Emphasis on potential harms of new technologies and screening in this week's Archives of Internal Medicine

Reuters reports on a study in the current Archives of Internal Medicine that shows that:

“…after the U.S. Congress had mandated Medicare coverage of a digital tool to help detect breast cancer, health providers were quick to pick it up even though it hadn’t showed clear-cut benefits for the women.

The technology, known as computer-aided detection, costs more than $100,000 to install, according to the researchers…

“It illustrates a bigger problem that exists in our society, where the rails are really greased to get new technologies into practice before we are sure that they are safe,” Dr. Joshua J. Fenton, who led the study, told Reuters Health.

“There is no evidence that the use of computer-aided detection reduces breast cancer mortality,” he added.

A commentary by Dr. Karla Kerlikowski in the same journal calls for “evidence of benefits outweighing harms before implementing new technologies.” Excerpt:

Why do new technologies get disseminated so quickly when evidence is incomplete and/or conflicting? One explanation is that the focus of evaluating new diagnostic tests is on providing evidence to support improved or at least equal benefit of the technology with much less attention to the potential harms of new technologies prior to dissemination. In other words, the benefit of the new technology compared with existing technologies is examined but not necessarily whether the potential benefit of the new technology outweighs the harms of the test. In addition, the designs of comparative studies are often maximized to measure the added benefit of the test to detect disease compared with standard tests rather than assessing effectiveness in community practice on important clinical outcomes. Lastly, there are several forces that may encourage the rapid adoption of new technologies, including investigators with professional interests, technology companies with financial investments, lobbyists with vested interests, and a public convinced that new advanced technology is always better.

Health care providers and individuals cannot presume that newer technologies are better than existing ones without actual data to that effect. Health care providers should not adopt new technologies without first demanding scientific evidence beyond that required for FDA approval. They need to ask how strong and consistent is the evidence for new technologies and whether the evidence shows an important clinical benefit, whether there are important harms, and whether the benefits outweigh the harms. To be responsible advocates for high-quality medical care, our enthusiasm for new technologies should not replace strong, consistent evidence that the benefits of the new technology outweigh the harms in a clinically important way.

Finally, in another commentary in the journal, this one by Dr. George Sawaya on the attempt to reduce harms of cervical cancer screening “by setting appropriate lower and upper age limits for screening and avoiding too-frequent testing among average- and low-risk individuals,” harms are another key focus:

To move forward, clinicians and patients must first be more cognizant of screening harms in all its forms, and studies must be designed to measure not only the likelihood of benefit with various screening strategies but also the likelihood of harm. Second, comprehensive and integrative methods must be identified and used to determine an appropriate balance between benefits and harms that seems reasonable to a variety of stakeholders. Finally, the rationale behind screening guidelines designed to maximize benefits and minimize harms must be clearly communicated to everyone.

While the “less is more” argument may never be convincing to many stakeholders in cancer screening, its rationale should resonate with many clinicians steeped in the tradition of doing no harm.

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