WCOE: Over-Diagnosis, Over-Treatment, and a Broader View of Health

In a Health Affairs blog post entitled, “Reconceptualizing Health and Health Care: Why Our Cancer Care Delivery System Is In Crisis,” Carolyn Payne and William Dale suggest that the health care system should look at patients more holistically, rather than focus on a single disease such as cancer. They cite last year’s report by the Institute of Medicine that concluded that the cancer care system is in crisis.

“We believe that this crisis is largely a result of our own misconceptions about health. In our rush to aggressively treat anything labeled as ‘cancer,’ even among older, frailer people with low-grade diseases who are much more likely to die from other causes, we often over treat patients, causing unnecessary costs, unnecessary care fragmentation, and unnecessary pain and suffering for patients. By focusing our attention on the continuing ‘War on Cancer,’ we are too often distracted from more important health concerns,” they write.

There has been much discussion among physicians and policymakers about over-treatment of cancer. A recent article in The Wall Street Journal by Melinda Beck entitled, “Some Cancer Experts See ‘Overdiagnosis,’ Question Emphasis on Early Detection,” discusses over-diagnosis, or the detection of cancers that are not likely to cause harm, and over-treatment in various types of cancer. Beck quotes Dr. Laura Esserman of the University of California, San Francisco, “We’re not finding enough of the really lethal cancers, and we’re finding too many of the slow-moving ones that probably don’t need to be found.”

Esserman and others have suggested that we change the lexicon and stop calling some early-stage lesions “cancer,” a suggestion Payne and Dale echo.

While Beck discusses efforts to devise new tests that will predict which cancers will grow quickly and which will not, Payne and Dale suggest a different way of thinking about over-treatment. They cite The National Social Life, Health, and Aging Project (NSHAP), a study that takes a broader view of health by incorporating sociological, psychological, and biological health factors, in line with the World Health Organization’s (WHO) definition of health: “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

Payne and Dale suggest that the mindset of aggressively treating every cancer misses the bigger picture of a patient’s overall health, co-morbidities, and situation in life. “Each patient’s disease, or more likely multiple diseases, need to be considered in light of his or her overall function, psychology, financial situation, social support options, and values. Treatment options may differ significantly based on each patient’s individual needs, and his or her preferences should be considered,” they write.

NCCS has long supported a cancer care planning process that would include a shared decision-making process that considers patients’ needs and preferences, and we support an approach that considers an individual’s overall burden of treatment and quality of life. Payne and Dale also recommend care coordination, psychosocial support, and physical therapy, all of which are essential elements of holistic cancer care.

However, we do have concerns that Payne and Dale underestimate the importance of cancer treatment and the emotional impact on individuals who have been diagnosed with cancer, when they suggest that “we should focus less on cancer care and more on other aspects of health.”