A few months ago, I went to my gynecologist looking for help with a menstrual problem. She put me in stirrups, and the next thing I knew, I was getting a Pap smear. That wasn’t what I’d come in for, but it had been a year since my last test for cervical cancer, so I went along. After all, catching cancer early is always the goal, right? To my surprise, I later learned that, according to the most recent science, it’s actually possible to catch a cancer too early. And being tested frequently—i.e., every year—was not my best game plan.
Most cervical cancers progress very slowly, and high-quality research has shown that some of the precursors to cancer that a Pap test can detect will go away without medical treatment. Right now, however, there’s no “wait and see” in the system. When the Pap reveals certain abnormalities, the immediate next steps are additional doctor visits, plus invasive and painful testing, says Russell Harris, MD, a professor of medicine at the University of North Carolina at Chapel Hill. This cascade of events saves some lives, but it also needlessly inconveniences and even harms many who were never in danger.
Experts have learned that we can have the best of both worlds: Because cervical cancer is so slow to spread, the Pap test can be done less frequently while still identifying the women who are at risk well within the window of when they can be successfully treated. At the same time, doctors can spare those who are not truly at risk from unnecessary callbacks and biopsies. That’s why most medical groups have called for women to be tested every three years instead of annually (those at high risk are an exception).
A shift in the frequency of Pap tests is only one small facet of a remarkable change taking place in the medical world. This new way of thinking contends that our medical system’s “more is better” mind-set has saddled healthy people with costly treatments that might actually hurt them, says Fiona Godlee, MD, editor-in-chief of the BMJ (formerly the British Medical Journal), a professional publication that’s leading the charge toward a risk-benefit approach to health care. As part of its Too Much Medicine campaign, the BMJ has presented a series of articles outlining how certain conditions, including osteoporosis, dementia, high cholesterol and breast cancer, are being overdiagnosed and overtreated by doctors.
Take osteoporosis. A study published in the BMJ in 2008 calculated that to prevent one woman from developing fractured vertebrae, 270 women with preosteoporosis would need to take osteoporosis drugs for three years. Two out of three of the vertebrae fractures prevented would not have caused symptoms or reduced the patient’s quality of life. So one woman would avoid a consequential fracture in her vertebrae, and the 269 other women would get no measurable benefit but would subject themselves to potential side effects such as diarrhea, an increased stroke risk, gastrointestinal troubles and a rare but very serious problem called osteonecrosis of the jaw, which causes the bone in the jaw to die.
Medical societies are another part of the “more isn’t necessarily better” movement. The ABIM Foundation created the Choosing Wisely campaign, for which 30 physician-specialty societies, such as the American Academy of Family Physicians (AAFP), each developed a list of actions doctors and patients should question. The AAFP list, for instance, includes “Don’t require a pelvic exam or other physical exam to prescribe oral contraceptive medications.” (For more examples, see “Are You Being Overtreated?”. Find each specialty’s Choosing Wisely list at choosingwisely.org.) The lists are intended to spur conversations between doctors and patients so that together they can choose the most appropriate and necessary treatments.