I den gode sags tjeneste - når forebyggelse gør mere skade end gavn

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1 I den gode sags tjeneste - når forebyggelse gør mere skade end gavn John Brodersen Professor, speciallæge i almen medicin, ph.d. Center for Forskning & Uddannelse i Almen Medicin, IFSV, KU Forskningsenheden for Almen Praksis, Region Sjælland [email protected]

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5 I den gode sags tjeneste - når forebyggelse gør mere skade end gavn John Brodersen Professor, speciallæge i almen medicin, ph.d. Center for Forskning & Uddannelse i Almen Medicin, IFSV, KU Forskningsenheden for Almen Praksis, Region Sjælland [email protected]

6 I den gode sags tjeneste Primær forebyggelse Sekundær forebyggelse Tertiær forebyggelse Kvartær forebyggelse Fremtiden? 6

7 Min forforståelse Hvad er evidensbaseret medicin? Gavn & skade: ikke sort & hvidt, men et kontinuum Forebyggelse: sprog og kultur Medicinsk etik 7

8 Min forforståelse Hvad er evidensbaseret medicin? Gavn & skade: ikke sort & hvidt, men et kontinuum Forebyggelse: sprog og kultur Medicinsk etik 8

9 Evidence-based medicine G. Guyatt, D. Rennie, M. Meade, D. Cook. Users' Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice, New York: McGraw-Hill Professional,

10 Evidence-based medicine Conceptually, EBM involves 3 fundamental principles. First, optimal clinical decision making requires awareness of best available evidence, which ideally will come from systematic summaries of that evidence. Second, EBM provides guidance do decide whether evidence is more or less trustworthy that is, how confident can we be of the properties of diagnostic tests, of our patients prognosis, or of the impact of the therapeutic options? Third, evidence alone is never sufficient to make a clinical decision. Decision makers must always trade off the benefits and risks, burden, and costs associated with the alternative management strategies and, in doing so, consider their patients unique predicament and values and preferences. G. Guyatt, D. Rennie, M. Meade, D. Cook. Users' Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice, New York: McGraw-Hill Professional,

11 Evidence-based medicine Conceptually, EBM involves 3 fundamental principles. First, optimal clinical decision making requires awareness of best available evidence, which ideally will come from systematic summaries of that evidence. Second, EBM provides guidance do decide whether evidence is more or less trustworthy that is, how confident can we be of the properties of diagnostic tests, of our patients prognosis, or of the impact of the therapeutic options? Third, evidence alone is never sufficient to make a clinical decision. Decision makers must always trade off the benefits and risks, burden, and costs associated with the alternative management strategies and, in doing so, consider their patients unique predicament and values and preferences. G. Guyatt, D. Rennie, M. Meade, D. Cook. Users' Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice, New York: McGraw-Hill Professional,

12 Evidence-based medicine Conceptually, EBM involves 3 fundamental principles. First, optimal clinical decision making requires awareness of best available evidence, which ideally will come from systematic summaries of that evidence. Second, EBM provides guidance do decide whether evidence is more or less trustworthy that is, how confident can we be of the properties of diagnostic tests, of our patients prognosis, or of the impact of the therapeutic options? Third, evidence alone is never sufficient to make a clinical decision. Decision makers must always trade off the benefits and risks, burden, and costs associated with the alternative management strategies and, in doing so, consider their patients unique predicament and values and preferences. G. Guyatt, D. Rennie, M. Meade, D. Cook. Users' Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice, New York: McGraw-Hill Professional,

13 Evidence-based medicine Conceptually, EBM involves 3 fundamental principles. First, optimal clinical decision making requires awareness of best available evidence, which ideally will come from systematic summaries of that evidence. Second, EBM provides guidance do decide whether evidence is more or less trustworthy that is, how confident can we be of the properties of diagnostic tests, of our patients prognosis, or of the impact of the therapeutic options? Third, evidence alone is never sufficient to make a clinical decision. Decision makers must always trade off the benefits and risks, burden, and costs associated with the alternative management strategies and, in doing so, consider their patients unique predicament and values and preferences. G. Guyatt, D. Rennie, M. Meade, D. Cook. Users' Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice, New York: McGraw-Hill Professional,

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15 Min forforståelse Hvad er evidensbaseret medicin? Gavn & skade: ikke sort & hvidt, men et kontinuum Forebyggelse: sprog og kultur Medicinsk etik 15

16 Balancen: gavn og skade Gavn Lav risiko Høj risiko 16

17 Balancen: gavn og skade Skade Lav risiko Høj risiko 17

18 Balancen: gavn og skade Gavn Skade Lav risiko Høj risiko 18

19 Balancen: gavn og skade Gavn Skade Lav risiko Høj risiko 19

20 Balancen: gavn og skade Gavn Skade Lav risiko Høj risiko? 20

21 Min forforståelse Hvad er evidensbaseret medicin? Gavn & skade: ikke sort & hvidt, men et kontinuum Forebyggelse: sprog og kultur Medicinsk etik 21

22 Kontraintuitivt Det er bedre at forebygge end at helbrede 22

23 Kontraintuitivt Det er bedre at forebygge end at helbrede er det altid sandt? 23

24 Kontraintuitivt Det er bedre at forebygge end at helbrede er det altid sandt? Jo før jo bedre 24

25 Kontraintuitivt Det er bedre at forebygge end at helbrede er det altid sandt? Jo før jo bedre kan det også være for tidligt? 25

26 (Medical) Prevention - idioms Prevention is better than cure An ounce of prevention is worth a pound of cure Better safe than sorry A stitch in time saves nine An apple a day keeps the doctor away 26

27 Min forforståelse Hvad er evidensbaseret medicin? Gavn & skade: ikke sort & hvidt, men et kontinuum Forebyggelse: sprog og kultur Medicinsk etik 27

28 Etik og forebyggelse Utilitarisme nytteetik Deontologi pligtetik Først og fremmest ikke skade Autonomi vs. paternalisme 28

29 Ved forebyggelse hos raske Først og fremmest ikke skade Deontologi pligtetik Autonomi Paternalisme Utilitarisme nytteetik 29

30 I den gode sags tjeneste Primær forebyggelse Sekundær forebyggelse Tertiær forebyggelse Kvartær forebyggelse Fremtiden? 30

31 31 Rask Illness Syg Patientens sygdomsopfattelse

32 Rask Disease Syg Medicinens sygdomsopfattelse 32

33 Rask Primær forebyggelse Rask Disease Syg Illness Medicinens sygdomsopfattelse Syg 33 Patientens sygdomsopfattelse

34 Primær forebyggelse Action taken to avoid or remove the cause of a health problem in an individual or a population before it arises. Includes health promotion and specific protection (e.g.immunization) Bentzen N. Wonca Dictionary of General/Family Practice, Copenhagen:Månedsskrift for Praktisk Lægergerning,

35 Primær forebyggelse Individorienteret Livsstilsintervention Strukturelt orienteret Vaccinationer Sundhedspædagogik: Kampagner Uddannelse Forbud/restriktioner Afgifter Nudging 35

36 Rask Primær forebyggelse Rask Disease Syg Incidensen Illness Medicinens sygdomsopfattelse Prævalensen Syg 36 Patientens sygdomsopfattelse

37 Individualistic primary prevention Tredive års forskning viser, at massekampagner og individorienteret forebyggelse kun har forbigående og ringe effekt. Man kan ganske enkelt ikke forvente, at borgeren gør det modsatte af, hvad det omkringliggende samfund lægger op til. Torben Jørgensen, Charlotte Glümer, and Charlotta Pisinger. Vi kan lære af fortiden. Nyt om Forebyggelse 15,

38 Individualistic primary prevention Når man bygger rulletrapper i stedet for trapper, når der overalt i bybillederne står slik og sodavandsautomater i stedet for frugt, når prisen på tobak og alkohol falder, ja så lægger samfundet op til, at det nemme valg er det usunde valg. Torben Jørgensen, Charlotte Glümer, and Charlotta Pisinger. Vi kan lære af fortiden. Nyt om Forebyggelse 15,

39 L. T. Krogsbøll, K.J. Jørgensen, Grønhøj Larsen C., P.C. Gøtzsche. General health checks in adults for reducing morbidity and mortality from disease. Cochrane.Database.Syst.Rev. 10:CD009009,

40 L. T. Krogsbøll, K.J. Jørgensen, Grønhøj Larsen C., P.C. Gøtzsche. General health checks in adults for reducing morbidity and mortality from disease. Cochrane.Database.Syst.Rev. 10:CD009009,

41 L. T. Krogsbøll, K.J. Jørgensen, Grønhøj Larsen C., P.C. Gøtzsche. General health checks in adults for reducing morbidity and mortality from disease. Cochrane.Database.Syst.Rev. 10:CD009009,

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44 Harms of influenza vaccine 44

45 Harms of HPV vaccine? POTS (Postural Tachycardia Syndrom) 45

46 Harms of HPV vaccine? POTS (Postural Tachycardia Syndrom) 46

47 I den gode sags tjeneste Primær forebyggelse Sekundær forebyggelse Tertiær forebyggelse Kvartær forebyggelse Fremtiden? 47

48 Rask Sekundær forebyggelse Rask Disease Syg Illness Medicinens sygdomsopfattelse Syg 48 Patientens sygdomsopfattelse

49 Sekundær forebyggelse Action taken to detect a health problem at an early stage in an individual or a population, thereby facilitating cure, or reducing or preventing it spreading or its longterm effects (e.g. screening and case finding) Bentzen N. Wonca Dictionary of General/Family Practice, Copenhagen:Månedsskrift for Praktisk Lægergerning,

50 Sekundær forebyggelse Case finding Screening: Befolkningsundersøgelse Højrisikoscreening Opportunistisk screening Gråzone screening 50

51 Screening - på godt og ondt GODT Nedsat morbiditet og mortalitet Mere skånsom behandling Tryghed for ikke at være syg Primær forebyggende effekt ONDT Patienter i flere år Overdiagnostik Falsk tryghed Falsk alarm Overbehandling Øget morbiditet og mortalitet Induceret sygdom 51

52 Screening - på godt og ondt GODT Nedsat morbiditet og mortalitet Mere skånsom behandling Tryghed for ikke at være syg Primær forebyggende effekt ONDT Patienter i flere år Overdiagnostik Falsk tryghed Falsk alarm Overbehandling Øget morbiditet og mortalitet Induceret sygdom 52

53 FOBT-screening Shaukat et al. Long-term mortality after screening for colorectal cancer. N.Engl.J.Med. 369 (12): ,

54 FOBT-screening Shaukat et al. Long-term mortality after screening for colorectal cancer. N.Engl.J.Med. 369 (12): ,

55 Hvorfor? Screening har ringe effekt eller virker slet ikke Sticky-diagnosis bias Sygdom er hyppigt forekommende, men få dør for tidligt 55

56 Dødsårsager aldersgrp år Sigurdsson, Getz, Sjönell, Vainiomäki, Brodersen. Marginal public health gain of screening for colorectal cancer. Modelling study, based on WHO and national databases in the Nordic countries. 19(2):400-7,

57 Dødsårsager aldersgrp år Sigurdsson, Getz, Sjönell, Vainiomäki, Brodersen. Marginal public health gain of screening for colorectal cancer. Modelling study, based on WHO and national databases in the Nordic countries. 19(2):400-7,

58 Screening - på godt og ondt GODT Nedsat morbiditet og mortalitet Mere skånsom behandling Tryghed for ikke at være syg Primær forebyggende effekt ONDT Patienter i flere år Overdiagnostik Falsk tryghed Falsk alarm Overbehandling Øget morbiditet og mortalitet Induceret sygdom 58

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62 Reassurance J. Østerø, V. Siersma, J. Brodersen. Breast cancer screening implementation and reassurance. Eur.J Public Health 24 (2): ,

63 J.F. Rasmussen, V. Siersma, J.H. Pedersen, J. Brodersen. Psychosocial consequences in the Danish randomised controlled lung cancer screening trial (DLCST). Lung Cancer 87 (1):65-72,

64 Tryghed? Min hypotese Implementering af screening inducere usikkerhed i samfundet Invitation og/eller faktisk deltagelse i screening giver nogen men ikke fuld tryghedsfølelse 64

65 Screening - på godt og ondt GODT Nedsat morbiditet og mortalitet Mere skånsom behandling Tryghed for ikke at være syg Primær forebyggende effekt ONDT Patienter i flere år Overdiagnostik Falsk tryghed Falsk alarm Overbehandling Øget morbiditet og mortalitet Induceret sygdom 65

66 NORCCAP: 11 års opfølgning Resultater: Deltagelse: 63% Incidens: HR 0,80 [95% CI 0,70-0,92] 66

67 Kardio-vaskulær risiko % CVD diseases and number of risk factors 0 1 risk factor 2 risk factors risk factors Age CVD, diabetes and treated hypertension H. Petursson et al. Can individuals with a significant risk for cardiovascular disease be adequately identified by combination of several risk factors? J.Eval.Clin.Pract. 15 (1): ,

68 Screening - på godt og ondt GODT Nedsat morbiditet og mortalitet Mere skånsom behandling Tryghed for ikke at være syg Primær forebyggende effekt ONDT Patienter i flere år Overdiagnostik Falsk tryghed Falsk alarm Overbehandling Øget morbiditet og mortalitet Induceret sygdom 68

69 Overdiagnosis (ODx) 69

70 Lung Cancer Screening: CT scan

71 Model: what happens at cancer screening? Cancer size Size at which cancer causes death Person A False negative screen from very fast growing cancer Persons B, C, D & E Screen-diagnosed cancer which would have progressed to symptoms and death Size at which cancer causes symptoms Size at which cancer can be detected Cancer diagnosis Cancer diagnosis Cancer diagnosis Cancer diagnosis Person F Overdiagnosed: Cancer would NOT have caused symptoms before death from other causes Person G No cancer diagnosis before death from other cause Death from other causes Death from other causes Abnormal cell Screening Test 1 Screening Test 2 Screening Test 3 Screening Test 4 Screening Test 5 Person H Overdiagnosed: Cancer spontaneously regressed before death from other cause Time Brodersen J., Schwartz L.M., Woloshin S. Overdiagnosis: How cancer screening can turn indolent pathology into illness. APMIS 122, 2014.

72 Breast, mammography Lung, chest x-ray Lung, CT Liver, ultrasound Prostate, PSA 72 Krag et al. Quantification of overdiagnosis in randomised trials of cancer screening: an overview of systematic reviews. POD conference 2015

73 Breast, mammography Lung, chest x-ray Lung, CT Liver, ultrasound Prostate, PSA 73 Krag et al. Quantification of overdiagnosis in randomised trials of cancer screening: an overview of systematic reviews. POD conference 2015

74 Screening - på godt og ondt GODT Nedsat morbiditet og mortalitet Mere skånsom behandling Tryghed for ikke at være syg Primær forebyggende effekt ONDT Patienter i flere år Overdiagnostik Falsk tryghed Falsk alarm Overbehandling Øget morbiditet og mortalitet Induceret sygdom 74

75 J. Brodersen & V. Siersma. Long-term psychosocial consequences of screening mammography. Annals of Family Medicine. 11 (2): ,

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77 FP: invasiveness? B. Heleno, V. D. Siersma, J. Brodersen. Diagnostic invasiveness and psychosocial consequences of false-positive mammography. Ann.Fam.Med. 13 (3): ,

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79 FP: waiting time? B. Heleno, V. Siersma, J. Brodersen. Waiting time and the psychosocial consequences of false-positive mammography: cohort study. J Negat.Results Biomed. 14 (1):8,

80 Rask Sekundær forebyggelse Rask Disease Syg Incidensen Illness Medicinens sygdomsopfattelse Prævalensen Syg 80 Patientens sygdomsopfattelse

81 I den gode sags tjeneste Primær forebyggelse Sekundær forebyggelse Tertiær forebyggelse Kvartær forebyggelse Fremtiden? 81

82 Rask Rask Disease Syg Illness Medicinens sygdomsopfattelse Tertiær forebyggelse Syg 82 Patientens sygdomsopfattelse

83 Tertiær forebyggelse Action taken to reduce the chronic effects of a health problem in an individual or a population by minimizing the functional impairment consequent to the acute or chronic health problem (e.g. prevent complications of diabetes) Bentzen N. Wonca Dictionary of General/Family Practice, Copenhagen:Månedsskrift for Praktisk Lægergerning,

84 Tertiær forebyggelse ASA til pt. med AMI & apopleksi Steroidinhalation til pt. med astma Motion til pt. med KOL 84

85 HRT ved menopause In current users of each type of HRT the risk of breast cancer increased with increasing total duration of use. 10 years' use of HRT is estimated to result in five (95% CI 3-7) additional breast cancers per 1000 users of oestrogen-only preparations and 19 (15-23) additional cancers per 1000 users of oestrogenprogestagen combinations. V. Beral. Breast cancer and hormone-replacement therapy in the Million Women Study. Lancet

86 HRT lille risiko? 10 years' use of HRT 19 (15-23) additional cancers per 1000 users of oestrogenprogestagen combinations. Mammografiscreening (Cochrane review): 2000 kvinder skal inviteres 5 gange på 10 år for at forebygge ét dødsfald af brystkræft RATIO 1:38 86

87 Rask Rask Disease Syg Incidensen Illness Medicinens sygdomsopfattelse Prævalensen Tertiær forebyggelse Syg 87 Patientens sygdomsopfattelse

88 I den gode sags tjeneste Primær forebyggelse Sekundær forebyggelse Tertiær forebyggelse Kvartær forebyggelse Fremtiden? 88

89 Rask Rask Disease Syg Illness Medicinens sygdomsopfattelse Kvartær forebyggelse Syg 89 Patientens sygdomsopfattelse

90 Kvartær forebyggelse Action taken to identify patient at risk of overmedicalisation, to protect him from new medical invasion, and to suggest to him interventions, which are ethically acceptable. Bentzen N. Wonca Dictionary of General/Family Practice, Copenhagen:Månedsskrift for Praktisk Lægergerning,

91 Kvartær forebyggelse Stoppe den medicinske Odyséen for at finde en biomedicinsk forklaring på (årsag til) patientens illness: 10 år i krig 10 år om at komme hjem 91

92 Kvartær forebyggelse Fibromyalgia Kronisk træthedssyndrom Utmattningssyndrom Whiplash MUS Funktionelle lidelser Psykosomatisk tilstand Stress 92

93 Rask Primær forebyggelse Sekundær forebyggelse Rask Incidensen Syg Prævalensen Medicinens sygdomsopfattelse Kvartær forebyggelse Tertiær forebyggelse Patientens sygdomsopfattelse Syg 93

94 Rask Primær forebyggelse Sekundær forebyggelse Rask Syg Medicinens sygdomsopfattelse Kvartær forebyggelse Tertiær forebyggelse Patientens sygdomsopfattelse Syg 94

95 Kvartær forebyggelse New Definition: Action taken to protect individuals (persons/patients) from medical interventions that are likely to cause more harm than good. Goal: Reduce overmedicalisation (overdiagnosis and overtreatment) and iatrogenenic harm Brodersen J., Schwartz L.M., Woloshin S. Overdiagnosis: How cancer screening can turn indolent pathology into illness. APMIS 122 (8): ,

96 Primary prevention Definition Action taken to prevent disease before it arises in people who feel well. Goal Decrease the incidence of disease Feels well Person perspective: Illness Secondary prevention Definition Action taken to detect disease at an early stage in people who feel well. Goal Reduce disease morbidity and mortality (non infectious diseases) and spread (infectious diseases) Medical perspective: Disease No disease Quaternary prevention Definition Action taken to protect individuals (persons/patients) from medical interventions that are likely to cause more harm than good. Goal Reduce overmedicalisation (overdiagnosis and overtreatment) and iatrogenenic harm Have disease Feels sick Tertiary prevention Definition Action taken to reduce the symptoms and complications of disease in people who feel sick. Goal Reduce progression of disease, and improve physical functioning and quality of life 96

97 I den gode sags tjeneste Primær forebyggelse Sekundær forebyggelse Tertiær forebyggelse Kvartær forebyggelse Fremtiden? 97

98 Fremtiden? Storm P: Det er svært at spå især om fremtiden 98

99 Fremtiden? Mere screening: Befolkningsundersøgelser og højrisiko Quantified Self Big data & Personalised Medicine 99

100 Nye screeningsprogrammer? CT-screening for lungekræft blandt storrygere Abdominalt aorta anuerisme: Befolkningsundersøgelse eller storrygere? 100

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104 Quantified Self Apps 104

105 Big data & Personalised Medicine 105

106 Big data & Personalised Medicine 106

107 Survivors stories drive screening towards more overdiagnosis More Intensive Screening More Useful Screening Appears To Be Popularity paradox More Overdiagnosis More Survivor Stories 107

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109 Cochrane & Holland "If a patient asks a medical practitioner for help, the doctor does the best possible. The doctor is not responsible for defects in medical knowledge. If, however, the practitioner initiates screening procedures the doctor is in a very different situation. The doctor should, in our view, have conclusive evidence that screening can alter the natural history of disease in a significant proportion of those screened." Validation of screening procedures. Br Med Bull 1971; 27:

110 Brodersen "If a patient asks a medical practitioner for help, the doctor does the best possible. The doctor is not responsible for defects in medical knowledge. If, however, the practitioner initiates preventive procedures the doctor is in a very different situation. The doctor should, in my view, have conclusive evidence that prevention can alter the natural history of disease, and/or reduce morbidity and/or mortality significantly. Moreover, these benefits should outweigh the harms substantially." 110