Introduction to Clinical

Introduction to Clinical Epidemiology

Epidemiology
•Module
Module
Introduction 1 –2: Video
to 5Clinical
| Video 2: Asking
Critical appraisal Questions
of RCTs – Was there a fair start?

Epidemiology
Module 10| Video 2: Overdiagnosis

Presented By SYDNEY MEDICAL SCHOOL

Dr Fiona Stanaway | Fiona.Stanaway@Sydney.edu.au

SYDNEY MEDICAL SCHOOL

DrDrFiona
Fiona Stanaway
Stanaway
Fiona.Stanaway@sydney.edu.au
Fiona.Stanaway@sydney.edu.au

1
Overdiagnosis – What do we mean?

- Patients are diagnosed with disease

that would not have resulted in
important morbidity in their lifetime

Relationship with overuse

- Can be related to overtesting but also

other contributing factors
- May lead to overtreatment

Pathways leading to overdiagnosis

- Screening detected overdiagnosis in

people without symptoms

- Increased sensitivity of tests used to

diagnose patients with symptoms

- Incidental findings in patients having a

test for another reason

- Widened disease definitions and lower

treatment thresholds

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 Overdiagnosis from screening

Cancer
death

Fast Slow
Cancer
symptoms
Very
slow
Overdiagnosis

Non progression
or regression

Death from
other cause

Changes to test or diagnostic criteria

Highly sensitive test
Number Good at picking up disease but
of people
may also wrongly label many
healthy people as having disease
Higher sensitivity
False may result from
positives
- Lower threshold
- New technology
- Broader disease
definition

Without disease With disease

Test result e.g. PSA ng/ml

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Increased sensitivity – Does it matter?

- False positives – mislabelling healthy people

- Change in spectrum of disease severity

Those only identified
by the lower threshold,
newer test or broader definition
may have milder disease
Can change
benefit to harm trade-off

New technology New spectrum

e.g. CT angiography for diagnosis of PE

Sheh SH et al. Pulmonary Embolism Diagnosis and Mortality With Pulmonary CT Angiography Versus Ventilation-Perfusion Scintigraphy:
Evidence of Overdiagnosis With CT? AJR Am J Roentgenol 2012 Jun;198(6):1340-5. doi: 10.2214/AJR.11.6426.

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 Increased sensitivity – Does it matter?

- Good at ruling out disease

Remember SnNOUT
- New test may have other advantages
BUT

Beware of blindly applying evidence of

treatment benefit that was established
on old spectrum of disease

Yoo HHB, Queluz THAT, El Dib R. Anticoagulant treatment for subsegmental pulmonary embolism. Cochrane Database
of Systematic Reviews 2016, Issue 1. Art. No.: CD010222. DOI: 10.1002/14651858.CD010222.pub3.

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 “Incidentalomas”
- Can be common
- Up to 40%Û of people undergoing
imaging for research purposes had
at least one incidental finding
- Higher if: -Older patients
-Body region e.g. abdomen
-CT > US and nuclear medicine
- Can lead to further clinical action
- Same study – about 6% had further action
- For most – unclear benefit or burden of
action
*Orme NM et al. Incidental findings in imaging research: evaluating incidence, benefit and burden. Arch Intern Med 2010; 170(17):1525-1532. doi:10.1001/archinternmed.2010.317.

Changes to treatment thresholds

Number
of people

Mild disease Severe disease

–happy to watch and wait – no hesitation to treat

With disease

Increasing benefit to harm trade-off

as disease severity increases

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Changes to treatment thresholds
Be aware of the drivers!

SHOULD be based on evidence of

benefit > harm in patients

Be aware of industry bias !

Change of
target range
from 11-12
to 11-13

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