Can having money make you sick?

New research suggests that the richer find and treat tumors that would not pose major problems. Is it possible to exaggerate in prevention?

Money does not buy health . There are situations where not even the greatest fortunes are capable of saving lives. Still, it seems logical that having the financial resources allows you to enjoy the knowledge of good doctors , advanced exams , new techniques. But this may not necessarily be good. A survey conducted by two American physicians at the University of Dartmouth came to a curious conclusion. They compared the number of diagnoses of four types of cancer - skin, prostate, breast and thyroid - in high and low income areas of the United States. In the richer, there were more diagnoses of tumors than in the poor, an expected finding.

The explanation is somewhat obvious: it is not because the richer people get sicker, but because they have more access to health and, therefore, more chances of detecting tumors. The surprise came from another analysis, as researchers looked at the number of deaths caused by these four types of cancer. In addition to mortality not increasing at the same rate as the number of diagnoses, there was no major difference between high and low income regions. That is, the people of the poorer regions, who did not discover the tumors, did not die any more because they stopped treating them or because they started therapy too late. The graph below shows the disparity between the number of diagnoses and deaths.

For the researchers, there is only one possible explanation: richer people are finding tumors in their exams that would not cause major problems or could be treated when the symptoms appeared, and no preventive tests were needed to detect them early. A classic case of superdiagnosis , better known by the English equivalent term: overdiagnosis . "My way of looking at these data is that having money is a potential risk of suffering too much medical care," says American physician Gilbert Welch, one of the authors of the study and one of the pioneering voices to warn about wasted resources and Risks of overexamination and treatment. "They turn people into patients unnecessarily,"

The idea sounds counterintuitive. Medicine has devoted much of its efforts in the last century to developing the ability to diagnose and treat diseases that afflict us ever more rapidly. The age of the imaging examinations , inaugurated in 1895 by the German physicist Wilhelm Conrad Röntgen, who was able to glimpse the bones of his wife's hand using X-rays, has made us persevering pursuers of precision in the diagnoses. Pondering that this is doing us more harm than good is something surprising. Going back to criticism of cancer screening, the objects of countless campaigns, seems like an even bolder (or risky) idea.

The criticisms came precisely from the popularization of the preventive exams, called traces . Long-term studies have begun to show that, in population terms, not everyone may benefit from early detection . "Now we know that seeing cancer as something that will kill you is a gross oversimplification," Welch says. "There is a lot of heterogeneity." Welch uses a metaphor from the animal world to explain the diversity of tumors. Birds represent the fastest, most aggressive growth cancers. "You can not get them because when you try to surround them, they've already flown." Rabbits represent tumors that screening can help detect and treat early, with more chances of success. "The rabbits are scattered and you can catch them if you build enough fences," says Welch. But there are also turtles: you do not need fences to protect them because they are not going anywhere. "There are many turtles in prostate, breast and skin cancer," says Welch. In this reasoning, the wear and tear caused by the effort to catch the turtles - anxiety, emotional stress and the risks of future interventions, such as surgeries and the side effects of medications - would be unnecessary.

It is irresistible to think that some birds can be captured. Like some turtles can also get away. Therefore, there is disagreement about how often screening tests should be done, including within the medical community. One of the most emblematic cases is prostate cancer . From the 1990s, doctors began encouraging men to measure in their blood a protein that could point to the presence of prostate tumors, the so-called PSA test . In 2012, a panel of US experts, the US Preventive Services Task Force , began to recommend no further screening: it did not significantly reduce deaths and could induce unnecessary treatment of non-dangerous tumors. The treatment, that yes, Could cause permanent damage such as urinary incontinence and sexual impotence . The orientation of abandoning the screening was endorsed in Brazil by the National Cancer Institute  ( INCA) , but challenged by the Brazilian Society of Urology . Last year, a study showed that early diagnosis of prostate cancer fell in the United States. This made the experts wonder: Would the recommendation against tracking have gone too far to put men at risk? The orientation of abandoning the screening was endorsed in Brazil by the National Cancer Institute ( INCA) , but challenged by the Brazilian Society of Urology . Last year, a study showed that early diagnosis of prostate cancer fell in the United States. This made the experts wonder: Would the recommendation against tracking have gone too far to put men at risk? The orientation of abandoning the screening was endorsed in Brazil by the National Cancer Institute ( Inca) , but challenged by the Brazilian Society of Urology . Last year, a study showed that early diagnosis of prostate cancer fell in the United States. This made the experts wonder: Would the recommendation against tracking have gone too far to put men at risk?

The result came in April of this year: the independent panel of experts who provides health recommendations to the US government has turned back and has recommended that men, over 50, discuss with their doctors the benefits and risks of crawling , According to their particular case. Men with a history in the family are still advised to take the exam, those over the age of 70 are still discouraged from doing so. With so many comings and goings, not infrequently, confused patients remain. "There is no doubt that we need to discuss the advantages and the risks," says urologist Carlos Sacomani of the Brazilian Society of Urology (SBU). "When enlightened, most men decide to take the test because it is not invasive." The SBU maintains its favorable position for screening as of 50 years. Men with risk factors - black,

Men are not the only ones who suffer from the twists and turns of the recommendations. Something similar has happened with breast cancer , which mainly affects - but not only - women. There have already been changes in recommendations because of studies that do not infrequently populate the scientific literature. One of the most recent, published in March this year, with data from Danish women collected between 1980 and 2010, suggests that diagnosing one in three invasive tumors or noninvasive lesions is a case of overdiagnosis. Studies of this type have prompted the American panel of experts to publish new guidelines in 2009 for mammography , the breast cancer screening exam. Instead of doing it once a year from the age of 40, The panel went on to support the idea that women, without risk factors, as cases in the family, should do mammography only from the age of 50, yes year, no year. In Brazil, the Inca adopted the policy, but the Brazilian Society of Mastology maintains the recommendation of annual mammograms from the age of 40.

Controversies are understandable. Although long-term studies on the effects of screening suggest that there is an excess of diagnoses, there are those who do not want to risk letting a tumor that could be tackled, with more chances of success, if caught at an early stage. For now, the discussion about the effects of overdiagnosis makes sense at the population level. In public health , it is pertinent to compare the costs of the two approaches to make the best use of ever finite resources. Therefore, research tries to answer whether most people benefit from the tests, ie whether they live longer than those undiagnosed on preventive tests or if the costs of unnecessary diagnoses outweigh the benefits.

When the discussion is individualized, it gains the name and the history of a person, it remains the certainty that the new studies are not a simple permission to leave the exams aside. And that the  risks and benefits need to be weighed. There are those who prefer to deal with the anxiety generated by possible false alarms found in an examination, rather than with the idea of ​​not detecting a health threat as soon as possible. There are those who do not tolerate living in the expectation of taking exams and prefer to look at a problem when - and if - it appears. The importance of studies that analyze the consequences of screening may be to remember that all conduct in medicine - examinations, medications, procedures - has side effects . And that the good relationship between doctor and patient, Plus a well-informed patient, is a key factor in choosing what is most appropriate for each person - and to deal with the effects of that decision. "There is no uniformity in the studies that allows us to make a single decision, not to do or to track," says oncologist Paulo Hoff , director of the Institute of Cancer of the State of São Paulo ( Icesp ). "The ideal would be to have genetic markers that tell us whether a detected tumor will develop or not, but that does not yet exist." Says the oncologist Paulo Hoff , director of the Institute of Cancer of the State of São Paulo ( Icesp ). "The ideal would be to have genetic markers that tell us whether a detected tumor will develop or not, but that does not yet exist." Says the oncologist Paulo Hoff , director of the Institute of Cancer of the State of São Paulo ( Icesp ). "The ideal would be to have genetic markers that tell us whether a detected tumor will develop or not, but that does not yet exist."

Welch himself, who has been studying the phenomenon of overexamination for decades, has followed the path of individualizing his decision. As his father had died from bowel cancer , Welch did at age 50 a preventive examination, called a colonoscopy . As the result was "totally normal," he chose not to repeat the exam periodically. His decision runs counter to the recommendation of the American Task Force itself - which is usually skeptical about the benefits of screening, but recommends screening for colon cancer in the 50-75 age group. At age 62, Welch says that today his greatest health fears are others. "I am more concerned about the slow and progressive decline in a nursing home, failing to recognize my wife and daughter," Says Welch. "My biggest concern is not to die, to live too much."