I'm going to give you a talk.
We're going to talk about overdiagnosis, explain how it affects me, how it might affect you, and how you might think a bit differently about it.
Okay. Well, when I first started thinking about this problem, I was in New York, actually, and that fixed avenue going down New York,
and I opened for the word the signpost here, caution with there because of the traffic.
But actually, as I progressed on it, it became a little bit darker.
I realised it was about this van that was on the side of the road, which was the Brain Tumour Foundation,
where you could have your scan of your brain on Sixth Avenue for about $700 that evening.
So this idea that the road to early detection and so this this presence of the idea, you'll be aware of C.T. scanning being around you in areas.
And then as I went through, you realise this sort of stuff everywhere in the newspapers, £120 test to spot genetic heart failure.
So you can have a test like that today. Everybody in this room can have it.
And when I got home I realised you get to a certain age, some of you are not there yet and people start sending you letters through the post.
And online letters are messages an urgent message about your examination?
And basically the suspect thing was telling me it's now over two years since your last examination.
And as we mentioned in our previous letter, you were due to have your eye test on 29th of August 2014, and now it's 415 for February 2016.
I'm a bad person now just to say I'm over 40 and I have a family history of glaucoma.
Anybody else in that situation in the room? A couple of people.
All right. So the good thing if you get free eye tests, don't you?
So if you want to get free eye test and you're over 40 telling me you've got family history of coma and they'll give you a free eye test,
both the secret. The second issue, though, then, is how often do you get a free eye test?
Whenever I feel like it. Every year. Every year.
So the NHS pays for people like me and our friends here to go for an examination every year.
However, I'm the professor of Ebola and I haven't been for nearly two years.
And so we've got differences of opinion every year. Whenever I feel like it so far, you know, I'd look at the evidence before we go.
How can that help me? And actually, the the systematic review and economic evaluation of the evidence for glaucoma screening.
And when you do that, you see that this often phenomenon of actually there doesn't seem to be much evidence.
There are only two randomised controlled trials and then two randomised trials have to do two important steps.
They have to extrapolate and they have to make assumptions.
Whenever anybody's doing that, I often think they must be making it up at that point.
But you can see that without treatment. Meantime, to blind for at least one eye with 23 years compared to 35 years with treatment.
That's assumption based, but immediately that tells you whenever you get a diagnosis,
you're going to have to take somewhere about 25, 30 years of treatment to realise the benefit.
And you might not know, but you are committing yourself. One point somebody is going to diagnose you with raised intracranial pressure in your eye,
intraocular pressure and you need to take 25 years of treatment.
So that's a first for process. Okay. But it appears not to be cost effective.
Okay. And the screening interval seems to be every ten years to approach cost effectiveness.
That's different from the benefit. That's how much we would screen you to say we generate a genuine benefit and then a go to obviously.
Well, look what see the US Preventive Task Force, they do guidelines and they do a rigorous job and they obviously do the systematic reviews.
Again, look at the evidence and come to a conclusion. And this was their conclusion.
And now we've got two people in here.
How does that really help you make a decision? Do you think do you think that makes you more likely or less likely to screen yourself?
Okay. Well, very helpful. Is it? So you have this discussion and so it went back to NHS choices.
NHS choices are are evidence based.
Tell us how to communicate to the public and it tells it is important to have regular eye
test though I problem with glaucoma can be diagnosed and treated as early as possible.
If you have glaucoma, it can take a long time before you realise you have a problem.
You should have an eye test at least every two years or more frequently if advised by your optometrist.
Well, it's obvious you're optometry. They make money out of it. You're going to tell you more frequently.
They'd like to do it every day, if possible, one day if you were expecting it.
But how is that compatible with that? Isn't that what's going on?
This is the NHS in complete opposite to that information.
We don't know what we're doing. Hey, do it every two years. So at that point, I'm like, feeling totally confused.
What do we do now? Well, I'll go and look at the evidence.
What did the test look like? And here's a test which have different ranges of sensitivity and specificity.
So this is the worst case scenario if I have the test. Okay.
So if I take a thousand white people like me, my prevalence of disease with a family history of about 5%.
That means 50 people have the disease. 950.
Will not everybody follow that? Happy with that? Okay.
The test ranges from 10% to 90% sensitivity and specificity of 81 to 90%.
So if you take the worst case scenario of a sensitivity of 10%, everybody is doing the MSI knows what that means.
Now, I'm not going to test you my overreading, but what it means is 10% of the people with the disease will test positive.
And if you take the specificity of 81, that means of the 950 who don't have the disease, 181 will test positive.
You had all the numbers together and you end up with this. Only five of 186 will actually have the disease if you have a positive test.
That's the worst case scenario. There are about 3% if I get a positive test.
But let's take the best case scenario. The systematic review evidence.
The best case scenario is a sensitivity of 90% and a specificity of 99%.
We're now in a really good test. Most people would go, Wow, that's a super test.
Sensitivity, 90% and very high specificity.
You get the same numbers here. Happy with that? If sensitivity 90 said 45 out of 50.
Yeah. So of the 50 people with disease, 90% of them will test positive, about 45.
And of the 950 without the disease, 99% specificity, 95% will test positive.
That means you end up with about 30% chance of having the disease if you have a positive test and a glaucoma screening as of tomorrow.
About one in three. So I find that I understand the evidence, but it still doesn't help me very much because now I'm stuck in alone thinking,
well, the US Preventive Task Force says we're not quite sure whether to screen or not.
NHS choices say do it every two years or less. The evidence is extrapolated.
There are three options and it's only two randomised trials and actually there's only
one in three times if you have a positive test that will actually have the disease.
I actually have. And so it leaves me in a position of uncertainty.
I still don't know what to do. Now, that's interesting.
And I've looked at all the evidence, and so I find this is a recurring theme whenever I go and look at types of evidence.
And so often you get this scenario where somebody said, Well, oh, but good news,
all I have to do is put I prescribed, I've dropped in few, I got diagnosed.
So you always get a case where somebody goes if without testing and screening, I wouldn't have been picked up.
Okay. The problem with that is the few if I've got to put eyedrops in my eyes now for 25
to 30 years and I don't really know whether it's going to make any difference.
Now it's an important issue. Second issue is when we label people with the disease.
I can go back to show you a particular study going back now to the 1978 in the New England Journal of Medicine.
This is David Sackett, and Brian Haines looked at what happens if you go to hypertension.
Diagnose hypertension in the workplace. If you go into the workplace, you go and get people like you.
And we say some of you have hypertension, some of you don't, and some of you never knew that.
Well, in fact,
one of the biggest issues about this paper is that actually what it showed is that labelling resulted in increased absenteeism from work.
So there's something we do. And it was quite significant that actually the amount of it within previously unaware subjects before screening,
they take about 2.7 days after screening, they take about 8.4 days off of work.
But huge implications, doesn't it, for how we think about when we give people a label.
If not just you're going to say, well, you have a diagnosis in here, some treatment now go away and get on with it.
Actually, we may increase their anxiety. We may increase their health seeking behaviour.
We certainly may increase the ability to take time off work because suddenly you think you might be a new person.
So what does it mean if you're prepared to have a label? Then you go back to the glaucoma.
Should I have a label or not? What? The other connotations?
What do I need to know about in terms of the quality of my life, who I am, what effect it might have on me before I make the decision?
I think this is really important stuff. We don't know the answer. Okay, so that's one example.
For myself. Here's a second example.
Dear Mr. Hennigan, I am pleased to invite you to a health screening clinic we are holding at the Kassam stadium on Thursday, the 25th of February.
Why have I been invited? When we organise the clinic, we write to a small number of people.
They are very special in your area for whom appointments are available.
This is a simpler system that keeps our administration costs low, meaning we can offer extensive health screening at a fee.
That is exceptional value to me. I'm told, look, well, the fee is £129.
And the good news is, if ever went to BUPA, it would be £424.
So I am being sold the message. And I was somebody I threw for Harry, the centre manager I talked to.
I said, Look, anybody here over 40 and we've one of them people.
And she was getting these electives as well, collective health screening letters,
the ones you hear about 40, you start to get invited to health screening.
Okay. And in that, you have to make a choice. Do I go?
And in this message, it talked about measurements such as age, sex, family history, height, weight and blood pressure.
Simple blood test to measure. And following the check, you will receive personal advice about what you can do to stay healthy.
That's what we're doing now in health care. We send out this is from a GP practice, not from private firms.
And then you get information like this, questions you may have. What happens at the check?
And when you read the information. It's so basic, it doesn't really help you in any way.
Make an informed choice. Do not talk about the tests, what the accuracy is.
Doesn't talk about the important effects it may have on you in terms of the benefits in the hand.
If you start pretty brown statements, some people with raised blood pressure will have their kidney checked through a blood test.
But what they do, treatment or medication, may be prescribed to help you maintain your health without really informing you.
Is that informed choice about the benefits and harms though?
Health checks. We actually have just done echo on a player who's not here.
It's done in evidence.
Sympathies with us for the show to look at health checks, cardiovascular risk screening, and that helped it prioritise where all the evidence is.
And here's one of the first bits of evidence about helping you make your decision about should you have a health check.
And this is the Cochrane Systematic Review, and it's done by Lafe Kroc's Bill, and it came out a couple of years ago.
Okay. And what does it show? This is what it show.
Again, only child about health. It did not find that health checks had any effect on hospital admissions, disability, war,
the number of referrals to special additional visits to doctors or absence from work.
And they were poorly studied, all the important work. So that doesn't work.
So it looked at this review. Here's another review that we found within the message.
And this one is looking at opportunity. Systematic reviews, opportunistic risk assessment.
Systematic is is we systematically call you in Ruth if you're in my practice and I opportunistically say I'll make you pressure,
or would you like to talk to me about this today? I could look at that.
Okay. Another Cochrane review. Okay.
So again, you'd expect to see these important effects like all cause mortality.
If you're going to invest in health checks, you would want to see some effect on all cause mortality.
No difference. Cardiovascular mortality. That's what you're hoping to see.
No effect. Have no effect on these outcomes.
All right. You can even drill down into this.
One is one of the only population based on where they've done it actually in primary care.
This was published in 2014 in the BMJ June 2014.
Effective screening and lifestyle counselling on incidence of ischaemic heart disease in a general population into 99 randomised trials in Denmark.
So this is not just screening, this is screening giving you some extra lifestyle conflict.
Okay, look at what they did though.
I would find this quite interesting invited for screening, risk assessment and lifestyle counselling up to four times over a five year period.
So it's not just one, it's four times over five years. It's you then have your tailored lifestyle and counselling all visits.
And those at high risk of IHT have fixed further suggestions of group based lifestyle counselling.
So now we really trying to make the intervention work online.
We are definitely making sure compared to doing nothing you are going to have some effect.
Yeah, and if there were any changes, final counselling session, you were referred to GP for medical treatment if relevant.
The control group was not invited for screening. Okay, that's pretty intensive, isn't it?
And look what happen.
So even if you go to that intensity level, know the different thing between intervention and control groups in terms of ischaemic heart disease,
even if you work really hard with people. And the combined endpoint, total mortality, no difference.
And you can see the complete conclusion is a community based, individually tailored intervention program with screening have no effect.
We though have rolled out a health screening programme in the UK and I can come back to that at the end.
There are interesting issues why this might never work and what the connotations and what the issues.
But at the moment I am ignoring my health check screen.
Okay. I'm quite happy to not know where I'm at.
What's going on. I do not know my cholesterol level at the moment and I'm quite happy.
Not tonight. Okay. So there's a second one here, the third one.
Okay. Now talking Jeff at the back about this.
This is I was feeling a bit on well, you know,
when you get the cold and flu and you feel in a bit miserable that everybody is not in, you can feel like that.
You feel a bit under the weather.
I felt while I'm doing that, I'm going to do my Q nine score, which is use of the Q nine to make a tentative depression diagnosis.
So these are the Q nine school. So I thought, well, I'll do my score.
Little interest of pleasure in doing things. Well, actually, I was about one for that several days.
I would also have trouble falling asleep, staying asleep, or sleeping too much.
In fact, I gave myself a free for all dependent with feeling pretty grotty.
I couldn't really sleep. And then sometimes in the day I felt like sleeping all the time.
When it came to my appetite, I was feeling tired or having little energy.
I had a poor appetite and I wasn't all overeating and I was overeating at some points as well.
You know that feeling when you did feel a bit thick, but then when you feel or you overeat, that happens to me on occasion.
And I also had trouble concentrating on things such as reading the newspaper or watching TV.
And so I ended up with a score of nine. And my nine gave me minimal symptoms.
The poor educate to call it worth returning one month treatment recommendation if I scored one more point.
I could have had a diagnosis of minor depression at that point in time,
and we started to use all of these schools a significant amount of time because come out of research and somehow
we've translated them into clinical practice without even thinking of what's the connotation of what we're doing.
And this is a really interesting issue because when you look at it,
you can start to look at depression and look at the validity of the diagnosis and what you don't see.
Identification of depression is strongly felt created with increased familiarity with the patient,
to the point that people who don't have depression are labelled as depressed, false, positive people.
Both these people who do have depression but are not labelled false negative.
The only thing that starts to distinguish them is they're identical in terms of
the clinician and the clinical characteristics is how many times you turn up.
So what happens if you think about it in depression when we've seen huge increases is if you go and see a GP quite a few times,
at some point you're going to go, I think you're depressed, have a treatment, have the medication.
Because it's really easy to do that. And so that has connotations for us as GP's to really think about.
Why is this person here? Has their symptoms changed in any way?
Are they really depressed? Now this is really interesting when you start to look at it, you look at the evidence.
Now I've looked at the evidence and I've kept looking for five or six years for the evidence in primary care to evolve.
And what I've noticed is actually this is published in 2009,
there were only 14 studies and only 2000 people globally involved in randomised trials for anti-depressant in the community in primary care.
That just seems outrageous to me. Not least we're of short duration, typically 6 to 8 weeks.
There is very limited evidence beyond eight weeks of what to do.
This is in an area when you marked in the product, you want to show some effect and get it out there quick.
Now, this was updated again in 2014. What they said that actually the number of studies with observation period of longer than 12 weeks,
comparative analysis of long term effects was not possible. Okay.
So that makes me concerned about the use of antidepressants in primary care.
There's a small effect and that small effect is over 6 to 8 weeks and beyond.
About 12 weeks is very little to inform what to do. Yet most people I see a month guideline say you should give it at least six month treatment.
And these treatments are really interesting. So here's some more interesting that I've always noticed about the way we prescribe, the way we medicate.
This is FDA data. This is the specific odds ratio for suicidal ideation and behaviour.
You can see below 18 on an antidepressant, the odds ratio is about to 18 to 24, it's about 1.5 and then it starts to decrease.
Happy with that? Yep.
So you would look at that and think, well, okay, anybody who's young under the age of 25, I will be more vigilant about using these treatments.
Yeah. You particularly know some of you about paroxetine.
That was a particular issue in adolescents. Yeah, I get these sorts of pieces, which I just cannot fathom what's going on.
This is the is published in 2016.
So only just last month there's been a rise in prescribing of anti-depressants in children of 50% in the last seven or eight years.
20% of taking tricyclic despite guidance, the 2009 guidance against the use of these agents in children and young people.
So we're using treatments more and more that we're being told not to use,
and we use them in the age group where we're having warnings about not using them.
And this is what we start to see. Globally in a decade, huge rises of antidepressants.
This one here is citalopram. Quadrupled over time, doubled over time.
And then you look at the prescribing around the UK of antidepressants.
Now at the back there, just look, this is the grape. It is.
This is 50,000 people in the grape bit. So Oxford's just in there is about 70 to 141 items per thousand people.
Yeah. The blue bits are not the Tory party.
The blue bits are 141 to 185.
Yellow bits are next. But when you get to the red, you're talking 225 to 331.
You're talking one in five people are on an antidepressant.
Yeah. Yeah. But they are in Norfolk. Mhm. Uh huh.
Even if in particular about Norfolk they're.
Well it's interesting I put the. You get the lowest. These are the same IMD for deprivation.
You can look at areas like that and show a little here's Brent that's actually it's not not deprivation
this is the data today from open describing which we do in the IBM data lab 39.5 per thousand.
This is over here. This is 176 per thousand.
It's about fourfold variation.
Oxford right there in the middle, you can explain some of this variation probably by age subgroups, but boy, can you explain all of that?
Can you explain the difference between that?
And it's a really interesting but what's happening is one in seven people is on an antidepressant in this country right now.
That's staggering in the 21st century. That suggests we've got a crisis in mental health, that despite all of our growth, everything we're doing,
we are becoming sadder and worse off or the summit structurally going wrong in how we use medications, how we diagnose people.
In fact, the prescribing is slightly higher than the rate for diagnosis.
Whether that's because there are some factors, but actually we're even giving treatments to people that we don't think are that depressed.
And I can see I get a lot into the jeep.
I get a lot of students who come out and they go into the workforce and they'll be 21, 22, and they'll turn up at my practice in the go.
I'm really tired. Can't get up in the morning and I'm a bit fed up with the world and I'm like, Yeah, that's what the real world like, isn't it?
But you can be careful if you come and do that. A couple of times I've told you going to end up on anti-depressant at some point, so.
And the issue is when you get on them, if you can't get off of them. And this is Peter Grotius position, who writes a lot about this,
is that the with discontinuation symptoms are so bad that it's very hard to get off them, so you end up staying on them.
So we have this epidemic where it continues in time, where you'd expect,
if they were working, that at some point people would actually be coming off these drug.
So although they may be coming on it, you get better. Then you come off. When you feel a bit better, you come down.
That's what we do a lot in medications, unless it's an irreversible that actually just on a continuum of depression.
And we can't do anything about it unless you're unless you're on the drugs.
Okay. So that's on to depression. We've done we've done glaucoma, we've done health screening.
And I've talked to you about antidepressants. Now we're going to just look a little bit at cancer.
And what's interesting about the cancer is the advert is how emotive they are.
This little kit saved lives from bowel cancer. The three vehicle screening test.
Put it on your left. Have a look at the picture.
My mom missed a smear test. Now I miss my mom. Really?
Get into your heartstrings, isn't it? Why? You should have a test? That's what we have to rely on.
We're marketing you to have your test. And I see this.
If you start to become aware, you'll notice these adverts are everywhere in your life.
They're all over the place and you get these ones. Text Test 802 Somebody could have a go if they want.
It'll cost you 8 to 12 p subsequent tax charge and it's done network, right?
And somebody is probably making some money somewhere. But then you get things like this.
I got this. This was on the London Underground.
First of all, it was some TV that I could buy at £23 for a plasma screen.
And so when I went and looked up at this, I nearly died because I nearly fell on the track at this point because I couldn't read it.
And it said the myriad to test it.
The first over-the-counter blood test that allows you to screen yourself and quickly indiscreetly for a range of 14 different health conditions.
So you can do that now. You can go and screen yourself, you can pick all these tests, you can have a CT scan,
you can go and see your doctor and you'll definitely get anti-depressant. By the time you're 40, you can have a health check.
But this is what seemingly is happening and this is data from Cancer Research UK.
While we are increasing the incidence of thyroid cancer per phone fans and people, this is what's happening to mortality.
Okay, it's flatlining. Very little effect.
So we diagnose in more conditions and this is what the term overdiagnosis is referred to.
Now, this is how they see it, the diagnosis of conditions that will never cause symptoms or harm during the patient's long time.
The consequences are unnecessary anxiety, harms from excessive treatment, and increased health care costs.
Risk that those who don't need treatment are prioritised over those who do.
And this is the thought diagram that you get seen a lot.
And Jason here will know this diagram very well in the cans and the stats people, you get diagnosed with an abnormal cell.
We don't know whether that's going to be a fast growing cancer, whether it's going to be slow on that,
get you to this at which line this is where it causes symptoms.
This is where you die or is it very slow cells? You'll die something else in your lifetime?
Or actually, is it just going to be non-core, progressive or actually going to be regressive over time and you'll return to normal?
That can happen in breast cancer and cervical cancer and all these areas where you make a diagnosis, you have abnormal cells.
We know very little about this right now. And so this is what it looks like for breast cancer.
The incidence has been going up and the mortality has been coming down.
People would like to say that screenings introduced. This is the effects that we see for screening, that this is what they like to say.
For every 10,000 women screened, 43 deaths from breast cancer would be prevented and 129 cases of breast cancer would be overdiagnosed.
So for about every one where we find a case, three of three cases of overdiagnosed are detected, somebody that something wouldn't happen to.
But that's assuming that all of this mortality through screening,
it's not it's not actually based on treatment effects, both treatments getting better.
So we don't really know about what's really happening with breast cancer screening the effect both
of the trial for 40 years old and I actually did this when I went to the W.H.O. believe it or not,
the W.H.O. figured in all the world problems that actually one of the priorities was to produce a guideline on breast cancer screening,
because there are only two camps there.
Either people who believe it's the best thing to do things like spread, or those people who think you should never do breath screening.
And in the middle, when I looked at the evidence, all I could see with huge amounts of uncertainty.
Evidence that with 40 years old, where the mortality reductions were based on whether you had a mastectomy or not,
which is what we don't even do anymore for the treatment changed and the data is very old.
So I would say that there is saying, wow, this is a real myth. How do we make sense of this?
Where do we go next? Okay.
And this is the sorts of things you see a lot of, don't you? Our survival rate lags years behind those in Europe.
In fact, the easiest way to improve survival rates is to just diagnose something earlier.
But it is not the same as improving overall mortality, because if you count it in five year survival,
you want to diagnose things much earlier and you can improve five year survival really quickly.
And that's when you hear about socialised medicine in America. What they're doing is, for instance, they diagnosed prostate cancer earlier.
A five year survival is better, but the overall mortality is no different.
People die at the same age from prostate cancer in the UK and in the U.S.
And that's important to know. And this is what's happening now.
We are referring more patients with low risk cancer systems under new knife guidance.
So, for instance, if you have a cough, how many people here have had a cough that's gone on for three weeks?
Okay. On the ninth guidance, you should have all been referred for a chest x ray because that's what knife is starting to tell it.
And in that position is saying what's happened in the last five years is the number of x rays in Oxford have doubled.
And Jack's just walked in the room and he knows that because that's what is felt about.
And somehow we're good. Who's accounted for all this extra work? Why is it people are not paying attention to when we do things like this?
You massively increase the amount of work in the NHS.
And everybody is now telling us, despite all the extra investment, the nature of even more crisis than it's ever been.
And that's interesting. And before I came here, I was having the question with Geoff at the back about this talk.
And in 1997, 20 years ago, there were 1437 billion into the health service and I worked with Jeff directly in the NHS.
20 years later, we now spend 120 billion.
And we have the same structural problems that we had 20 years.
In some ways, they're even worse. Now, why is that occurring if we put all that extra investment in as a huge amount of money, isn't it?
We've doubled the number of doctors in that town. We train twice as many doctors now than we did then.
And what has happened. You can do this.
And there's Dylan at the back. You can do this all the time. You can go and get yourself tested all the time.
You can be advertised to. You can be marketed to. You can be at the airport.
And you can do your blood pressure from the fly healthy seat on the machine.
And what does all that mean? Here's where I'm at. When you have things like this, you have to think about.
Do you want to know? Would you be happy to live with the disease or not?
Would you happy to be live with the risk or not? Does it ultimately help you to know whether you've got a high risk or not?
Are you the sort of person that can tolerate that or will it make you take more time off work?
Do you want to know? Do we want to know? We had that debate.
And so when you do things like that, often go back in time and think, well, somebody must have said something sensible about this in the past.
And in going back, this is the first thing I think most information relates to tested patients.
It seems you've already had the test to get you to screening.
You have to be most information is emotive relying on scare tactics and you most individuals are not equipped to decide whether to take tests or not.
That fair comment you might be once you've had the test, but beforehand I'm showing you all the illustrations where I'm in a position where I'm going.
I'm not quite sure about this. And so I look back at the World Health Organisation in 1971, the screening criteria,
and there's one thing that sticks out to me screening most lead to an improvement in end results defined in terms of mortality,
physical, social and emotional function, pain and satisfaction among those in whom early diagnosis is achieved or in other members of the community.
If I applied that definition to health screening, would I have achieved that?
Ask yourself, then, if we haven't achieved that, why have we rolled it out on a national basis for everybody to make it available?
Have I achieved that for depression? Am I sure about that when it comes to the glaucoma?
And there are many instances where I don't think we are in that position.
So this is where I am with the overdiagnosis that too much demand, too much screening,
too much testing, too much treatment, and therefore overdiagnosis is really just too much health care.
And that's where we are today. Thank you very much.