W. Advances in radiology and the real versus apparent diabetes—a pause for thought? Diabet Med 2012;29: At a policy level, reform of the process of defin- effects of early diagnosis. Eur J Radiol 1998;27:116–22. 176-80. 6 Moynihan R, Heath I, Henry D. Selling sickness: the 32 Levey AS, Stevens LA, Schmid CH, Zhang YL, Castro AF 3rd, ing disease is urgently required, with one model pharmaceutical industry and disease-mongering. BMJ Feldman HI, et al. A new equation to estimate glomerular coming from the National Institutes of Health in 2002;324:886-91. filtration rate. Ann Intern Med 2009;150:604-12. 7 Berwick D, Hackbarth, A. Eliminating waste in US health care. 33 National Kidney Foundation. Clinical practice guidelines the United States, where people with financial or JAMA 2012;307:1513-6. for chronic kidney disease: evaluation, classification and reputational conflicts of interest are disqualified 8 Moynihan R, Cassels A. Selling sickness: how the world’s stratification. Am J Kidney Dis 2002;39(suppl 1):s17-31. 20 biggest pharmaceutical companies are turning us all into 34 Glassock R. Estimated glomerular filtration rate: time for a from panel membership. Dispassionate assess- patients. Nation Books, 2005. performance review? Kidney Int 2009;75:1001-3. ment of evidence may result in disease defini- 9 Grady D, Redberg R. Less is more: how less health care can 35 Winearls C, Haynes, R, Glassock R. CKD staging—evolution tions being narrowed, as has been seen with the result in better health. Arch Intern Med 2010;170:749-50. not revolution. Nefrologia 2010;30:493-500. 10 European Health Forum Gastein. Innovation and wellbeing: 36 Eknoyan G. Chronic kidney disease definition and classification: recent tentative proposals to raise thresholds for living longer—but are we living better? Press release, 8 the quest for refinements. Kidney Int 2007;72:1183-5. high blood pressure that could demedicalise up September 2011. www.ehfg.org/826.html#c1950. 37 Aaron S, Vandemheen K, Boulet L, McIvor R, FitzGerald J, 54 11 Choosing Wisely. US physician groups identify commonly Hernandez P, et al. Overdiagnosis of asthma in obese and to 100 million people. Processes for defining used tests or procedures they say are often not necessary. nonobese adults. CMAJ 2008;179:1121-31. disease may also benefit from an attempt to syn- Press release, 4 April 2012. http://choosingwisely.org/ 38 Lucas A, Smeenk F, Smeele I, van Schayck C. Overtreatment wp-content/uploads/2012/03/033012_Choosing-Wisely- with inhaled corticosteroids and diagnostic problems in thesise the evidence from clinical medicine with National-Press-Rls-FINAL.pdf . primary care patients, an exploratory study. Fam Pract literature on the wider social and environmen- 12 Welch G, Black W. Overdiagnosis in cancer. JNCI 2008;25:86-91. 2010;102:605-13. 39 Prasad V, Rho J, Cifu A. The diagnosis and treatment of tal determinants of health. Other policy reforms 13 Lauer M. Pseudodisease, the next great epidemic in coronary pulmonary embolism. Arch Intern Med 2012 Apr [Epub could review the permanency of some diagnostic atherosclerosis? Arch Intern Med 2011;171:1268-9. ahead of print]. 14 Woolfe S, Harris R. The harms of screening. JAMA 40 Weiner R, Schwartz LM, Woloshin S. Time trends in labels, address calls for increased independence 2012;307:565-6. pulmonary embolism in the United States. Arch Intern Med in the design and running of scientific studies,55 15 Orme NM, Fletcher JG, Siddiki HA, Harmsen WS, O’Byrne 2011;171:831-7. MM, Port JD, et al. Incidental findings in imaging research: 41 Carrier M. A study to evaluate the safety of withholding and adjust the structural and legal incentives evaluating incidence, benefit, and burden. Arch Intern Med anticoagulation in patients with subsegmental PE who have driving overdiagnosis. 2010;170:1525-32. a negative serial bilateral lower extremity ultrasound (SSPE). 16 Schwartz LM, Woloshin S. Changing disease definitions: 2011. http://clinicaltrials.gov/ct2/show/NCT01455818. Concern about overdiagnosis does not pre- implications for disease prevalence: analysis of the third 42 Angell M. The epidemic of mental illness: why? New York clude awareness that many people miss out national health and nutrition examination survey, 1988– Review Books 2011 Jun 23. on much needed healthcare. On the contrary, 1994. Effect Clin Pract 1999;2:76-85. 43 Frances A. The first draft of DSM-V. BMJ 2010;340:c1168. 17 Kaplan R, Ong M. Rationale and public health implications of 44 Healy D. The latest mania: selling bipolar disorder. PLoS Med resources wasted on unnecessary care can be changing CHD risk factor definitions. Annu Rev Public Health 2006;3:e185. much better spent treating and preventing genu- 2007;28:321-44. 45 Thomas R. The diagnostic variability in attention deficit 18 Herndon MB, Schwartz LM, Woloshin S, Welch G. hyperactivity disorder. Presentation to Overdiagnosis ine illness. The challenge is to work out which Implications of expanding disease definitions: the case of Meeting, Coolangatta, 29-30 April 2012. is which, and to produce and disseminate evi- osteoporosis. Health Aff 2007;26:1702-11. 46 Morrow R, Garland E, Wright J, Maclure M, Taylor S, Dormuth 19 Moynihan R. Merging of marketing and medical science: C. Influence of relative age on diagnosis and treatment of dence to help us all make more informed deci- female sexual dysfunction. BMJ 2010;341:c5050. attention-deficit/hyperactivity disorder in children. CMAJ sions about when a diagnosis might do us more 20 Moynihan, R. A new deal on disease definition. BMJ 2012;184:755-62. 2011;342:d2548. 47 Heath I, Hippisley-Cox J, Smeeth L. Measuring performance good than harm. 21 Ahmed A, Blake G, Rymer J, Fogelman I. Screening for and missing the point. BMJ 2007;335;1075-6. Ray Moynihan is senior research fellow , Bond University, osteopenia and osteoporosis: do the accepted normal ranges 48 Greene J. Prescribing by numbers; drugs and the definition of Robina, Queensland, Australia lead to overdiagnosis? Osteoporos Int 1997;7:432-8. disease. Johns Hopkins University Press, 2007. 22 Hodgkinson J, Mant J, Martin U, Guo B, Hobbs F, Deeks J, et 49 Fenton J, Jerant A, Bertakis K, Franks P. The cost of satisfaction. [email protected] al. Relative effectiveness of clinic and home blood pressure Arch Intern Med 2012;172:405-11. Jenny Doust is professor of clinical epidemiology, Centre monitoring compared with ambulatory blood pressure 50 Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, for Research in Evidence-Based Practice, Faculty of Health monitoring in diagnosis of hypertension: systematic review. Pinder EL. The implications of regional variations in Medicare Sciences and Medicine, Bond University, Australia BMJ 2011;342:d3621. spending, part 2: health outcomes and satisfaction with care. 23 Winearls C, Glassock R. Classification of chronic kidney Ann Intern Med 2003;138:288-98. David Henry is chief executive officer, Institute for Clinical disease in the elderly: pitfalls and errors. Nephron Clin Pract 51 Kramer B. Current and future perspectives on cancer prevention Evaluative Sciences, Toronto, Canada 2011;119(suppl 1):c2-4. research. National Cancer Advisory Board, 2012. http:// We thank the participants at the April 2012 Coolangatta 24 Biesheuvel C, Barratt A, Howard K, Houssami N, Irwig L. deainfo.nci.nih.gov/advisory/ncab/161_0212/Kramer.pdf. planning meeting on overdiagnosis: Paul Glasziou, Kirsten Effects of study methods and biases on estimates of invasive 52 Schwartz L, Woloshin S, Fowler F, Welch G. Enthusiasm for McCaffery, Melissa Sweet, Hilda Bastion, Andrew Wilson, Ian Scott, breast cancer overdetection with mammography screening: cancer screening in the United States. JAMA 2004;291:71-8. Suzanne Hill, Alexandra Barratt, Steve Woloshin, Lisa Schwartz, a systematic review. Lancet Oncol 2007;8:1129-38. 53 Elmore J, Fletcher S. Overdiagnosis in breast cancer screening: Fiona Godlee, and Rae Thomas. We also thank Julia Lowe. 25 Morrell S, Barratt,A, Irwig L, Howard K, Biesheuvel C, time to tackle an underappreciated harm. Ann Intern Med Armstrong B. Estimates of overdiagnosis of invasive breast 2012;156:536-7. Competing interests: All authors have completed the ICMJE cancer associated with screening mammography Cancer 54 Taylor B, Wilt T, Welch G. Impact of diastolic and systolic uniform disclosure form at www.icmje.org/coi_disclosure. Causes Control 2010;21:275-82. blood pressure on mortality: implications for the definition of pdf (available on request from the corresponding author) and 26 Kalager M, Adami H, Bretthauer M, Tamimi R. Overdiagnosis “normal”. J Gen Intern Med 2011;26:685-90. declare: JD is supported by NHMRC project grant 511217; they of invasive breast cancer due to mammography screening: 55 Prasad V, Cifu A, Ioannidis J. Reversals of established medical have no financial relationships with any organisations that might results from the Norwegian screening program. Ann Intern practices. JAMA 2012;307:37-8. have an interest in the submitted work in the previous three years; Med 2012;156:491-9. 56 Reich J. A critical appraisal of overdiagnosis: estimates of all authors were at the April 2012 planning meeting for the 2013 27 Tan G, Gharib H. Thyroid incidentalomas: management its magnitude and implications for lung cancer screening. conference and RM is undertaking a PhD on overdiagnosis. approaches to nonpalpable nodules discovered Thorax 2008;63:377-83. Provenance and peer review: Commissioned; externally peer incidentally on thyroid imaging. Ann Intern Med reviewed. 1997;126:226-31. Cite this as: BMJ 2012;344:e3502

BMJ | 2 JUNE 2012 | VOLUME 344 23 BMJ GROUP IMPROVING HEALTH AWARDS 2012 Safer sport, shock treatment, stroke care, and safety triumph at the BMJ Group awards It was the “medical version of the Oscars,” according to one description. Rebecca Coombes reports on the fourth BMJ Group awards ceremony A world record for HIV testing, a clinical trial to Clockwise from top left: Kathryn Maitland, prevent child deaths in Africa, and a project to Research Paper of the Year; Tony Rudd and Ruth bmj.com/multimedia make safer cricket helmets scooped some of the Carnall, Improvement in Patient Safety; Lucy ЖЖBernard Lown gives a frank and top prizes at the BMJ Group Improving Health Mathen, the Karen Woo Award; 90Ten with 56 Dean Street, G-A-Y club, and Boyz magazine, fascinating interview about his life Awards 2012 last week. Healthcare Communication Campaign; hosts Sally and work in a BMJ video. He talks The awards, now in their fourth year and Phillips and BMJ Editor in Chief Fiona Godlee; about subverting institutional racism sponsored by doctors’ insurer MDDUS, honoured Alastair Campbell speaks on behalf of Mind. in hospitals, getting heart failure those who have made outstanding contributions patients out of bed, and meeting to improving healthcare in a dozen categories. in Kenya, Tanzania, and Uganda and found that Mikhail Gorbachev to discuss nuclear More than 500 guests and 45 finalists gath- giving fluid increased 48 hour mortality. The trial disarmament. www.bmj.com/ ered at the London Hilton on Park Lane for was stopped as soon as the risks became clear, multimedia the event, cohosted by BMJ editor in chief, and the findings should help avert thousands of Fiona Godlee, and actress Sally Phillips, who deaths a year from the inappropriate use of fluid. has appeared in Bridget Jones’ Diary and the Professor Kathryn Maitland, one of the BBC comedy Miranda. Phillips, who called the paper’s authors, had staked her “entire career” evening the “medical version of the Oscars,” on the project: “We are very honoured. The mused on what the collective noun for a group teams at the hospitals dedicated two years of of doctors was—a “diagnosis of doctors” was the work, which will certainly influence how Afri- audience’s consensus. can children are managed in future. Three lives First up was the Research Paper of the Year in every 100 severely ill children will be saved if award, which went to the FEAST trial. This the results are implemented.” studied over 3000 children with severe shock The NHS in London walked away with the

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Improvement in Patient Safety award for a new Top row: NHS Nottingham City Clinical Commissioning Group, Clinical Commissioning Team of the Year; model of acute stroke services, which they hope Mike Shaw and colleague, the Family Drug and Alcohol Court Intervention Team, Working in Partnership will help save up to 400 lives a year. NHS London Award. Middle row: Alexander Finlayson, Junior Doctor of the Year; Jon Cardy, Clinical Leader of the Year; chief executive, Ruth Carnall, said: “This shows Nick Peirce, centre, and colleagues from the England and Wales Cricket Board, Sports and Exercise Team of the Year. Nottingham University Hospitals NHS Trust, Transforming Patient Care using Technology; Maria that reorganising care can save lives and at a Ahmed and colleague, Excellence in Healthcare Education; Bernard Lown, Lifetime Achievement Award. lower cost.” Another London team, the Family Drug and Alcohol Court Intervention Team, won whose players travel for 250 days of the year. “I working system to improve overnight care in hos- the Working in Partnership Award for helping remember going to Australia and a professional pitals. Dominic Shaw, associate professor, said: London families to overcome addiction. Michael cricketer walking off the pitch and bursting into “It’s all about team working—we’ve brought the Shaw, child and adolescent child psychiatrist, tears. We need to overcome stigma and support nurses with us tonight.” said: “Health has an enormous amount to con- these needs.” Other winners from the city, which has a life tribute to child protection. It is very nice to be rec- It was a sentiment echoed by former Downing expectancy three years below the national aver- ognised by a mainstream journal such as the BMJ Street director of communications Alastair Camp- age, included the NHS Nottingham City Clinical because we often feel on the fringes of things.” bell, who launched a collection in aid of mental Commissioning Group, which was named Clini- The England and Wales Cricket Board was health charity Mind. “There should be parity in cal Commissioning Team of the Year. named the Sports and Exercise Team of the Year physical health and mental health, and we are Jon Cardy was named Clinical Leader of the for its work to reduce the number of facial injuries a long way from that,” he said. The BMJ Group Year for transforming emergency services at through the manufacture of safer helmets. matched the £2000 donation raised by guests West Suffolk Hospital. Cardy, whose depart- Accepting the award, Nick Peirce, the board’s on the night. ment was the best performing accident and chief medical officer, also highlighted the impor- The award for Transforming Patient Care Using emergency department in England last year, tance of looking after the mental as well as physi- Technology went to a team from Nottingham according to quality indicators, was nominated cal wellbeing of England’s top cricketing teams, University Hospitals NHS Trust for their wireless for the award by a junior member of his team,

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a fact which impressed the judges. Cardy told BMJ.COM BLOGS Stephen Ginn the audience that he had too many “career heroes and heroines” to mention but shared A disaster for humanity and the planet? his achievements in West Suffolk with a team of Is medical control of human ageing a worthy to defeat ageing an “incredible range of age amazing people “who are not all doctors—they goal? Despite the moisturisers you can buy, it related disorders would have to be defeated.” are just the tip of the iceberg.” “If you are a doc- is impossible to reverse the damage of ageing Blakemore also says that the emergence tor you must value all your colleagues, not just and very few of us will live to anywhere near the of technology that will substantially prolong the medical ones,” he said. theoretical maximum of human age, estimated human life will be a “disaster for humanity and Alexander Finlayson was named Junior Doc- to be 125. Yet some people think the first human the planet.” tor of the Year for his MedicineAfrica project, who will live substantially longer is alive today. I agree. I don’t think that it’s inherently which links up medical students and doctors in Aubrey de Grey is one of them. He recently unethical to seek to extend the human lifespan. Somaliland with UK educators. spoke at a debate at the Oxford University But I am worried about the consequences. The Excellence in Healthcare Education Scientific Society, for the motion “This house Even the prophets of life extension such as de award was scooped by a team at Imperial Col- wants to defeat ageing entirely.” de Grey is the Grey concede that, without a drop in birth rate, lege London for their Lessons Learnt: Building a chief scientific officer of the SENS foundation problems of rising population will become even Safer Foundation project, to drive improvements and a cheerleader for bringing ageing under more acute.We will need to choose between in patient safety. medical control. “This is no longer a radical living longer and having children, as doing both A new award for this year was the Karen Woo heretical idea,” he says. For de Grey, defeating will be catastrophic. Award, which recognises individuals who have ageing is at the heart of what medicine is As for my profession, I fear the emergence gone beyond their call of duty to care for patients. about. And when we treat ageing, longevity is a of life extending technology will divide the Karen Woo was a doctor killed in Afghanistan in welcome side effect. medical world. At present many doctors do 2010 while working for a relief charity. Methods to extend the human lifespan not consider ageing to be a “disease,” and Sneh Khemka, medical director of Bupa are speculative, and de Grey’s ideas are it is therefore a questionable target for our International, which sponsored the award and controversial. Calorie restriction is shown attentions. Despite this objection, many for which Karen worked before travelling over- to increase the lifespan of several species, doctors’ careers do not focus on acquired seas, said: “She is the true embodiment of what including rodents and fish, but there is no disease but on treating the consequences of an altruistic doctor is all about.” The inaugural evidence that this finding will translate to age related decay. Either way, once we are able winner was Lucy Mathen, founder of the char- humans. Nanomedicine is a futuristic strategy, to arrest ageing, life extension will be the only ity Second Sight, which has helped restore sight with constant corporeal repair provided by show in town. to more than 50 000 patients in India. Mathen microscopic robots. Another proposal is for How else would living to 150, 300, or 1000 praised colleagues at the Bihar hospital from cloning to generate cells, body parts, or even affect us and our societies? There are many which the charity operates, including one eye entire replacement bodies. potential pitfalls. Progress in many spheres— surgeon “who could be making a fortune in the de Grey is bullish about the future and the scientific, political, commercial—happens private sector but comes to us on the bus and emergence of new technologies: “If you tried to when its opponents die. Life extension will then carries out 50 exquisite eye operations.” predict the rate of improvement in the Atlantic profoundly affect power structures, as death One of the biggest cheers of the night went to crossing by looking at ocean going liners you’d will no longer serve as the ultimate solution to have been wrong,” he says. Another of his entrenched authority. If life extension were to 90Ten with 56 Dean Street, G-A-Y club, and Boyz proposals is of a “human longevity escape be restricted to a wealthy few, this would further magazine in London, which won the award for velocity,” which supposes that initial life exacerbate our already deep social divisions. best Healthcare Communication Campaign. 56 extension therapies will only grant a modest Perhaps most fundamentally, without a Dean Street, a sexual health and HIV clinic, and life extension. This extra lifespan will see a sense of urgency, what sense will we make of partners staged the event “A World Record for recipient through until the development of our lives? Will a longer lifespan allow us to live World AIDS Day,” which broke a world record by more advanced therapies. In this way the first all the lives we want, or will boredom overtake encouraging more than 450 people to take an person to live to 150 might also be first person us, leading to widespread demoralisation? Or HIV test in a single day. Health workers tested to live to 1000. maybe, with so many more years to lose, we patients for a solid eight hours, and it was “a I find this reasonably persuasive. Colin will all become more careful with our bodies, wonderful collaboration,” said the organisers. Blakemore, professor of neuroscience at reflective in our relations, and optimistic in our Winner of the Lifetime Achievement Award Oxford University, does not. He was speaking outlook. was Bernard Lown, the cardiologist and Nobel against de Grey.“Utterly unrealistic” is how he Stephen Ginn is Roger Robinson editorial registrar, BMJ Prize winner who also developed the defibrilla- describes de Grey’s proposals, and he says that • Read this blog and others at bmj.com/blogs tor. Lown, aged 91, has devoted over 50 years to the practice of medicine, particularly in car- diology, and is also a keen peace activist. In a pre-recorded video from Boston, United States, Bernard lambasted the overmedication and overdiagnosis of care in his home country. “Our healthcare is enormously costly and I hope that the UK can avoid that model,” he said. Rebecca Coombes is features editor, BMJ, London [email protected]

Cite this as: BMJ 2012;344:e3741 MICHELTCHEREVKOFF/STONE/GETTY IMAGES

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