The “The Age of Diagnosis” is a best-selling book by Suzanne O’Sullivan1. It raises major issues about how we age.

Dr O’Sullivan is writing about overdiagnosis and over medicalization. It is only in the very last Chapter that she devotes a few paragraphs to the implications for ageing. They are powerful paragraphs.

Overdiagnosis

Overdiagnosis is not about misdiagnosis, about misunderstanding a patient’s illness. Instead the diagnosis is correct but giving it is not helpful to the patient. In fact it may well be harmful. In previous Newsletters I have talked about Placebos and Nocebo’s (See Newsletter #228 Placebo and Nocebo"). A diagnosis may trigger the symptoms of an illness when none were previously present.

Doctors instinctively think that a diagnosis is a success. O’Sullivan describes a genetic diagnosis for a sick child. After a full DNA analysis, a mutant gene is discovered. It turns out that there are only a handful of children in the world with this mutation. There is therefore no prognosis for the future health of the child. There is no treatment. Does the diagnosis help the parents? Will it instead induce fatalistic acceptance? Will it mean that treatable symptoms will be ignored?

She argues that over diagnosis rests on a series of assumptions that are not being tested. That early diagnosis is always the best. That having a diagnosis is always best for the patient, even if there is no treatment. That more medicine is better medicine and that more modern medicine is the best. There is evidence that these assumptions are wrong. Large scale screening is identifying many more people with some cancerous cells. But data have suggested that at least 30% of breast cancer diagnoses over the age of 70 are over diagnosed. Patients were treated for those cancerous cells often invasively. If left alone, they would have not caused any problems. Screening studies for prostate cancer do not seem to save lives.

Over Medicalization

In these cases normal human differences are given medical labels. These can be differences in behaviour or our body. Differences that we may “grow out of”. They become the business of doctors. Often this comes about when the definition of a disease is broadened. A disease which has very clear acute cases is redefined to include symptoms that are much milder. O’Sullivan uses as an example autism. The definition of this disease has been broadened by successive changes over many years. The number of sufferers has increased dramatically. She raises the same issue over whether being given a medical label benefits the patients. Whether there is the capacity or tools to treat such over medicalized diseases. Whether those in most need are marginalized by the majority. Whether the label carries a stigma that impacts people’s lives.

The definition of pre-diabetes is broadening all over the world. One proposal in China would have meant that 40% of the population would have been so labelled. As Dr Sullivan points out, a better solution might be to start a public health campaign on weight loss and diets. Has it benefited patients to have ageing labelled as a disease?

Ageing Through a “Diagnosis” Lens.

O’Sullivan points out that we have become a wellness society. We have come to expect a lot from our minds and our bodies. Sadness at the loss of a loved one is natural. In today’s culture how long will it be before sadness is redefined as depression? If we can’t achieve our goals, how long is it before we start to look for a medical explanation?

If we expect constant good health, then we become ageist. A failing body is no longer “ natural”. We resist the impact of ageing. We distance ourselves from those that remind us that our health too will fail. Over diagnosis means we have many more “diseases”. We medicalize the natural symptoms of old age. This gives us hope that we won’t catch that “disease”. It gives us hope that medicine can cure the symptoms.

Fighting Stereotypes or Preparing for Decline

The Age of Diagnosis, Suzanne O’Sullivan p262 In my Newsletters I challenge the negative stereotypes of age. Those stereotypes can and do become self-fulfilling. Negative attitudes to ageing are the best predictors of future physical and mental decline. The stereotypes are 30 years out of date. Those years of decline are still there but at a much older age. Am I painting too good a picture?

Should I instead be preparing people for decline? Individuals spend their last years adapting to inevitable frailty of body and mind. Should we all be focusing on highlighting those adaptations. The Maggies Cancer Charity has a motto:

“nobody should lose the joy of living in the fear of dying when diagnosed with cancer”

Not a bad motto for ageing?