Do psychological harms result from being labelled with an unexpected diagnosis of abdominal aortic aneurysm or prostate cancer through screening? A systematic review

Early Relative Growth Rate of Abdominal Aortic Aneurysms and Future Risk of Rupture or Repair

OBJECTIVE

This study aimed to test whether the relative growth rate of subthreshold abdominal aortic aneurysms (AAAs) in the first 24 months of surveillance predicts the risk of future rupture or repair.

METHODS

This was a single centre retrospective observational analysis of all small (< 45 mm diameter) and medium (45 - 54 mm in men, 45 - 50 mm in women) AAAs entered into ultrasound surveillance between January 2002 and December 2019, which received ≥ 24 months of surveillance. Relative growth rates were calculated from measurements taken in the first 24 months of surveillance. The Kaplan-Meier method was used to estimate intervention and rupture free proportions five years following diagnosis for AAAs growing by < 5% and by ≥ 5% in the first 24 months of surveillance. Multivariable Cox regression analysis was used to further analyse this relationship by adjusting for factors found to be significantly associated with outcome in univariable analysis.

RESULTS

A total of 556 patients with AAAs (409 men, 147 women) were followed for ≥ 24 months. This included 431 small AAAs. Of these, 109 (25.3%) grew by < 5% in the first 24 months of surveillance and had a cumulative event free proportion of 0.98 ± 0.05 at five years compared with 0.78 ± 0.05 for the ≥ 5% growth group (p < .001). Of 125 medium AAAs, 26 (20.8%) grew by < 5% in the first 24 months of surveillance and had a cumulative event free proportion of 0.73 ± 0.11 at five years compared with 0.29 ± 0.13 for the ≥ 5% growth group (p = .024). Baseline diameter and early relative growth rate were strongly and independently predictive of future intervention or rupture with hazard ratios of 9.16 (95% CI 5.98 - 14.03, p < .001) and 4.46 (95% CI 2.45 - 8.14, p < .001), respectively.

CONCLUSION

The results suggest that slow expansion of small (< 45 mm) AAAs observed over an isolated 24 month period is indicative of a very low risk of rupture or repair in the medium term. Isolated growth rates may be a useful tool with which to triage low risk AAAs and prevent unnecessary surveillance.

[Geriatric ultrasound : Prospective evaluation of ultrasound as extended screening in acute geriatric patients]

BACKGROUND

The aim of this study was to evaluate ultrasound as a routinely used procedure and extended physical examination in geriatric patients in acute care.

METHODS

Prospective study of 86 patients using ultrasound as a screening examination (abdomen, basal sections of the thorax, thyroid glands) under comparative use of a hand-held ultrasound device (HHUSD) and a high-end ultrasound (HEUS = gold standard).

RESULTS

In 20/86 (23.2%) clinically relevant findings with therapeutic consequences were found (pleural effusion, urinary retention, choledocholithiasis metatases, colon tumor). In 22/86 (25.6%) patients, additional questions existed besides the screening indication: tumor search (9.3%), anemia (5.8%), liver value elevation (5.8%), dyspnea (5.8%), splenic pathologies (2.3%), weight loss (1.2%), infectious focus (1.2%), diarrhea (1.2%), intra-abdominal hematoma (1.1%), abdominal aortic aneurysm (1.2%). The most common sonographic findings included: cholecystolithiasis (32.6%); right pleural effusion (31.4%), thyroid nodules (30.2%), renal cysts (27.9%), and fatty liver (26.7%). There were significant differences in sizing between HHUSD and HEUS (kidneys, pancreatic corpus and pancreatic caudal diameters, portal vein, left hepatic vein) without diagnostic relevance.

CONCLUSION

The extended screening by ultrasound provided important answers to classical questions in geriatrics (e.g. urinary retention, volume deficiency/pleural effusion) in many cases. The new findings had therapeutic consequences in one fifth of the patients. The HHUSD can be used in screening.

Psychosocial consequences after screening of abdominal aortic aneurysm among 65 year old men

BACKGROUND

In order to reduce the incidence of abdominal aortic aneurysm rupture and mortality, the Swedish Medical Council has introduced a national abdominal aortic aneurysm (AAA) screening program that offers ultrasound examination of 65-year-old men. Screening programmes of AAA may confer both benefits and harms. The study aim was to investigate the psychosocial consequences of AAA screening among men with screening-detected AAA as compared to men identified as AAA-negative at screening, using an AAA-specific questionnaire.

METHODS

This cross-sectional study investigated the psychosocial consequences of AAA screening measured with a condition-specific questionnaire. This study focused on the Experience of the Diagnosis and the Screening Procedure in terms of Anxiety, Sense of Dejection and Existential Values. One hundred and fifty-eight men with AAA (63%) and 275 with normal aorta size (55%) completed the diagnosis-specific questionnaire.

RESULTS

Ninety-six percent of men with screening detected AAA did not regret the screening examination, the corresponding figure for controls being 99.6%. Seventy percent of AAA patients were surprised that something was wrong in their body. Some (85%) of men with AAA were current or previous smokers, about half of them (45%) felt guilty about it and 78% of the current smokers in the AAA group had considered stopping smoking. Both groups considered changing lifestyle, although at a higher rate (32%) among AAA cases than controls (20%), with differences both in intention to change their ways to exercise (p = 0.019) and food intake (p = 0.001). Intergroup differences were identified for the majority of items as captured by the questionnaire where men identified with AAA reported more negative psycho-social consequences for all evaluated items except for the items: Regret of the screening examination (p = 0.069) and feeling terrified (p = 0.10). Fifty-one percent of AAA cases stated that they feared rupture, and 12% were anxious about rupture during sexual activity whereas 57% were worried about rupture during intense physical activity.

CONCLUSION

Men who were diagnosed with AAA reported more psychosocial consequences compared to controls; still only a minority of AAA cases reported psychosocial consequences in greater occurrence. To some degree, men with AAA also feared rupture during various types of activities. There appears to be a need for improved patient information and easy access to caregivers for men with screening-detected AAA, which might help to reduce psychosocial consequences associated with the diagnosis.

Incidental Findings in Pediatric Patients: How to Manage Liver Incidentaloma in Pediatric Patients

The World Federation for Ultrasound in Medicine and Biology (WFUMB) is addressing the issue of incidental findings (IFs) with a series of publications entitled "Incidental imaging findings-the role of ultrasound". IFs in the liver of newborns and children are rare and much less commonly encountered than in adults; as a result, they are relatively much more frequently malignant and life-threatening, even when they are of benign histology. Conventional B-mode ultrasound is the well-established first line imaging modality for the assessment of liver pathology in pediatric patients. US technological advances, resulting in image quality improvement, contrast-enhanced ultrasound (CEUS), liver elastography and quantification tools for steatosis have expanded the use of ultrasound technology in daily practice. The following overview is intended to illustrate incidentally detected liver pathology covering all pediatric ages. It aims to aid the examiner in establishing the final diagnosis. Management of incidentally detected focal liver lesions (FLL) needs to take into account the diagnostic accuracy of each imaging modality, the patient's safety issues (including ionizing radiation and nephrotoxic contrast agents), the delay in diagnosis, the psychological burden on the patient and the cost for the healthcare system. Moreover, this paper should help the pediatric clinician and ultrasound practitioner to decide which pathologies need no further investigation, which ones require interval imaging and which cases require further and immediate diagnostic procedures.

Abdominal aortic aneurysm screening in an academic family practice: Short-term impact of guideline changes

OBJECTIVE

To investigate abdominal aortic aneurysm (AAA) screening rates in the 6 months before and after the introduction of updated Canadian Task Force on Preventive Health Care (CTFPHC) guidelines to determine effects on practice patterns, as well as to determine whether certain patient characteristics impact AAA screening rates.

DESIGN

Retrospective chart review.

SETTING

Academic family health centre in London, Ont.

PARTICIPANTS

Male patients between the ages of 65 and 80.

MAIN OUTCOME MEASURES

Screening rates for AAA before and after the guideline update were compared using the normal approximation of the binomial distribution. Analysis of demographic characteristic effects on screening rates was completed with the Fisher exact test. Number of visits to the clinic with a primary care provider within the study period and imaging type were collected.

RESULTS

Of the 266 patients included in the study, 160 patients were eligible for screening at the start of the study period, 6 months before publication of the CTFPHC AAA guideline. Individuals eligible for screening visited the clinic an average (SD) of 2.44 (1.82) times in the 6 months before and 2.66 (1.99) times in the 6 months after. Overall, 69 individuals had AAA screening completed and 9 had a discussion of AAA screening without any imaging, for a total uptake rate of 88.5% for those who had screening recommended. The overall imaging rate was 48.9%. There was no statistically significant difference in screening rates between the time periods (P=.337) among those eligible for screening. For demographic characteristics for risk stratification, 7 individuals had a documented family history, of whom 5 had imaging of their abdominal aorta performed, plus 1 additional individual who had screening recommended but not completed. This was not statistically significant relative to the total population (P=.0598). Positive smoking status (active or ex-smoker) was more common, with 135 individuals having a relevant smoking history. Approximately half of these current and former smokers (68 individuals [50.4%]) had any sort of abdominal aortic imaging performed or recommended, which was not statistically significantly different compared with non-smokers (62 of 126 imaging performed or recommended, 49.2%; P=.9016).

CONCLUSION

Screening practices did not change appreciably with the introduction of the CTFPHC AAA screening guidelines. Further research is needed to improve AAA screening rates. It is worth exploring electronic medical record-based reminders, nursing staff involvement in screening, screening programs via public health, and point-of-care ultrasound screening in a primary care setting.

Investigating the feasibility and ethical implications of phenotypic screening using stem cell-derived tissue models to detect and manage disease

Stem-cell-derived tissue models generated from sick people are being used to understand human development and disease, drug development, and drug screening. However, it is possible to detect disease phenotypes before a patient displays symptoms, allowing for their use as a disease screening tool. This raises numerous issues, some of which can be addressed using similar approaches from genetic screenings, while others are unique. One issue is the relationship between disease disposition, biomarker detection, and patient symptoms and how tissue models could be used to define disease. Other issues include decisions of when to screen, what diseases to screen for, and what treatment options should be offered.

Short and long-term psychosocial consequences of participating in a colorectal cancer screening programme: a matched longitudinal study

OBJECTIVES

To investigate the psychosocial consequences of receiving a false-positive (no abnormalities) result or being diagnosed with polyps compared with receiving a negative result in a colorectal cancer (CRC) screening programme.

DESIGN AND SETTING

This was a longitudinal study nested in the roll-out of the Danish CRC screening programme that targets all individuals aged 50-74 years.

PARTICIPANTS

In the inclusion period (April-September 2017), all positive screenees (n=1854) were consecutively enrolled and matched 2:1:1 on sex, age (±2 years), municipality and screening date with negative screenees (n=933) and individuals not yet invited to screening (n=933).Questionnaires were sent by mail to all eligible participants in Region Zealand, Denmark, after the screening result, 2 months and 12 months after the final result.Positive screenees who did not receive the follow-up procedure were excluded.

MAIN OUTCOME MEASURES

The primary outcomes were psychosocial consequences. Outcomes were measured with the CRC screening-specific questionnaire Consequences of screening in CRC with 11 outcomes after the screening result and with 21 outcomes at the two later assessments.

RESULTS

After receiving the screening result, individuals with no abnormalities, low-risk and medium-risk and high-risk polyps scored significantly worse on 8 of 11 outcomes compared with the negative screenee group. At the 12-month follow-up, the differences were still significant in 8 of 21 outcomes (no abnormalities), 4 of 21 outcomes (low-risk polyps) and 10 of 21 outcomes (medium-risk and high-risk polyps). The negative screenee group and the group not yet invited to screening differed psychosocially on 5 of 11 outcomes after the screening result, but on none of the 21 outcomes at the 2 months and 12 months follow-up.

CONCLUSIONS

The study showed that there are both short-term and long-term psychosocial consequences associated with receiving a no abnormalities result or being diagnosed with polyps. The consequences were worst for individuals diagnosed with medium-risk and high-risk polyps.

Pharmacy-Based Opportunistic Atrial Fibrillation Screening at a Community Level: A Real-Life Study

Purpose: Opportunistic pharmacy-based screening of atrial fibrillation (AF) appears effective, but the proportion of detected citizens is unknown. The aim of our real-life study was to determine rates of screening in a community population according to age group and gender. Methods: We conducted four community campaigns of pharmacy-based single-time point AF screening that involved individuals ≥65 years. We used a single-lead and hand-held device MyDiagnostick (6229 EV Maastricht, The Netherlands) that generates a 60-s ECG trace. All pharmacies of the communities (n = 54) were involved. Rates of screening were assessed on the base of the French National Institute for Statistics and Economic Studies data and were expressed as percentage and 95% Confidence interval (CI). Results: We screened 4208 individuals (Mean age, 74.2 ± 6.6 years; females, 60.2%). The screening rate in citizens aged ≥65 years was 17.2% (16.6–17.7), and higher in females than in males (17.9% [17.3–18.6] versus 16.0 [15.3–16.8], p < 0.001). The 70–74 age group showed the highest rate (25.7% [24.4–27]) compared to other groups. After 74 years, screening rates decreased steadily with age and dropped to 4.8% [3.8–6.1] in very elderly (≥90). Among the 188 (4.47%) positive screening, 117 (2.78%) showed an AF that was unknown in 53 (1.26%). Increasing age (OR: 1.05 [1.00–1.09], p = 0.04), male sex (OR: 4.30 [2.33–7.92], p < 0.0001) and high CHA2DS2-Vasc (OR: 1.59 [1.21–2.09], p = 0.0008) were independent predictors of unknown AF. Conclusion: Single-lead AF detection performed in community pharmacies result in screening one in six elderly citizens. Although male sex and elderly predicted unknown AF diagnosis, they were less involved in such designed campaigns.

Cancer diagnosis and suicide outcomes: Umbrella review and methodological considerations

BACKGROUND

Suicide outcomes in cancer patients represent a major public health concern. We performed an umbrella review (UR) including all meta-analyses (MAs) and systematic reviews (SRs) published on the association between cancer and suicide outcomes.

METHODS

Eligible studies were searched in the main scientific databases up to January 23rd, 2021. Eligible MAs/SRs focused on all suicide phenotypes among cancer patients. Evidence of the association was extracted; the credibility and quality of the included studies were evaluated using ad-hoc tools, including "A MeaSurement Tool to Assess systematic Reviews-2-Revised" (AMSTAR-2-R).

RESULTS

Six MAs and 6 SRs were included. The standardized mortality ratio of suicide in cancer patients was 1.5 to 1.7-fold higher than in the general population. Risk factors for suicide outcomes among cancer patients were male sex and older age, a cancer diagnosis within the prior year, and some specific cancer sites. Among 107 associations, 90 (84.1%) were supported by high credibility of evidence (class II). However, all studies reported a large heterogeneity (I²> 50%) and the majority of them reported considerable heterogeneity (I²> 75%). All MAs used random-effects measures. All MAs but one assessed publication bias and only one disclosed it. The majority of MAs/SRs showed critically low quality based on AMSTAR-2-R.

LIMITATIONS

We could not perform additional analyses due to the limited number of MAs.

CONCLUSIONS

This UR underlines the inflated risk for suicide among cancer patients. Upcoming, well-designed studies are needed to account for a broader set of variables. Several methodological issues likewise warrant attention.

Psychosocial consequences of screening-detected abdominal aortic aneurisms: a cross-sectional study

OBJECTIVE

In Sweden, an abdominal aortic aneurysm (AAA) screening programme was gradually implemented from 2009 to reduce the incidence of rupture and thereby mortality. AAA screening introduces a variety of unintended, but generally unavoidable, harms, e.g. stress and worry. Such psychosocial consequences have previously only been investigated with generic measures. Therefore, the aim of this study was to describe and compare the psychosocial consequences in men with a screening detected AAA to men with a normal screening result after they participated in the Swedish national AAA-screening programme using a validated psychometric instrument.

MATERIAL AND METHODS

This study was a cross-sectional survey. Data were originally collected to validate the COS-AAA and has previously been published in details. The Consequences of Screening in Abdominal Aortic Aneurysm (COS-AAA) questionnaire was sent to 250 men with a screening detected AAA and 500 with a normal screening result who were randomly selected from a Swedish population-based screening register.

RESULTS

In total, 158 (63%) men with a screening detected AAA and 275 (55%) men with a normal screening result completed the COS-AAA. We found that men with a screening detected AAA reported negative psychosocial consequences to a greater extent in 10 of 13 COS-AAA Part 1 scales, all statistically significant except three (behaviour, sleep and negative experiences from examination). For COS-AAA Part 2, there was a statistically significant difference between groups in four of five scales.

CONCLUSIONS

Men diagnosed with a screening detected AAA, reported more negative psychosocial consequences compared to men with a normal result. Screening for abdominal aorta aneurism (AAA) introduces intended benefits and unintended harms. Adequate measures are necessary to determine the balance between them.Key points:This study applied a condition-specific questionnaire with high content validity and adequate psychometric properties to measure psychosocial consequences in men participating in AAA screening.We found that men with a screening detected AAA reported more negative psychosocial consequences than men with a normal aorta size.The risk of negative psychosocial consequences is important to include in the decision making on whether to participate in screening or not.

Risk-stratified strategies in population screening for colorectal cancer

Colorectal cancer (CRC) screening has been demonstrated to reduce CRC incidence and mortality. However, besides such benefits, CRC screening is also associated with potential harmful effects. In an ideal world, screening would only be directed to the small proportion of the population that might potentially benefit. Risk‐based screening can be seen as a first step towards this ideal world, by redistributing screening resources from low‐risk to high‐risk individuals. In theory, this should result in scarce resources being used in individuals who benefit most, while intensity of screening is reduced in individuals who benefit less, hence improving the benefit‐harm ratio among all invitees. Available strategies that have been proposed for risk‐based CRC screening include using information on age, sex, prior screening history, lifestyle and/or genetic information. Implementation of risk‐based screening requires careful consideration of reliable risk prediction models, participation with screening and informed decision‐making. While it is important to recognise the limitations of current approaches, available evidence suggests that it might be feasible to start planning the introduction of tailored strategies within screening programmes. Implementing risk‐based screening based on age, sex and prior screening history alone would already represent a substantial improvement over current uniform screening approaches. We propose that it is time that screening programmes start there and continue striving towards more comprehensive approaches embedding primary prevention as an effective approach to lower risk for everyone.

Consequences of health condition labelling: protocol for a systematic scoping review

INTRODUCTION

When health conditions are labelled it is often to classify and communicate a set of symptoms. While diagnostic labelling can provide explanation for an individual's symptoms, it can also impact how individuals and others view those symptoms. Despite existing research regarding the effects of labelling health conditions, a synthesis of these effects has not occurred. We will conduct a systematic scoping review to synthesise the reported consequences and impact of being given a label for a health condition from an individual, societal and health practitioner perspective and explore in what context labelling of health conditions is considered important.

METHODS AND ANALYSIS

The review will adhere to the Joanna Briggs Methodology for Scoping Reviews. Searches will be conducted in five electronic databases (PubMed, Embase, PsycINFO, Cochrane, CINAHL). Reference lists of included studies will be screened and forward and backward citation searching of included articles will be conducted. We will include reviews and original studies which describe the consequences for individuals labelled with a non-cancer health condition. We will exclude hypothetical research designs and studies focused on the consequences of labelling cancer conditions, intellectual disabilities and/or social attributes. We will conduct thematic analyses for qualitative data and descriptive or meta-analyses for quantitative data where appropriate.

ETHICS AND DISSEMINATION

Ethical approval is not required for a scoping review. Results will be disseminated via publication in a peer-reviewed journal, conference presentations and lay-person summaries on various online platforms. Findings from this systematic scoping review will identify gaps in current understanding of how, when, why and for whom a diagnostic label is important and inform future research.

A discussion on controversies and ethical dilemmas in prostate cancer screening

Prostate cancer (PCa) is one of the the most common cancers in men. A blood test called prostate-specific antigen (PSA) has a potential to pick up this cancer very early and is used for screening of this disease. However, screening for prostate cancer is a matter of debate. Level 1 evidence from randomised controlled trials suggests a reduction in cancer-specific mortality from PCa screening. However, there could be an associated impact on quality of life due to a high proportion of overdiagnosis and overtreatment as part of the screening. The US Preventive Services Task Force (USPSTF) in 2012 recommended that PSA-based PCa screening should not to be offered at any age. However, considering the current evidence, USPSTF recently revised its recommendation to offer the PSA test to men aged 55-69 years with shared decision-making, in line with earlier guidelines from the American Cancer Society and the American Urological Association. A shared decision making is necessary since the PSA test could potentially harm an individual. However, the literature suggests that clinicians often neglect a discussion on this issue before ordering the test. This narrative discusses the main controversies regarding PCa screening including the PSA threshold for biopsy, the concept of overdiagnosis and overtreatment, the practical difficulties of active surveillance, the current level 1 evidence on the mortality benefit of screening, and the associated pitfalls. It offers a detailed discussion on the ethics involved in the PSA test and highlights the barriers to shared decision-making and possible solutions.

Patients' views about screening for atrial fibrillation (AF): a qualitative study in primary care

OBJECTIVES

There has been increased interest in screening for atrial fibrillation (AF) with commissioned pilot schemes, ongoing large clinical trials and the emergence of inexpensive consumer single-lead ECG devices that can be used to detect AF. This qualitative study aimed to explore patients' views and understanding of AF and AF screening to determine acceptability and inform future recommendations.

SETTING

A single primary care practice in Hampshire, UK.

PARTICIPANTS

15 participants (11 female) were interviewed from primary care who had taken part in an AF screening trial. A semistructured interview guide was used flexibly to enable the interviewer to explore any relevant topics raised by the participants. Interviews were recorded, transcribed verbatim and analysed using inductive thematic analysis.

RESULTS

Participants generally had an incomplete understanding of AF and conflated it with other heart problems or with raised blood pressure. With regards to potential drawbacks from screening, some participants considered anxiety and the cost of implementation, but none acknowledged potential harms associated with screening such as side effects of anticoagulation treatment or the risk of further investigations. The screening was generally well accepted, and participants were generally in favour of engaging with prolonged screening.

CONCLUSIONS

Our study highlights that there may be poor understanding (of both the nature of AF and potential negatives of screening) among patients who have been screened for AF. Further work is required to determine if resources including decision aids can address this important knowledge gap and improve clinical informed consent for AF screening.

TRIAL REGISTRATION NUMBER

ISRCTN 17495003.

Abdominal aortic aneurysm in prostate cancer patients: the "road map" from incidental detection to advanced predictive, preventive, and personalized approach utilizing common follow-up for both pathologies

Abdominal aortic aneurysm (AAA) is often a hidden pathological process showing no clinical symptoms. Genetic burden, smoking, male gender, age > 65 years, and white race have been identified as the main risk factors. A regular screening program has been introduced but is, as yet, unclear and is not performed in most countries. Prostate cancer is the most frequent male malignant disease in Western countries. Prostate cancer is a disease of older age with a median primary diagnosis of over 60 years. In recent years, advanced imaging methods have been established as important diagnostic tools in prostate cancer diagnostics. The incidental detection of AAA during diagnostic imaging performed due to prostate cancer diagnosis could reveal some asymptomatic aneurysms. Using our experience, the incidental detection of AAA during ¹⁸F-fluoromethylcholine PET/CT imaging, performed due to the staging, follow-up, and restaging of the prostate cancer, was reworked into a regular tool of secondary prevention within the framework of personalized medicine strategies. Experience with this type of AAA detection is demonstrated by a cohort of 500 patients who underwent ¹⁸F-fluorometylcholine PET/CT examination due to the staging or restaging of prostate cancer. A total of 28 aneurysms were detected (26 aneurysms < 50 mm, 2 aneurysms > 50 mm). In 2 cases (diameter < 50 mm), serious complications were found (penetrating aortic ulcer). The detection and monitoring of AAA in patients undergoing ¹⁸F-fluorometylcholine PET/CT due to the prostate cancer offers the possibility of a secondary prevention of AAA, patient stratification, and common follow-up for both pathologies.

Harms of hepatocellular carcinoma surveillance

Purpose of review

Hepatocellular carcinoma (HCC) surveillance in patients with cirrhosis is associated with decreased mortality by enabling early tumor detection. However, the benefits of any cancer screening program must be considered in light of potential physical, financial, and psychological harms, as well as the risk of overdiagnosis. Herein, we summarize the potential harms of HCC surveillance.

Recent findings

To date, two retrospective studies have addressed physical harms of HCC surveillance. Based on these data, 15% to 28% of patients undergoing HCC surveillance experience physical harm including additional cross-sectional imaging or liver biopsy. Although psychological and financial harms have been reported for other cancers, there are currently limited data specific to HCC. An ongoing multi-center prospective study assessing all four types of harms should provide data in near future.

Summary

HCC screening may prevent death by diagnosing tumors at an early stage, but limited sensitivity and specificity of screening tests can result in unintended harms. There is a need for further quality data evaluating both the benefits and harms of HCC surveillance.

Invited Commentary: Beyond Overdiagnosis-Diagnosis Without Benefit

In an accompanying article, Hofmann (Am J Epidemiol. 2019;188(10):1812-1817) seeks to clarify the concept of overdiagnosis by screening. He makes a helpful suggestion to reconnect diagnosis with patient suffering, pointing out the underlying issue in overdiagnosis of prognostic uncertainty. He then divides prognostic uncertainty into developmental and progression uncertainty, using a categorical model of disease progression through indicators to manifest disease. This model could be improved by considering the heterogeneity of patient-condition combinations. This leads to an understanding of the probabilistic nature of the connection between any indicator in a specific individual and patient suffering. The model also needs to consider the time span over which the patient-condition combination leads to patient suffering. I propose a simpler approach that goes further to focus not only on overdiagnosis but also on the broader problem of diagnosis without benefit and diagnosis without net benefit. This makes measurement easier and focuses attention where it belongs: on the harm caused by overly aggressive screening programs.

Prevalence and Cost of Care Cascades After Low-Value Preoperative Electrocardiogram for Cataract Surgery in Fee-for-Service Medicare Beneficiaries

IMPORTANCE

Low-value care is prevalent in the United States, yet little is known about the downstream health care use triggered by low-value services. Measurement of such care cascades is essential to understanding the full consequences of low-value care.

OBJECTIVE

To describe cascades (tests, treatments, visits, hospitalizations, and new diagnoses) after a common low-value service, preoperative electrocardiogram (EKG) for patients undergoing cataract surgery.

DESIGN, SETTING, AND PARTICIPANTS

Observational cohort study using fee-for-service Medicare claims data from beneficiaries aged 66 years or older without known heart disease who were continuously enrolled between April 1, 2013, and September 30, 2015, and underwent cataract surgery between July 1, 2014 and June 30, 2015. Data were analyzed from March 12, 2018, to April 9, 2019.

EXPOSURES

Receipt of a preoperative EKG. The comparison group included patients who underwent cataract surgery but did not receive a preoperative EKG.

MAIN OUTCOMES AND MEASURES

Cascade event rates and associated spending in the 90 days after preoperative EKG, or in a matched timeframe for the comparison group. Secondary outcomes were patient, physician, and area-level characteristics associated with experiencing a potential cascade.

RESULTS

Among 110 183 cataract surgery recipients, 12 408 (11.3%) received a preoperative EKG (65.6% of them were female); of those, 1978 (15.9%) had at least 1 potential cascade event. The comparison group included 97 775 participants (63.1% female). Those who received a preoperative EKG experienced between 5.11 (95% CI, 3.96-6.25) and 10.92 (95% CI, 9.76-12.08) additional events per 100 beneficiaries relative to the comparison group. This included between 2.18 (95% CI, 1.34-3.02) and 7.98 (95% CI, 7.12-8.84) tests, 0.33 (95% CI, 0.19-0.46) treatments, 1.40 (95% CI, 1.18-1.62) new patient cardiology visits, and 1.21 (95% CI, 0.62-1.79) new cardiac diagnoses. Spending for the additional services was up to $565 per Medicare beneficiary (95% CI, $342-$775), or an estimated $35 025 923 annually across all Medicare beneficiaries in addition to the $3 275 712 paid for the preoperative EKGs. Among preoperative EKG recipients, those who were older (adjusted odds ratio [aOR] for patients aged 75 to 84 years vs 66 to 74 years old, 1.42; 95% CI, 1.28-1.57), had more chronic conditions (aOR for each additional Elixhauser condition, 1.18; 95% CI, 1.14-1.22), lived in more cardiologist-dense areas (aOR, 1.05; 95% CI, 1.02-1.09), or had their preoperative EKG performed by a cardiac specialist rather than a primary care physician (aOR, 1.26; 95% CI, 1.10-1.43) were more likely to experience a potential cascade.

CONCLUSIONS AND RELEVANCE

Care cascades after preoperative EKG for cataract surgery are infrequent but costly. Policy and practice interventions to reduce low-value services and the cascades that follow could yield substantial savings.

Media Coverage of the Benefits and Harms of Testing the Healthy: a protocol for a descriptive study

INTRODUCTION

Much testing in medicine is aimed at healthy people to facilitate the early detection of health conditions. However, there is growing evidence that early detection is a double-edged sword that may cause harm in the form of overdiagnosis. The media can be seen as a major generator of consumer demand for health services. Previous research shows that media coverage tends to overstate the benefits and downplay the harms of medical interventions for the sick, and often fails to cover relevant conflicts of interest of those promoting those interventions. However, little is known about how the benefits and harms of testing the healthy are covered by media. This study will examine the media coverage of the benefits and harms of testing the healthy, and coverage of potential conflicts of interest of those promoting the testing.

METHODS AND ANALYSIS

We will examine five tests: 3D mammography for the early detection of breast cancer; blood liquid biopsy for the early detection of cancer; blood biomarker tests for the early detection of dementia; artificial intelligence technology for the early detection of dementia; and the Apple Watch Series 4 electrocardiogram sensor for the early detection of atrial fibrillation. We will identify media coverage using Google News and the LexisNexis and ProQuest electronic databases. Sets of two independent reviewers will conduct story screening and coding. We will include English language media stories referring to any of the five tests from January 2016 to May 2019. We will include media stories if they refer to any benefits or harms of the test for our conditions of interest. Data will be analysed using categorical data analysis and multinomial logistic regression.

ETHICS AND DISSEMINATION

No ethical approval is required for this study. Results will be presented at relevant scientific conferences and in peer-reviewed literature.

Clinical and pathophysiological aspects of bicuspid aortic valve disease

A bicuspid aortic valve is not only a common congenital heart defect but also an enigmatic condition that can cause a large spectrum of diseases, such as aortic valve stenosis and severe heart failure in newborns whereas aortic dissection in adults. On the contrary, a bicuspid aortic valve can also occur with normal function throughout life and never need treatment. Numerous genetic mechanisms are involved in the abnormal cellular functions that may cause abnormal development of the aortic valve during early foetal life. As several chromosomal disorders are also associated with a bicuspid valve, there does not appear to be an apparent common trigger to the abnormal development of the aortic valve. The clinical care of the bicuspid aortic valve patient has been changed by a significant body of evidence that has improved the understanding of the natural history of the disease, including when to best intervene with valve replacement and when to provide prophylactic aortic root surgery. Moreover, as bicuspid valve disease is also part of various syndromes, we can identify high-risk patients in whom a bicuspid valve is much more unfavourable than in the normal population. This review provides an overview of all aspects of the bicuspid aortic valve condition and gives an updated perspective on issues from pathophysiology to clinical care of bicuspid aortic valve disease and associated aortic disease in asymptomatic, symptomatic, and pregnant patients, as well as our viewpoint on population screening.

Development of a Conceptual Map of Negative Consequences for Patients of Overuse of Medical Tests and Treatments

IMPORTANCE

Overuse of medical tests and treatments is an increasingly recognized problem across health systems; best practices for reducing overuse are not clear. Framing the problem in terms of the spectrum of potential patient harm is likely to be an effective strategy for clinician and patient engagement in efforts to reduce overuse, but the scope of negative consequences of overuse for patients has not been well described.

OBSERVATIONS

We sought to generate a comprehensive conceptual map documenting the processes through which overused tests and treatments lead to multiple domains of negative consequences for patients. For map development, an iterative consensus process was informed by structured review of the literature on overuse using PubMed and input from a panel of 6 international experts. For map verification, a systematic review was performed of case reports involving overused services, identified through literature review and manual review of relevant article collections. The conceptual map documents that overused tests and treatments and resultant downstream services generate 6 domains of negative consequences for patients: physical, psychological, social, financial, treatment burden, and dissatisfaction with health care. Negative consequences can result from overused services and from downstream services; they can also trigger further downstream services that in turn can lead to more negative consequences, in an ongoing feedback loop. Case reports on overuse confirmed the processes and domains of the conceptual map. Cases also revealed strengths and weaknesses in published communication about overuse: they were dominated by physical harms, with other negative consequences receiving far less attention.

CONCLUSIONS AND RELEVANCE

This evidence-based conceptual map clarifies the processes by which overused tests and treatments result in negative consequences for patients; it also documents multiple domains of negative consequences experienced by patients. The map will be useful for facilitating comprehensive communication about overuse, estimating harms and costs associated with overused services, and informing health system efforts to reduce overuse.

Overdiagnosis in primary care: framing the problem and finding solutions

Overdiagnosis, is defined as the diagnosis of a condition that, if unrecognized, would not cause symptoms or harm a patient during his or her lifetime, and it is increasingly acknowledged as a consequence of screening for cancer and other conditions. Because preventive care is a crucial component of primary care, which is delivered to the broad population, overdiagnosis in primary care is an important problem from a public health perspective and has far reaching implications. The scope of overdiagnosis as a result of services delivered in primary care is unclear, though overdiagnosis of indolent breast, prostate, thyroid, and lung cancers is well described and overdiagnosis of chronic kidney disease, depression, and attention-deficit/hyperactivity disorder is also recognized. However, overdiagnosis is a known consequence of all screening and can be assumed to occur in many more clinical contexts. Overdiagnosis can harm patients by leading to overtreatment (with associated potential toxicities), diagnosis related anxiety or depression, and labeling, or through financial burden. Many entrenched factors facilitate overdiagnosis, including the growing use of advanced diagnostic technology, financial incentives, a medical culture that encourages greater use of tests and treatments, limitations in the evidence that obscure the understanding of diagnostic utility, use of non-beneficial screening tests, and the broadening of disease definitions. Efforts to reduce overdiagnosis are hindered by physicians' and patients' lack of awareness of the problem and by confusion about terminology, with overdiagnosis often conflated with related concepts. Clarity of terminology would facilitate physicians' understanding of the problem and the growth in evidence regarding its prevalence and downstream consequences in primary care. It is hoped that international coordination regarding diagnostic standards for disease definitions will also help minimize overdiagnosis in the future.

Analysis of clinical benefit, harms, and cost-effectiveness of screening women for abdominal aortic aneurysm

BACKGROUND

A third of deaths in the UK from ruptured abdominal aortic aneurysm (AAA) are in women. In men, national screening programmes reduce deaths from AAA and are cost-effective. The benefits, harms, and cost-effectiveness in offering a similar programme to women have not been formally assessed, and this was the aim of this study.

METHODS

We developed a decision model to assess predefined outcomes of death caused by AAA, life years, quality-adjusted life years, costs, and the incremental cost-effectiveness ratio for a population of women invited to AAA screening versus a population who were not invited to screening. A discrete event simulation model was set up for AAA screening, surveillance, and intervention. Relevant women-specific parameters were obtained from sources including systematic literature reviews, national registry or administrative databases, major AAA surgery trials, and UK National Health Service reference costs.

FINDINGS

AAA screening for women, as currently offered to UK men (at age 65 years, with an AAA diagnosis at an aortic diameter of ≥3·0 cm, and elective repair considered at ≥5·5cm) gave, over 30 years, an estimated incremental cost-effectiveness ratio of £30 000 (95% CI 12 000-87 000) per quality-adjusted life year gained, with 3900 invitations to screening required to prevent one AAA-related death and an overdiagnosis rate of 33%. A modified option for women (screening at age 70 years, diagnosis at 2·5 cm and repair at 5·0 cm) was estimated to have an incremental cost-effectiveness ratio of £23 000 (9500-71 000) per quality-adjusted life year and 1800 invitations to screening required to prevent one AAA-death, but an overdiagnosis rate of 55%. There was considerable uncertainty in the cost-effectiveness ratio, largely driven by uncertainty about AAA prevalence, the distribution of aortic sizes for women at different ages, and the effect of screening on quality of life.

INTERPRETATION

By UK standards, an AAA screening programme for women, designed to be similar to that used to screen men, is unlikely to be cost-effective. Further research on the aortic diameter distribution in women and potential quality of life decrements associated with screening are needed to assess the full benefits and harms of modified options.

FUNDING

UK National Institute for Health Research Health Technology Assessment programme.