![Page 1: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/1.jpg)
Overdiagnostik – en uundgåelig konsekvens af medicinsk screening
John Brodersen Professor, speciallæge i almen medicin, ph.d.
Center for Forskning & Uddannelse i Almen Medicin, IFSV, KUForskningsenheden for Almen Praksis, Region Sjælland
![Page 2: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/2.jpg)
Overdiagnostik v. screening
Post-moderne medicin
Definition
Overdetektion ved screening
Hvorfor?
Eksempler
Stadieskifte
Incidens og mortalitet
Konsekvenser af overdiagnostik
Fremtiden?
2
![Page 3: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/3.jpg)
Overdiagnostik v. screening
Post-moderne medicin
Definition
Overdetektion ved screening
Hvorfor?
Eksempler
Stadieskifte
Incidens og mortalitet
Konsekvenser af overdiagnostik
Fremtiden?
3
![Page 4: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/4.jpg)
Traditionel medicin
symptomer
klinisk undersøgelse
4
![Page 5: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/5.jpg)
Curative Medicine
Help!
5
![Page 6: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/6.jpg)
Moderne medicin
symptomer
klinisk undersøgelse
mikroskopi/mikrobiologi/medikoteknologi/epidemiologi
afvigelse/abnormitet/risikofaktor/patologi
diagnose6
![Page 7: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/7.jpg)
Preventive Medicine
I have something to offer you
7
![Page 8: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/8.jpg)
Post-moderne medicin
mikroskopi/mikrobiologi/medikoteknologi/epidemiologi
afvigelse/abnormitet/risikofaktor/patologi
korrekt diagnose + overdiagnostik
illness
8
![Page 9: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/9.jpg)
Post-moderne medicin
mikroskopi/mikrobiologi/medikoteknologi/epidemiologi
afvigelse/abnormitet/risikofaktor/patologi
korrekt diagnose + overdiagnostik
illness
9
![Page 10: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/10.jpg)
Overdiagnostik v. screening
Post-moderne medicin
Definition
Overdetektion ved screening
Hvorfor?
Eksempler
Stadieskifte
Incidens og mortalitet
Konsekvenser af overdiagnostik
Fremtiden?
10
![Page 11: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/11.jpg)
Overdiagnostik - definition
“Overdiagnosis is the diagnosis of ‘illnesses’ that would never have caused patients harm but potentially exposes them to treatments where the risks outweigh the benefits.”
Doust & Glasziou. Is the problem that everything is a diagnosis?Australian Family Physician 42:856-859, 2013.
11
![Page 12: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/12.jpg)
Overdiagnostik - beskrivelse
“Overdiagnosis occur when individuals are diagnosed with conditions that will never cause symptoms or death”
“…the ultimate criterion for overdiagnosis: at the end of life, if the person never developed a problem from her condition, she has been overdiagnosed”
Welch, Schwartz, Woloshin. Overdiagnosed. Making People Sick in the Pursuit of Health, Boston: Beacon Press, 2011.
12
![Page 13: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/13.jpg)
Overdiagnostik - min definition
Diagnosticering af afvigelser, abnormiteter, risikofaktorer og/eller patologiske forandringer, som uopdaget eller udiagnosticeret aldrig i sig selv vil;
give personen symptomer (eks. afvigelser),
vil medføre sygelighed eller
vil være årsag til personens død.
13
![Page 14: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/14.jpg)
Overdiagnostik - 3 områder
Nedsætte grænseværdier og/eller udvide sygdomsklassifikation
Opfinde nye ”sygdomme” (disease mongering)
Overdetektion ved screening
14
![Page 15: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/15.jpg)
Overdiagnostik - 3 områder
Nedsætte grænseværdier og/eller udvide sygdomsklassifikation
Opfinde nye ”sygdomme” (disease mongering)
Overdetektion ved screening
15
![Page 16: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/16.jpg)
Overdiagnostik v. screening
Post-moderne medicin
Definition
Overdetektion ved screening
Hvorfor?
Eksempler
Stadieskifte
Incidens og mortalitet
Konsekvenser af overdiagnostik
Fremtiden?
16
![Page 17: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/17.jpg)
The Screening Cascade
Negative
screening result
Positive
screening result
People who
are screened
True positive False positive
Treatment
works better
early than later
Rapidly
progressive
disease; person
would die even if
treated
Mild, easily
treatable disease;
person would do
well even if
treated later
Person would
never have
developed
symptoms, even
if untreatedBenefit
No Benefit
Incidental
finding
Separate
cascade
Workup
Treatment
Indeterminate
findingSurveillance
Modified slide: Professor Russ Harris 17
![Page 18: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/18.jpg)
The Screening Cascade
Negative
screening result
Positive
screening result
People who
are screened
True positive False positive
Treatment
works better
early than later
Rapidly
progressive
disease; person
would die even if
treated
Mild, easily
treatable disease;
person would do
well even if
treated later
Person would
never have
developed
symptoms, even
if untreatedDelayed Benefit
No Benefit
Incidental
finding
Separate
cascade
Workup
Treatment
Indeterminate
findingSurveillance
Types of “true positives”
Modified slide: Professor Russ Harris 18
![Page 19: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/19.jpg)
The Screening Cascade
Negative
screening result
Positive
screening result
People who
are screened
True positive False positive
Treatment
works better
early than later
Rapidly
progressive
disease; person
would die even if
treated
Mild, easily
treatable disease;
person would do
well even if
treated later
Person would
never have
developed
symptoms, even
if untreatedDelayed Benefit
No Benefit
Incidental
finding
Separate
cascade
Workup
Treatment
Indeterminate
findingSurveillance
Types of “true positives”
Immediate harms/costs
Modified slide: Professor Russ Harris 19
![Page 20: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/20.jpg)
The Screening Cascade
Negative
screening result
Positive
screening result
People who
are screened
True positive False positive
Treatment
works better
early than later
Rapidly
progressive
disease; person
would die even if
treated
Mild, easily
treatable disease;
person would do
well even if
treated later
Person would
never have
developed
symptoms, even
if untreated
No Benefit
Incidental
finding
Separate
cascade
Workup
Treatment
Indeterminate
findingSurveillance
Overdiagnosis
Delayed Benefit
Modified slide: Professor Russ Harris 20
![Page 21: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/21.jpg)
Screening - på godt og ondt
GODT
Nedsat morbiditet
og mortalitet
Mere skånsom
behandling
Tryghed for
ikke at være syg
Primær forebyg-
gende effekt
ONDT
Patienter i flere år
Overdiagnostik
Falsk tryghed
Falsk alarm
Overbehandling
Øget morbiditet
og mortalitet
Induceret sygdom
21
![Page 22: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/22.jpg)
Screening - på godt og ondt
GODT
Nedsat morbiditet
og mortalitet
Mere skånsom
behandling
Tryghed for
ikke at være syg
Primær forebyg-
gende effekt
ONDT
Patienter i flere år
Overdiagnostik
Falsk tryghed
Falsk alarm
Overbehandling
Øget morbiditet
og mortalitet
Induceret sygdom
22
![Page 23: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/23.jpg)
Overdiagnostik v. screening
Post-moderne medicin
Definition
Overdetektion ved screening
Hvorfor?
Eksempler
Stadieskifte
Incidens og mortalitet
Konsekvenser af overdiagnostik
Fremtiden?
23
![Page 24: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/24.jpg)
Mammografiscreening
24
![Page 25: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/25.jpg)
17.08.05 17.11.05 01.03.06 16.10.06 10.10.07
29.11.08 26.02.09 10.08.09 10.08.09 17.08.09
Lungecancerscreening m. CT-skanning
25
![Page 26: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/26.jpg)
Natural History of Lung Cancer
R. M. Lindell, T. E. Hartman, S. J. Swensen, J. R. Jett, D. E. Midthun, and J. N. Mandrekar. 5-year lung cancer screening experience: growth curves of 18 lung cancers compared to histologic type, CT attenuation, stage, survival, and size. Chest. 136 (6):1586-1595, 2009.
26
![Page 27: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/27.jpg)
Heterogenitet i vækstrater ved AAA-screening
Thompson et al. Systematic review and meta-analysis of the growth and rupture rates of small abdominal aortic aneurysms: implications for surveillance intervals and their cost-effectiveness. Health Technol.Assess. 17 (41):1-118, 2013.
27
![Page 28: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/28.jpg)
Person AFalse negative screen
from very fast growing
cancer
Size at which cancer can be detected
Abnormal cell
Size at which cancer causes symptoms
Cancer size
Size at which cancer causes death
Death from other causes
Person HOverdiagnosed: Cancer
spontaneously regressed
before death from other cause
Person FOverdiagnosed: Cancer would
NOT have caused symptoms
before death from other causes
Person GNo cancer diagnosis before
death from other cause
Screening
Test 1
Screening
Test 2
Screening
Test 3
Screening
Test 4
Screening
Test 5
Cancer
diagnosis
Cancer
diagnosis Cancer
diagnosisCancer
diagnosis
Time
Death from other causes
Persons B, C, D & EScreen-diagnosed cancer which would
have progressed to symptoms and death
Persons B, C, D & EScreen-diagnosed cancer which would
have progressed to symptoms and death
Model: what happens at cancer screening?
Brodersen J., Schwartz L.M., Woloshin S. Overdiagnosis: How cancer screening can turn indolent pathology into illness. APMIS 122, 2014.
![Page 29: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/29.jpg)
Overdiagnostik v. screening
Post-moderne medicin
Definition
Overdetektion ved screening
Hvorfor?
Eksempler
Stadieskifte
Incidens og mortalitet
Konsekvenser af overdiagnostik
Fremtiden?
29
![Page 30: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/30.jpg)
AAA screening: 38-44% ODx
M. Johansson, A. Hansson, and J. Brodersen. Estimatingoverdiagnosis in screening for abdominal aorticaneurysm: could a change in smoking habits and loweredaortic diameter tip the balance of screening towardsharm? BMJ 350:h825, 2015.
30
![Page 31: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/31.jpg)
AAA screening: 38-44% ODx
http://www.bmj.com/content/350/bmj.h825/infographic
31
![Page 32: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/32.jpg)
Breast, mammography
Lung, chest x-ray
Lung, CT
Liver, ultrasound
Prostate, PSA
Krag et al. Quantification of overdiagnosis in randomisedtrials of cancer screening: an overview of systematicreviews. POD conference 201532
![Page 33: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/33.jpg)
Breast, mammography
Lung, chest x-ray
Lung, CT
Liver, ultrasound
Prostate, PSA
Krag et al. Quantification of overdiagnosis in randomisedtrials of cancer screening: an overview of systematicreviews. POD conference 201533
![Page 34: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/34.jpg)
Overdiagnostik (ODx) vedlungecancer CT screening
NLST: 18,5% ODx
Kontrolgruppen: Rtg. af thorax
Mayo Lung Project: 51% ODx
Best case: 18,5% ODx
Worst case: 40,3% ODx
34
![Page 35: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/35.jpg)
Danish lung cancer screeningtrial (DLCST): design
Pedersen et al. The Danish Randomized Lung Cancer CT Screening Trial – Overall Design and Results of the Prevalence Round. Journal of Thoracic Oncology 4 (5):608-614, 2009.
35
![Page 36: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/36.jpg)
Hvor meget ODx i DLCST?
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Best case: 18,5% ODx
Worst case: 40,3% ODx
36
![Page 37: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/37.jpg)
Overdiagnosis in DLCST at 5 year follow-up
37
![Page 38: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/38.jpg)
96
53
Overdiagnosis in DLCST at 5 year follow-up
68
24
38
![Page 39: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/39.jpg)
68
24
96
5344
43
Overdiagnosis in DLCST at 5 year follow-up
39
![Page 40: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/40.jpg)
96
53
43
Overdiagnosis in DLCST at 5 year follow-up
68
24
44
40
![Page 41: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/41.jpg)
Extra antal af LC: 43 (96-53)
ODx: 43/68=63% [95% CI;33%-88%]
Overdiagnostik i DLCST efter 5 års follow-up
Wille MMW et al. Results of the randomized Danish Lung Cancer Screening Trial with focus on high-risk profiling. Accepted for publication August 2015 in AJRCCM
41
![Page 42: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/42.jpg)
Styrker & svagheder
Ingen screening i kontrolgruppen
Lille kontaminering i kontrolgruppen
For kort follow-up?
Ulige fordeling af storrygere efter randomiseringen?
Participation bias i DLCST?
42
![Page 43: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/43.jpg)
Kardio-vaskulær risiko
CVD diseases and number of risk factors
0
10
20
30
40
50
60
70
80
90
100
20 25 30 35 40 45 50 55 60 65 70 75
Age
%
1 risk factor
0
CVD, diabetes and
treated hypertension
≥ 3 risk factors
2 risk factors
H. Petursson et al. Can individuals with a significant risk for cardiovascular disease be adequately identified by combination of several risk factors? J.Eval.Clin.Pract. 15 (1):103-109, 2009.
43
![Page 44: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/44.jpg)
0
50
100
150
200
250
300
350
400
450
500
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
An
tal i
nci
de
nte
can
cer
pro
stat
a
An
tal p
røve
r
Almen praksis er rekvirent Speciallæge/sygehus er rekvirent Incidente cancer prostatae
PSA-test and Pca in DK
T. O. Mukai, F. Bro, K. V. Pedersen, P. Vedsted. Brug af undersøgelse for prostataspecifikt antigen . Ugeskr.Laeger 172 (9):696-700, 2010.
44
![Page 45: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/45.jpg)
Overdiagnostik v. screening
Post-moderne medicin
Definition
Overdetektion ved screening
Hvorfor?
Eksempler
Stadieskifte
Incidens og mortalitet
Konsekvenser af overdiagnostik
Fremtiden?
45
![Page 46: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/46.jpg)
A: Optimalt scenarium
Esserman L., Shieh Y., & Thompson I. Rethinking Screening for Breast Cancer and Prostate Cancer. JAMA: 302 (15):1685-1692, 2009.
46
![Page 47: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/47.jpg)
B: Værste scenarium
Esserman L., Shieh Y., & Thompson I. Rethinking Screening for Breast Cancer and Prostate Cancer. JAMA: 302 (15):1685-1692, 2009.
47
![Page 48: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/48.jpg)
C: Intermediært scenarium
Esserman L., Shieh Y., & Thompson I. Rethinking Screening for Breast Cancer and Prostate Cancer. JAMA: 302 (15):1685-1692, 2009.
48
![Page 49: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/49.jpg)
Stadieskifte
Esserman L., Shieh Y., & Thompson I. Rethinking Screening for Breast Cancer and Prostate Cancer. JAMA: 302 (15):1685-1692, 2009.
49
![Page 50: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/50.jpg)
Breast cancer screening
Esserman L., Shieh Y., & Thompson I. Rethinking Screening for Breast Cancer and Prostate Cancer. JAMA: 302 (15):1685-1692, 2009.
50
![Page 51: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/51.jpg)
PSA-screening
Esserman L., Shieh Y., & Thompson I. Rethinking Screening for Breast Cancer and Prostate Cancer. JAMA: 302 (15):1685-1692, 2009.
51
![Page 52: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/52.jpg)
Overdiagnostik v. screening
Post-moderne medicin
Definition
Overdetektion ved screening
Hvorfor?
Eksempler
Stadieskifte
Incidens og mortalitet
Konsekvenser af overdiagnostik
Fremtiden?
52
![Page 53: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/53.jpg)
Incidens og mortalitet
Brodersen J., Schwartz L.M., Woloshin S. Overdiagnosis: How cancer screening can turn indolent pathology into illness. APMIS 122, 2014.53
![Page 54: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/54.jpg)
1995
2000
2005
1980
1985
1990
1995
2000
2005
2010
1985
1990
10000
20000
30000
40000
50000
60000
Cases
per year
Years Years Years
LungWithout screening
Breast (women)Increasing screening
ProstateIncreasing screening
Cancer death and invasive cancer diagnosis with and without screening
Lung, breast and prostate. France 1980-2010
Death Diagnosis
1980
1995
2000
2005
1980
1985
1990
2010
2010
54
![Page 55: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/55.jpg)
1995
2000
2005
1980
1985
1990
1995
2000
2005
2010
1985
1990
10000
20000
30000
40000
50000
60000
Cases
per year
Years Years Years
LungWithout screening
Breast (women)Increasing screening
ProstateIncreasing screening
Cancer death and invasive cancer diagnosis with and without screening
Lung, breast and prostate. France 1980-2010
Death Diagnosis
1980
1995
2000
2005
1980
1985
1990
2010
2010
55
![Page 56: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/56.jpg)
1995
2000
2005
1980
1985
1990
1995
2000
2005
2010
1985
1990
10000
20000
30000
40000
50000
60000
Cases
per year
Years Years Years
LungWithout screening
Breast (women)Increasing screening
ProstateIncreasing screening
Cancer death and invasive cancer diagnosis with and without screening
Lung, breast and prostate. France 1980-2010
Death Diagnosis
1980
1995
2000
2005
1980
1985
1990
2010
2010
56
![Page 57: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/57.jpg)
Hvilke kræftsygdom er dette?
57
![Page 58: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/58.jpg)
58
![Page 59: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/59.jpg)
59
![Page 60: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/60.jpg)
60
![Page 61: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/61.jpg)
Screening med smartphone
61
![Page 62: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/62.jpg)
Overdiagnostik v. screening
Post-moderne medicin
Definition
Overdetektion ved screening
Hvorfor?
Eksempler
Stadieskifte
Incidens og mortalitet
Konsekvenser af overdiagnostik
Fremtiden?
62
![Page 63: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/63.jpg)
Skadevirkning af overdiagnostik
Overundersøgelse
Overbehandling
Overforbrug
63
![Page 64: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/64.jpg)
financial strain
hassles/inconveniences
medical costs
opportunity costs
physical harms
psychological harms
societal costs
+ work-related costs
Harris R.P. et al. The
Harms of Screening:
A Proposed Taxonomy
and Application to Lung
Cancer Screening,
JAMA 2014
Skadevirkning af overdiagnostik
64
![Page 65: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/65.jpg)
Overdiagnostik v. screening
Post-moderne medicin
Definition
Overdetektion ved screening
Hvorfor?
Eksempler
Stadieskifte
Incidens og mortalitet
Konsekvenser af overdiagnostik
Fremtiden?
65
![Page 66: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/66.jpg)
Fremtiden?
Storm P:
”Det er svært at spå – især om fremtiden”
66
![Page 67: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/67.jpg)
Fremtiden?
Mere screening:
Befolkningsundersøgelser og højrisiko
Quantified Self
Big data & Personalised Medicine
67
![Page 68: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/68.jpg)
Nye screeningsprogrammer?
CT-screening for lungekræft blandt storrygere
Abdominalt aorta anuerisme:
Befolkningsundersøgelse eller storrygere?
68
![Page 69: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/69.jpg)
Quantified Self
69
![Page 70: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/70.jpg)
Big data & Personalised Medicine
70
![Page 71: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/71.jpg)
P4 or Personalised medicine
Predictive
Preventive
Personalised
Participatory
71
![Page 72: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/72.jpg)
P4 among healthy
Predictive & Preventive = Screening Incognito
72
![Page 73: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/73.jpg)
Big data & Personalised Medicine
73
![Page 74: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/74.jpg)
Survivors stories drive screening towards more overdiagnosis
Popularity paradox
More UsefulScreening
Appears To Be
More IntensiveScreening
MoreOverdiagnosis
More ”Survivor”Stories
74
![Page 75: Overdiagnostik — en uundgåelig konsekvens af medicinsk ...jydskmedicinskselskab.org/wp-content/uploads/2015/... · –en uundgåelig konsekvens af medicinsk screening John Brodersen](https://reader035.vdocuments.pub/reader035/viewer/2022081406/5f0fb8c27e708231d4458f72/html5/thumbnails/75.jpg)
75