Purpose of investigation: Difference between revisions

* Screening (healthy or not healthy)

* Lab diagnosis

A frail elderly patient living in an institution (like a nursing home) has a positive faecal occult blood test. The physician considers to refer them to colonoscopy, but stops to consider: how will a colonoscopy be of value to the patient? In their current state, even if the colonoscopy would show colorectal cancer, the patient would not be a candidate for any anticancer surgery or chemotherapy, so even if a diagnosis is made, nothing will change for the patient (except the stress of knowing they have cancer). In addition, colonoscopy is an invasive investigation which requires strict patient preparation, which can be difficult for a frail elderly to perform or even survive.

If they have colorectal cancer and it grows and eventually causes intestinal obstruction, colonoscopy may be indicated for stenting the bowel, in which case the colonoscopy would have value for the patient as palliative therapy

One can also argue that even performing a faecal occult blood test in this case has no value for the patient, because the next step after a positive test would be a colonoscopy, a procedure which would not be of value to the patient anyway

A young male has had back pain for a few days. The pain is not severe, and there are no red flags for cauda equina syndrome. He wants an MRI to know what's going on, but the physician stops to consider: how will an MRI be of value to the patient? The patient may or may not have a herniated disc, but even if they do, a herniated disk without red flags isn't an indication for surgery anyway. As such, whether the MRI shows a herniated disc or not, the management will be the same (no surgery, only physical therapy and pain relief), and the MRI is therefore of no value to the patient (and it is resource-intensive)

On the other hand, if the patient has debilitating pain or there are red flags present, he may have cauda equina syndrome, in which case surgery is indicated. In this case, MRI has value: it determines whether they need surgery or not

A middle aged woman has symptoms of an upper respiratory tract infection. After taking the anamnesis and physical examination, you're certain that it's a viral infection. You reflexively want to order a CRP or leukocyte count, but you stop to consider: will the laboratory investigation likely be of value to the patient? You know that viral URTIs only cause mildly elevated inflammatory parametres, so that's likely what you'll find anyway. And even if the CRP is higher than you expect, you're certain enough that this is not a bacterial infection, so you won't be administering antibiotics anyway. So even after making the investigation, you'll most likely not be changing your management of this patient; managing their symptoms and encouraging rest, without antibiotics

On the other hand, if the patient has symptoms which make it difficult to distinguish between viral and bacterial infection clinically, a laboratory investingation is merited, as it provides additional information which can aid in the diagnosis and therefore the treatment in this case

== Screening ==

Screening refers to using an investigation to detect a disease which has not yet caused symptoms, so-called subclinical disease, with the aim of initiating management as early as possible, to improve the prognosis.  Examples include:

 

* [[Non-invasive prenatal test]] (NIPT) for trisomies during pregnancy

 

=== Screening tests ===

 

Because many of those who have a positive screening test are false positives, positive screening test must always be confirmed by a more specific test.

 

Screening may have many advantages. The main advantage, and the intention behind screening, is that treatment can be started at an earlier time, before symptoms even appear, which usually improves the prognosis considerably, and may allow for curative treatment, which may not have been an option if the disorder was not diagnosed at the asymptomatic stage.

 

Most national screening programmes are backed up by evidence that they reduce mortality or morbidity. For example, breast cancer screening reduces risk of dying from breast cancer by approximately 20-30%.<ref>https://pubmed.ncbi.nlm.nih.gov/32326646/</ref>

 

 

==== Low specificity of tests causing worry and more testing ====

Because screening tests necessarily have low specificity, there will be many false positives. Testing positive on a screening test, especially for cancer, leads to considerable worry for a person. Considering that most people who test positive on a screening test is false positive, the positive predictive value is low as well, meaning that the chance of having the disorder when testing positive is low. This concept is very difficult for laypeople to understand.

 

Because screening tests must be confirmed by a confirmatory test, screening for a disease always leads to more testing. In many cases, these tests are invasive, either entailing radiation exposure ([[CT]] scan) or complicated patient preparation and discomfort during the procedure ([[colonoscopy]]). In some cases, for example with NIPT testing, the confirmatory test ([[amniocentesis]] or [[chorionic villus sampling]]) is invasive and increase the risk of harm ([[abortion]] of the foetus in this case), which may lead to harm for people who are actually healthy.

 

It is reasonable to assume that early diagnosis always improves the prognosis, but that is not always the case. In many cases, the cancer would develop so slowly that the person would never have known of it, or possibly only developed mild symptoms. However, cancer diagnosis almost always leads to aggressive treatment, which has its own effects on quality of life.

 

This is especially important for [[prostate cancer]], for example. Prostate cancer is relatively common in elderly, but research has shown that many who are treated for subclinical prostate cancer would never have developed symptoms of the cancer, and would rather have died peacefully, never knowing that they even had the cancer. Also important to consider that cancer treatment causes significant reduction in quality of life, which is especially unfortunate if the cancer would never have caused symptoms anyway.

 

South Korea started screening for thyroid cancer in the late 20th century. Up until relatively recently, research showed that, while the incidince increased significantly (more cases of thyroid cancer were discovered), the mortality remained the same. In other words, screening detected more cases and lead to more people being treated for cancer, which is a burden to both the healthcare system and the individual, but screening could not demonstrate a reduction in mortality, which is arguably one of the most important goals of screening. This shows that screening can lead to significant overdiagnosis.<ref><nowiki>https://www.nejm.org/doi/full/10.1056/NEJMp1409841</nowiki></ref>

 

In Norway, it is estimated that for every 6 case of breast cancer that is discovered due to screening, 1 of those cases are overtreated, meaning that the cancer in that one case would not have needed treatment if it wasn't screened for.

 

As already established, pre-test probability influences the predictive value of a test. In asymptomatic people (the target population of screening tests), the pre-test probability is equal to the prevalence of the disorder. The disorder we screen for often have a very low prevalence; for example, breast cancer has a prevalence of 0,4%.

Because the disorders we screen for is so rare, the positive predictive value decreases.

==== A negative screening test does not guarantee disease-freedom ====

Even though most tests used to screen populations have high sensitivity and therefore a low rate of false negatives, false negatives still occur, giving many people the impression that they do not have a disorder when they do. This may lead to them not seeking healthcare for new symptoms which are actually due to a disorder, because they think the screening test has cleared them.

==== Screening a population is expensive ====

For screening to be effective, it needs to screen many people, usually many thousands. This is expensive, money which could be used to research other fields of medicine.

When an investigation is ordered for diagnosis, one should already have a list of differential diagnoses before ordering the test, and the test should be able to narrow down the list of differential diagnoses. It's important to consider the test's specificity, sensitivity, positive predictive value, and negative predictive value in this. There is no reason to perform an investigation if it doesn't help narrow doen the number of differential diagnoses.  

=== Using pre-test probability wisely ===

Because positive and negative predictive values depend on the pre-test probability, it's important to keep the it in mind.

For example, a negative D-dimer has a high negative predictive value for VTE. However, negative predictive value decreases with increasing pre-test probability. A person with a high pre-test probability (Wells score for PE of 7 or more) have a 40+% pre-test probability of PE. If the patient has a high pre-test probability, determined by their Wells score, the patient no longer has the same pre-test probability as the general population (which is low). The negative predictive value decreases, which makes a negative D-dimer unsuitable for ruling out PE in a person with high pre-test probability.

* CRP or leukocyte count following antibiotic prescription to evaluate the treatment response

In some cases, performing an investigation even though it won't change patient management can be useful if it provides information on patient prognosis. This is most common in case of patients with cancer.