Quaternary prevention

May 22, 2021,

Cécile Bour, MD

A point of view in The Guardian

A researcher, Dr Ranjana Srivastava, Australian oncologist and author (book "A better death"), shares in The Guardian her personal experience at the end of her training and the questions she had regarding the systematic tests offered to patients, and which imply the responsibility of the doctors, although they are not always aware of it.

As the author explains in her testimony, every test is supposed to have a clinical rationale, and poses (or it should pose) an ethical dilemma for the prescriber.

This point of view of the author was motivated by the death of a woman (in Melbourne, Victoria, April 2021) following a coronary CT angiogram. This examination, performed routinely, was offered by the company where the woman worked and was not justified by any clinical indication. The examination was complicated by the occurrence of anaphylactic shock after the injection of the contrast medium. 

This case appears to be unthinkable and, according to Dr. Srivastava, provides a major lesson to us, health professionals, but also to patients, who are increasingly anxious, carcinophobic and seeking routine examinations.

We are living in a society where people want to feel good and have access to simple ways of preventing disease and its consequences. The public is misled by media messages that are very often enthusiastic and lacking in discernment, and that praise routine screening to "be safe". Pink October is the emblematic example.

The author of the article warns of a very real risk: with the profusion of medical tests marketed as "convenient" and also for many "non-invasive", it is tempting for the public to consider them as an alternative to well-proven, but more difficult to follow recommendations, such as eating with moderation, exercising and working on bad hygienic and dietary habits. 

Actually, it is somewhat the same kind of concern that one encounters for the promoted but very controversial screening of lung cancer by low-dose CT scans, and the french Academy of Medicine has raised the argument that a good primary prevention campaign is certainly more relevant.

It is difficult for the public to understand how anything labeled "medical" can be harmful to health, yet there is ample evidence that unnecessary testing can cause harm.

The scientist cites the example of South Korea, which has introduced a national screening program for certain cancers, including thyroid cancer. Thyroid cancer diagnoses have increased 15-fold in 20 years, while mortality has remained stable, according to a study in the New England Journal of Medicine

Indeed, one third of adults are believed to have tiny papillary thyroid cancers that remain asymptomatic throughout life. But almost the entire population of South Korea that has been diagnosed with thyroid cancer through screening has undergone major surgery or radioactive iodine treatment, each with potentially serious complications. 

This is why it is important for doctors and patients to understand the benefits and risks of a screening test before recommending it.

In another example, oncology researchers have just reported their disappointment with the results of a three-decade study on ovarian cancer[1] [2] [3] involving more than 200,000 women, which found that screening for ovarian cancer via a blood test and ultrasound provided early detection but no survival benefit.
Ovarian cancer is almost always diagnosed at a late stage and associated with poor survival.
The researchers explained educationally that diagnosing ovarian cancer at an early stage does not change when patients die, because the cancer is inherently more aggressive.[4] 
However, they point to many recent advances in cancer treatment, including symptom management, targeted therapies, and the hope of using knowledge about evolution of the disease, to create better screening tests in  future, and to conduct further studies. 

Dr. Srivastava emphasizes the professionalism of these researchers and oncologists, which neither feeds the hype nor extinguishes hope. This is what every physician should seek.

Patients have a legitimate right to expect information, says the scientist.

One organization, Choosing Wisely Australia, has come up with a list of five questions that every patient should keep in mind before deciding to accept a routine test: Do I need this test? What are the risks? Is there an alternative? What is the cost (financial, emotional or time cost)? What happens if I do nothing? 

It's that last question, the option of doing nothing, that so few patients ask, says Dr. Srivastava, because they have tremendous faith in their doctor's knowledge and ability to do the "best" thing.

We need to learn the lesson of moderation and never let a patient suffer through an unnecessary test.

From overdiagnosis to overtreatment

The reason why we are alerting patients to the lack of information about overdiagnosis in breast cancer, which is blatantly absent from the official documents given to women invited to breast cancer screening[5] [6], is that this overdiagnosis has a materialization, a perceptible concretization for the patients in their body. And that is overtreatment.

This concerns surgical procedures, mastectomies, which have been constantly increasing since the introduction of screening, contrary to the "therapeutic reduction" promised to women. But this is not all.

Radiotherapy treatments are also on the rise, and a recent article in the French magazine Que Choisir warns about the poorly evaluated side effects of radiotherapy.

The nature and quantification of the side effects of these treatments is difficult to know, the article says, because no authority lists the side effects of ionizing radiation in a systematic way.

Professor Jean-Luc Perrot, dermatologist at the University Hospital of Saint-Etienne, raises the problem of evaluating the relevance of a treatment when we do not know all of the undesirable effects that this treatment generates. This question emerges in the face of the observation of skin cancers, obviously radiation-induced, in people who have been irradiated for other cancers.

According to this practitioner, a centre recording the effects, even late, of radiotherapy would be indispensable, but the proposal for a dedicated observatory, relayed by the ISRN (Institute for Radiation Protection and Nuclear Safety) more than 10 years ago, has never been followed up.

The assertion of "less heavy" treatments promised to women thanks to screening, as presented on the official INCa website (french national cancer institute), appears all the more cynical as overdiagnosis is barely explained. Over-treatment, although mentioned in the title of the paragraph, is nowhere explained on the site[7]. And to suffer the heavy consequences of a possibly useless radiotherapy is intolerable.

In this context, it is impossible not to mention the thorny issue of carcinoma in situ, a particular entity of breast cancer, largely over-detected by screening and treated by radiotherapy. Their treatment and the treatment of their recurrence do not reduce the number of deaths due to invasive breast carcinoma.

The question is not to propose a "light" treatment whose lightness is relative, or a more "targeted" radiotherapy. The question is rather to not propose a treatment at all to women  who are going to be treated because of an unnecessary detection of cancer that would never have affected them in the absence of screening.

Quaternary prevention

This point of view brings us to quaternary prevention.

This term has recently changed its meaning; initially used for all palliative care of a patient who has exceeded the curative stage, it now designates all actions carried out to prevent patients and more generally populations from over-medicalization, avoiding invasive medical interventions by favouring ethically and medically acceptable procedures and care.

The central precept is primum non nocere.

The means are narrative-based medicine and evidence-based medicine (EBM).

    - Narrative-based medicine

This is listening to the patient and involves adapting the "medically possible" to the person's needs and demands.

    - Evidence-based medicine

EBM is based on a tripod:

1) external experience, which basically refers to scientific studies

2) Internal experience: what we learn from our professional practice

3) patients' preferences and values.

This notion of quaternary prevention will undoubtedly be at the center of public health concerns in the future, because over-medicalization, which is costly both in terms of health care and human lives, also raises the question of the financial costs absorbed by this unnecessary medicine, which creates needs and encumbers the field of "prevention".

On this subject, it is worth reading the article co-authored by several doctors in 2011 which makes quaternary prevention one of the essential tasks of the doctor: Quaternary prevention, a task of the general practitioner

In 2020, an article[8] was published proposing recommendations to limit and stop unnecessary routine examinations in primary care, which we have previously covered.

In conclusion

It is essential that all health professionals become aware of the importance of quaternary prevention, i.e. the protection of populations from deleterious overmedicalization.

At the same time , public health education is also needed, but unfortunately there is a lack of official and media support. It is necessary to make people understand that it is in the interest of patients to conceive medicine within a relevant approach to care, without abuse, and above all towards a de-escalation of irrelevant routine care.


[1] https://www.news-medical.net/news/20210517/Early-detection-of-ovarian-cancer-does-not-translate-into-saving-lives.aspx

[2] https://www.lapresse.ca/actualites/sante/2021-05-18/depistage-du-cancer-de-l-ovaire-deception.php#

[3] https://www.theage.com.au/national/desperately-disappointing-setback-for-ovarian-cancer-screening-hopes-20210512-p57reg.html?btis

[4] We have now learned that cancer does not develop in a linear manner, but that there are a multitude of possibilities, with slow, even nonprogressive cancers, while others may evolve quite fast, and are intrinsically immediately aggressive, due to their molecular characteristics. Read here: https://cancer-rose.fr/en/2020/11/30/how-does-a-cancer-develop/

[5] https://cancer-rose.fr/en/2021/01/01/critical-analysis-of-the-new-inca-information-booklet/

[6] https://cancer-rose.fr/2018/02/11/10552/

[7] https://cancersdusein.e-cancer.fr/questions/surdiagnostic-surtraitement-quest-ce-que-cest/

[8] https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2770724

Read more : The dark side of early detection

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