Renowned glaucoma specialist James D. Brandt, MD, delivered this year’s AGS Lecture at the 2024 American Glaucoma Society annual meeting, sharing his perspective on the growing issues of overdiagnosis and overtreatment in glaucoma with a talk entitled “The Worried Well.”
Strong Positive Predictive Value Is Great . . . Usually
Dr. Brandt began with an overview of the achievements in glaucoma over the past 20 years, largely due to studies like the 1994–2019 Ocular Hypertension Treatment Study (OHTS) and European Glaucoma Prevention Study (EGPS). These studies were instrumental in expanding glaucoma knowledge, showing that topical treatment is beneficial, that it is possible to identify at-risk patients, and that models can determine who is most likely to benefit from glaucoma treatment.
However, Dr. Brandt cautioned that just because it is possible to identify at-risk or early-stage patients, it may not necessarily mean they need immediate treatment. With today’s advancements in the ability to predict risk, there are patients identified as having glaucoma who may not actually have experienced harm from the disease during their lifetime had the disease never been recognized (overdiagnosis). Furthermore, treatment of these patients could not only result in no real benefit but also could potentially cause more harm than good (overtreatment).
The Reasons for Overdiagnosis and Overtreatment Are Numerous
Many factors contribute to the overdiagnosis/overtreatment problem. Broadened disease definitions have resulted in lower diagnostic thresholds and the labeling of patients with certain risk factors as having “pre-disease.” Technological advancements have led to more sensitive and widely available screening tests, which lends itself to an increase in incidental disease detection. Also, clinicians excited by the potential for early detection and the promise of treatment can be lured into overestimating the benefits of therapy for patients with low-risk disease.
Why Should We Care?
Dr. Brandt presented some findings from the Sight Outcomes Research Collaborative (SOURCE), which found that approximately one-quarter of patients whose data identified them as being in the lowest risk group for glaucoma were being treated with glaucoma medications, while many of the highest-risk patients were not receiving treatment. These findings support Dr. Brandt’s concerns that ophthalmologists may be focusing too much attention on managing low-risk or early-stage patients.
From a healthcare resource perspective, treatment of very low-risk patients uses resources that may be better applied to the treatment of patients with more moderate or advanced disease who are likely to achieve greater benefit from treatment. Also, Dr. Brandt asked the audience to consider the significant psychological stress that can come along with a glaucoma diagnosis, especially in patients who have mild indicators of disease or risk but minimal, if any, visual deficits.
Awareness and Education Are Key to Moving Forward
“A window is opening to better understand and quantify the problem of overdiagnosis,” said Dr. Brandt. He advised audience members, particularly young ophthalmologists, to study the issue of overdiagnosis and overtreatment and spread awareness among their colleagues. He also recommended improving and implementing risk models such as polygenic risk scores, which have been shown to greatly improve predictions in other areas of medicine. Perhaps most importantly, Dr. Brandt cautioned glaucoma specialists not to rush into a treatment decision. “Don’t get so caught up in the ability to identify risk that you forget that not every patient is a disease suspect.” He shared some key advice originally given to him by mentor Donald S. Minckler, MD: “Glaucoma is a slow-moving disease. It will usually tell you what you need to do if you pay attention.”