From “pre-cancer” to back pain: The tide is turning on overtreatment

Is American medicine finally waking up to the harm caused by overtreating common health conditions? And is Group Health Research Institute (GHRI) on track in finding practical ways to improve care while reducing harms from too much treatment? Signs point to “yes.” On July 29, two Journal of the American Medical Association (JAMA) publications released important papers on overtreatment: One focused on how certain premalignant conditions are defined, detected, and treated. The other outlined problems in back pain treatment.

A National Cancer Institute (NCI) working group recommended policies to reduce overdiagnosis and overtreatment of “pre-cancerous” conditions. Examples include non-lethal abnormalities detected in screening for prostate, thyroid, and lung cancers—and ductal carcinoma in situ (DCIS), a common breast disease that rarely becomes invasive. In JAMA, the group proposed using words like “carcinoma” or cancer only for lesions likely to threaten life without treatment. They also recommended developing better ways for providers and patients to make informed decisions about treating nonmalignant conditions. And they called for better research through creating observational registries for such findings with low malignant potential.

Effective screening programs for colorectal and cervical cancers have reduced the likelihood of late-stage occurrence and deaths from these diseases. But the NCI group’s recommendations signal an emerging view that our nation may have gone too far in aggressively pursuing early detection for some other types of cancer where screening and early-stage detection have increased dramatically without proportionally reducing late-stage diagnosis or death rates. And “incidentalomas”—harmless masses detected while screening for more dire problems—are being treated increasingly often. Many worried patients undergo potentially harmful procedures to remove pre-cancerous and slow-growing growths unlikely to cause illness or death.

The NCI group wants its recommendations to spur new ways to avoid overdiagnosis and overtreatment—goals Group Health scientists have long pursued in breast and colorectal cancer. For example, GHRI is working with Fred Hutchinson Cancer Research Center to identify biomarkers that may distinguish aggressive from non-aggressive or non-progressing breast cancers. Other projects have focused on better detecting aggressive tumors that are invisible on screening.  And Group Health is evaluating how “nurse navigators” can help patients make important treatment decisions after a cancer diagnosis. Another study is examining using online videos as decision-making tools for patients and doctors. Results to date have shown that introducing shared decision making may reduce overuse of surgery for arthritis. And for DCIS and benign prostate disease? Studies underway may tell.

On the issue of back pain, JAMA Internal Medicine published another important paper on overtreatment. Harvard investigators found doctors nationwide don’t follow approved practice guidelines, such as using non-opioid painkillers, avoiding high-end imaging, and referring patients to physical therapy. Their survey of nearly 24,000 visits over 12 years showed advanced imaging rose by 60 percent, use of narcotics increased by 51 percent, and referrals to other physicians, often for surgery, doubled.

Lead author Dr. John Mafi said his work pointed to “a huge opportunity” for “improving quality of care in the management of back pain.” Again, Group Health is providing leading-edge research to drive such improvement. For years, we have shown yoga eases back pain. Two years ago, Group Health’s opioid prescribing initiative showed how to reduce overprescribing narcotics for chronic pain. We’re also reducing unnecessary high-end imaging.

GHRI Senior Investigator Dr. Dan Cherkin has received funding from the Patient Centered Outcomes Research Institute for a new back pain study. Working with Group Health providers and patients, his team will develop and test a tool to identify patients at risk for long-term back pain and evidence-based treatments most likely to help them. Another study, led by the University of Washington’s Dr. Jeffrey Jarvik, will investigate whether giving Group Health patients and their providers better radiology-report information can prevent overtreatment of back pain.

Dr. Mafi said opportunities to address overtreatment are “huge.” Fortunately, we at Group Health have the experience, talent, and organizational support for this work. Now others in U.S. health care are joining us. Welcome aboard.

Eric B. Larson, MD, MPH