A Review of the Presentation of Overdiagnosis in Cancer Screening Patient Decision Aids

Abstract

Introduction. Patient decision aid (PDA) certification standards recommend including the positive and negative features of each option of the decision. This review describes the inclusion of concepts related to overdiagnosis and overtreatment, negative features often ambiguously defined, in cancer screening PDAs. Methods. Our process followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We reviewed 1) current systematic reviews of decision aids, 2) the Ottawa Hospital Research Institute Decision Aid Library Inventory, and 3) a web-based, gray literature search. Two independent reviewers identified and evaluated PDAs using content analysis. Reviewers coded whether overdiagnosis/overtreatment was described as 1) detecting cancer that would not lead to death, 2) detecting cancer that would not cause symptoms, and/or 3) a potential harm or consequence of screening. Coding discrepancies were resolved through consensus. Results. A total of 904 records (e.g., articles, PDAs) were reviewed and 85 PDAs were identified: prostate ( n = 36), breast ( n = 26), lung ( n = 10), colorectal ( n = 10), and other ( n = 3). Sixty-seven PDAs included concepts related to overdiagnosis/overtreatment; 57 (67.1%) used a term other than overdiagnosis/overtreatment, 23 (27.1%) used the specific term “overdiagnosis,” and 13 (15.3%) used “overtreatment.” PDAs described overdiagnosis/overtreatment as a potential harm or consequence of screening ( n = 62) and/or a detection of a cancer that would not cause symptoms (n = 49). Thirty-six described overdiagnosis as the detection of a cancer that would not result in death. Twenty PDAs described the probabilities associated with overdiagnosis/overtreatment. Conclusions. Over three quarters of cancer screening PDAs addressed concepts related to overdiagnosis/overtreatment, yet terminology was inconsistent and few included probability estimates. Consistent terminology and minimum standards to describe overdiagnosis/overtreatment would help guide the design and certification of cancer screening PDAs.

Effects of awareness of breast cancer overdiagnosis among women with screen-detected or incidentally found breast cancer: a qualitative interview study

“…Consistent terminology and minimum standards to describe overdiagnosis and overtreatment as a potential downside of cancer screening 33 should be prioritised in information resources. Information about overdiagnosis and overtreatment must be prominent during consent.…”

Multicriteria Decision Support Would Avoid Overdiagnosis and Overtreatment

“…Provide relevant numerical rate/s of OD/OT as discrete information to be input into a verbal deliberative process, either without a decision aid or incorporated within one. This is the current dominant strategy, so we quote extensively from four of the 67 breast cancer screening aids that introduced OD/OT according to the Housten systematic review [4]. (The remaining 18 aids did not mention this possibility.…”

“…Housten and colleagues have recently reviewed how OD/OT is treated -or not -in 85 cancer screening patient decision aids [4]. Their systematic review embraces the various verbalisations of the concept/s which avoid using the specific OD/OT terms, such as 'experiencing testing or treatment which would turn out to have been unnecessary'.…”

“…Moreover, there is a strong ethical need to include the potential harms of cancer screening, including overdiagnosis, that can be understood by a broad population." [4] (p9).…”

Overdiagnosis and overtreatment; how to deal with too much medicine

“…Another way in which overdiagnosis can happen is when the definitions of diseases are broadened (e.g., creating the term pre-hypertension, so that more no of people are leveled as hypertensives), meaning that people even at minimal risks receive permanent medical labels and lifelong treatments that will fail to benefit many of them. [ 6 7 ]…”