June 24, 2024, Dr C.Bour
The term “quaternary prevention” has changed its meaning over time. Initially used to refer to all palliative care of a patient who has passed the therapeutic stage, it now designates all actions taken to prevent patients and populations in general from over-medicalization, avoiding invasive medical interventions by favoring ethically and medically acceptable procedures and care.
The central precept of medical practice is primum non nocere – first, do no harm.
This concept of quaternary prevention is currently at the heart of public health concerns, because over-medicalization, which is costly both in terms of healthcare and human lives, also raises the crucial question of the financial costs consumed by this unnecessary medicine, which creates needs and encumbers the field of “prevention”.
We were already talking about this in 2021, in connection with a viewpoint published in the Guardian.
An article by authors from the Department of General Medicine, Primary Care and Health Research Unit, University of Liège, revisits this concept and argues that, apart from the concern to do no harm and to better assess the risks of a medical procedure, it is also appropriate to share the decision with an informed patient.
We have summarized the passages concerning screening. In the introduction, Henrard G, Joly L, Buret L and Giet D write: “Prevention is better than cure. As therapists, we are often steeped in this adage. It pushes us towards the “enthusiastic” side of medicine, that which embraces innovations and proposes maximalist solutions, particularly in the field of cancer screening.
More skeptical approaches co-exist and raise the question of whether, beyond a certain point, an increase in medical investments makes them counter-productive.”
Quaternary prevention “… is essentially a questioning of the wisdom of taking action. It was a Belgian general practitioner, Marc Jamoulle, who formalized this concept, defining it as “any action taken to identify a patient or population at risk of over-medicalization”.
Overestimation of benefits
The authors point out that both doctors and patients often tend to overestimate the benefits of promoted medical devices:
“more often than not, they (clinicians) overestimate the benefits and underestimate the harms (7, 8). According to a 2012 study, the majority of primary care physicians in the USA had difficulty correctly interpreting the key statistical concepts used to present the performance of cancer screening tests (9). This lack of “risk literacy” on the part of healthcare professionals often leads to an exaggeration of the benefits of intervening, and may foster a sense of “urgency to act” that feeds the tendency to overdiagnose.”
(You can find an exhaustive article and educational visuals on the notion of overdiagnosis here)
In this regard, an article published in July 2018 supported the direction of fewer screening recommendations, based on a better understanding of the statistics we read in publications or in the media. What do they really say, and what do the figures, often presented as spectacular, really announce?
In this context, we recall the study by Domenighetti et al. which offers a very eloquent diagram of how we perceive the benefit-risk balance of breast cancer screening in relation to reality; article found here: https://cancer-rose.fr/en/2017/01/03/perception-and-reality/
Domenighetti G, D’Avanzo B, Egger M, et al. Women’s perception of the benefits of mammography screening: population-based survey in four countries. Int J Epidemiol2003;32:816-821
These perceptual biases are obviously also linked to emotional factors, linked to the experiences of the professionals themselves among their patients, but also among their own entourage, a factor mentioned in the article by the authors from Liège.
We’d also add the emotional exaggeration conveyed by the media, through the reporting of biographical events about the illnesses of stars and celebrities, who promote their own medical experience and above all their own convictions as “survivors” and “cancer-heroes”), acting as missionaries and becoming spokespeople for screening (“so that it doesn’t happen to others”), drowning out the medical message and making it impossible to provide any nuanced or sensible information. We see this drift with every pink campaign. In these times, no neutral, balanced message can be heard.
Wilson and Jungner criteria
The Wilson and Jungner criteria were published in 1968 and form the basis of the WHO criteria for screening.
The main determinants for initiating population screening are as follows:
– The disease under study must present a major public health problem
– The natural history of the disease must be known
– A diagnostic technique must be able to visualize the early stage of the disease
– The results of treatment at an early stage of the disease must be superior to those obtained at an advanced stage.
– The sensitivity and specificity of the screening test must be optimal
– The screening test must be acceptable to the population
– The means for diagnosing and treating abnormalities discovered during screening must be acceptable.
– It must be possible to repeat the screening test at regular intervals if necessary.
– The physical and psychological inconvenience caused by screening must be less than the expected benefits.
– The economic cost of a screening program must be outweighed by the expected benefits.
Our collective had taken a stand in 2018 on a publication addressing women’s informed consent about breast cancer screening, on the basis of these principles which, however old, are fundamental before launching any screening program, and yet are often not respected, as is the case for mammographic screening.
They are remarkably durable, but they certainly need to be modernized. So, in 2022, two authors proposed to dust them off a bit, to be read here: https://cancer-rose.fr/en/2022/09/12/the-risks-of-screening-an-elephant-in-the-room/
The authors from Liège propose an update from a Canadian team in a table that we have included here:
(Dobrow MJ, Hagens V, Chafe R, et al. Consolidated principles for screening based on a systematic review and consensus process. CMAJ 2018;190:E422 9.)
Shared decision support tools
Several studies show that women want to be well informed about mammography screening.
https://bmjopen.bmj.com/content/bmjopen/12/11/e064488.full.pdf
https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-022-14685-6
A French study showed that women were less likely to undergo screening if they received full information.
On the other hand, the manipulation of women to force them to take part in screening with as little information as possible is also a scientific issue, as explained by this shocking Italian study….
As the authors from Liège point out, providing patients with information that is both honest and reliable is first and foremost an ethical obligation.
To this end, they detail a three-stage process:
1° “The first stage comprises two objectives: building a team relationship and clarifying a choice identified as open”.
2° “The second stage is the exchange of information about the alternatives identified”.
3° “The third step is to help the patient clarify his or her own preferences.”
In our interactive training course, aimed primarily at healthcare professionals, we propose a scheme for providing information on mammographic screening that should ideally take place in 4 stages during the consultation:
1- Verify what the woman knows about mammography screening
2- Use what she knows as a starting point to provide relevant information
3- Invite women to react to it (feedback)
4- Help women imagine each situation (with or without screening).
We also suggest some useful recommendations for healthcare professionals
Henrard G, Joly L, Buret L, Giet D, in their article, write: “It has been shown that interventions aimed at strengthening DMP (shared medical decision) taking can reduce overprescribing. For example, short training courses for GPs can reduce the use of antibiotics for respiratory tract infections (23), and the use of tools to help patients make shared medical decisions reduces the use of statins in low-risk cardiovascular patients (24). To our knowledge, the actual impact on cancer screening has been little studied. (Editor’s note: see, however, the studies cited above).
Risk communication is therefore extremely important, and should not be downplayed. To this end, decision aids are invaluable, and we’ve devoted an entire section of the site to them, where you’ll find a number of clear, pedagogical decision aids.
Very recently, the Canadian health care group, CanTaskForce, has come up with some very useful ones, updated according to age groups for mammography screening, currently in English but soon to be available in French.
A decision-support tool often takes the form of a dot-matrix visual, like this one (CanTaskForce) :
Or like the one you’ll find in our new decision-support tool in downloadable brochure form, designed using French data, or on the printable poster we produced using data from the Nordic Cochrane collective.
The authors from the University of Liège make extensive reference to the use of decision aids, citing two useful links: “Some organizations producing clinical guidelines are imaginative in communicating with their target audience, as illustrated by a short video presenting lung cancer screening (see https://canadiantaskforce.ca/tools-resources/videos/).
Internet sites also attempt to provide scientifically reliable and formally accessible health information, directly to patients and via professional computer file management software. This is the case, for example, of the “Infosante.be” website.
Authors’ conclusion
” .. We will close this article by simply recalling the two essential functions of all interpersonal communication: exchanging information and establishing a relationship(33). We believe that, in a therapeutic relationship, information must circulate, but that power – to opt for screening or not, for example – must also be shared (34). Models of shared medical decision-making offer us a concrete guide to try and move in this direction.”
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