PROBLEMS OF
OVERDIAGNOSIS

Medicine’s much hailed ability to help the sick is fast being challenged by its propensity to harm the healthy. A burgeoning scientific literature is fuelling public concerns that too many people are being overdosed,1 overtreated,2 and overdiagnosed.3 Screening programmes are detecting early cancers that will never cause symptoms or death,4 sensitive diagnostic technologies identify “abnormalities” so tiny they will remain benign,5 while widening disease definitions mean people at ever lower risks receive permanent medical labels and lifelong treatments that will fail to benefit many of them.3 6 With estimates that more than $200bn (£128bn; €160bn) may be wasted on unnecessary treatment every year in the United States,7 the cumulative burden from overdiagnosis poses a significant threat to human health. Narrowly defined, overdiagnosis occurs when people without symptoms are diagnosed with a disease that ultimately will not cause them to experience symptoms or early death.3 More broadly defined, overdiagnosis refers to the related problems of overmedicalisation and subsequent overtreatment, diagnosis creep, shifting thresholds, and disease mongering, all processes helping to reclassify healthy people with mild problems or at low risk as sick.8

The downsides of overdiagnosis include the negative effects of unnecessary labelling, the harms of unneeded tests and therapies, and the opportunity cost of wasted resources that could be better used to treat or prevent genuine illness. The challenge is to articulate the nature and extent of the problem more widely, identify the patterns and drivers, and develop a suite of responses from the clinical to the cultural.

At the clinical level, a key aim is to better discriminate between benign “abnormalities” and those that will go on to cause harm. In terms of education and raising awareness among both the public and professionals, more honest information is needed about the risk of overdiagnosis, particularly related to screening. More deeply, mounting evidence that we’re harming healthy people may force a questioning of our faith in ever-earlier detection, a renewal of the process of disease definition, and a fundamental shift in the systemic incentives driving dangerous excess.

Annually, an international scientific conference called Preventing Overdiagnosis aims to deepen understanding and awareness of the problem and its prevention. The conference is timely, as growing concern about overdiagnosis is giving way to concerted action. The Archives of Internal Medicine’s feature “Less is More” now regularly augments the evidence base,9 high level health policy groups in Europe are debating ways to tackle excess,10 and the recently launched Choosing Wisely campaign warns about dozens of potentially unnecessary tests and treatments across nine specialties.11

Many factors—including the best of intentions—are driving overdiagnosis, but a key contributor is advances in technology. The literature suggests several broad and related pathways to overdiagnosis: screening detected overdiagnosis in people without symptoms; overdiagnosis resulting from use of increasingly sensitive tests in those with symptoms; overdiagnosis made incidentally—“incidentalomas”; and overdiagnosis resulting from excessively widened disease definitions.

Screening detected overdiagnosis

This pathway to overdiagnosis occurs when a screening programme detects disease in a person without symptoms but the disease is in a form that will never cause that person symptoms or early death. Sometimes this form of disease is called pseudodisease. Contrary to popular notions that cancers are universally harmful and ultimately fatal, some cancers can regress, fail to progress, or grow so slowly that they will not cause harm before the individual dies from other causes.5 As we will discuss below, there is now strong evidence from randomised trials and other studies comparing screened and unscreened populations that an important proportion of the cancer detected through some popular screening programmes may be pseudodisease.4 12 Evidence from autopsy studies suggests a large reservoir of subclinical disease in the general population, including prostate, breast, and thyroid cancer, the bulk of which will never harm.12 Similarly, screening the hearts of people without symptoms or at low risk may also lead to overdiagnosis of coronary atherosclerosis and subsequent unnecessary interventions.13 Our understanding of the nature and extent of overdiagnosis and the amount of pseudodisease detected by screening is evolving, and as Woolfe and Harris observed recently in JAMA, “concern about overdiagnosis is justified.”14

Increasingly sensitive tests

People presenting to doctors with symptoms can also be overdiagnosed because changes in diagnostic technologies or methods have enabled the identification of less severe forms of diseases or disorders. It is becoming clearer that a substantial proportion of these earlier “abnormalities” will never progress, raising awkward questions about exactly when to use diagnostic labels and therapeutic approaches traditionally deployed against much more serious forms of disease.

Incidentalomas

Diagnostic scanning of the abdomen, pelvis, chest, head, and neck can reveal “incidental findings” in up to 40% of individuals being tested for other reasons.15 Some of these are tumours, and most of these “incidentalomas” are benign. A very small number of people will benefit from early detection of an incidental malignant tumour, while others will suffer the anxiety and adverse effects of further investigation and treatment of an “abnormality” that would never have harmed them. As others have shown, the rapidly rising incidence for some cancers, set against relatively stable death rates, is a phenomenon suggestive of widespread overdiagnosis, whether from screening or the detection of incidentalomas (figure⇓).12

Rates of new diagnosis and death for five types of cancer in the US, 1975-2005. Adapted from Welch and Black 12

figure

Excessively widened definitions

Another pathway to overdiagnosis is through disease boundaries being widened and treatment thresholds lowered to a point where a medical label and subsequent therapy may cause people more harm than good. Changing diagnostic criteria for many conditions are routinely increasing the numbers of people defined as sick,16 causing virtually the entire older adult population to be classified as having at least one chronic condition.17 This widening has happened both with asymptomatic conditions that carry a risk of an adverse event, such as osteoporosis, where treatments may do more harm than good for those at very low risk of fracture,18 and for behavioural conditions such as female sexual dysfunction, where common difficulties have been reclassified as dysfunctions.19

Such changes in diagnostic criteria are commonly made by panels of health professionals with financial ties to companies that benefit directly from any expansion of the patient pool.20 As definitions broaden and thresholds fall, people with smaller risks or milder problems are labelled, which means the potential benefits of treatment decline, raising the possibility that harms will outweigh benefits. As Welch and colleagues estimated in their 2011 book Overdiagnosed,3 many people diagnosed and treated long term for near-normal cholesterol concentration or near-normal osteoporosis may be “overdiagnosed,” in the sense that they would never have experienced the events their treatments are designed to prevent.

A related form of overdiagnosis occurs when people are diagnosed outside of already widened diagnostic criteria, as can occur when inappropriate manufacturers’ norms exaggerate the incidence of abnormality,21 when diagnostic methods wrongly label random or normal fluctuations in biomarkers as true abnormalities,22 or when important qualifiers are left out of the process of diagnosis.23

Examples of overdiagnosis

The growing evidence on overdiagnosis suggests the problem may exist to varying extents across many conditions (box 1), including those for which underdiagnosis may simultaneously be a feature. For some conditions, the evidence remains tentative and speculative, for others it has become much more robust.

box1

Breast cancer

Arguably the strongest evidence of overdiagnosis comes from studies of screening detected breast cancers, though estimates of its extent are wide ranging. A 2007 systematic review in Lancet Oncology found the proportion of overdiagnosis of invasive breast cancer among women in their 50s ranged from 1.7% to 54%.24 An Australian study estimated the rate was at least 30%,25 while a Norwegian study calculated 15-25%.26 A 2009 systematic review in the BMJ concluded up to one third of all screening detected cancers may be overdiagnosed.4

Thyroid cancer

While the chances of tests detecting a thyroid “abnormality” are high, the risk it will ever cause harm is low.3 27 Analysis of rising incidence shows many of the newly diagnosed thyroid cancers are the smaller and less aggressive forms not requiring treatment,28 which itself carries the risk of damaged nerves and long term medication.3

Gestational diabetes

A 2010 revision of the criteria defining gestational diabetes recommended a dramatic lowering of the diagnostic threshold, more than doubling the number of pregnant woman classified to almost 18%.29 Proponents argue universal screening with the new definition will reduce health problems, including babies being “large for gestational age.”29 Critics, however, are calling for an urgent debate before the new expanded definition is more widely adopted, because they fear many women may be overmedicalised and overdiagnosed, that the screening test has poor reproducibility for mild cases, the evidence of benefit for the newly diagnosed pregnant women is weak, and the benefit modest at best.30 31

Chronic kidney disease

More than 10% of adults in the United States are now classified as having some form of chronic kidney disease.32 A working definition launched as part of new clinical guidelines33 asserts that an estimated glomerular filtration rate (eGFR) below 60 ml/min/1.73m2 and sustained for three months or longer is deemed abnormal, a decision critics argue automatically creates the potential for overdiagnosis, particularly among elderly people.34 According to Winearls and Glassock in an article last year the new classification system is “like a fishing trawler” and “captures many more innocent subjects than it should.”23 They estimate that up to one third of people over 65 may meet the new criteria, yet of these, fewer than 1 in 1000 will develop end stage renal disease each year. They also point to major problems with the reliability and consistency of the eGFR test and express concern many older people are being labelled on the basis of a single and potentially inaccurate laboratory measure. Elsewhere they have argued that “the majority of those held to have CKD [chronic kidney disease] have no identifiable kidney disease” and they’ve highlighted attempts by some organisations to move away from the controversial new definition, raise the threshold for diagnosis, and dramatically reduce prevalence.35 Responding to criticisms, proponents have defended the new definition as being “clear, simple, and useful.”36

Asthma

Although asthma can be severe and may be underdiagnosed and undertreated, some studies suggest that there may also be substantial overdiagnosis. One large study in 2008 found that almost 30% of people diagnosed as having asthma did not have the condition, and almost 66% of those did not need drugs or asthma care during six months of follow-up.37 The authors concluded, “A substantial proportion of people . . . may be overdiagnosed with asthma and may be prescribed asthma medications unnecessarily.” In the same year a Dutch study found that of 1100 patients using inhaled corticosteroids, 30% may have been using the drugs without any clear indications.38

Pulmonary embolism

Doctors think of pulmonary embolism as a “not to be missed” diagnosis, because failure to detect it can have catastrophic consequences. Historically it was diagnosed only when the blockage was large enough to cause infarction of part of the lung or haemodynamic instability. In such patients, treatment with an anticoagulant or a thrombolytic agent was considered mandatory. Now, however, computed tomography (CT) pulmonary angiography can detect smaller clots, and there is uncertainty about whether treatment is always necessary.39 Analysing trends before and after the widespread introduction of CT pulmonary angiography, Weiner and colleagues suggested that the almost doubling in incidence “reflects an epidemic of diagnostic testing that has created overdiagnosis,” with much of the increase consisting of “clinically unimportant” cases that “would not have been fatal even if left undiagnosed and untreated.”40 An observational study is investigating the safety of not treating people with very small blood clots.41

Attention deficit hyperactivity disorder

Much has been written about expanding diagnostic definitions within mental illness and concerns about the dangers of overtreatment.42 Debate has intensified with suggestions that current processes for defining disease may be contributing to the widespread overdiagnosis of conditions such as bipolar, autistic disorder, and attention deficit hyperactivity disorders.43 44 One focus of concern is the possible overdiagnosis of children, who have no say in the appropriateness of a label that can permanently change their lives. This is particularly salient with attention deficit hyperactivity disorder.45 A recent study of almost a million Canadian children found boys born in December (typically the youngest in their year) had a 30% higher chance of diagnosis and 40% higher chance of receiving medication than those born in January, with the authors concluding their findings “raise concerns about the potential harms of overdiagnosis and overprescribing.”46

Drivers of overdiagnosis

The forces driving overdiagnosis are embedded deep within the culture of medicine and wider society, underscoring the challenges facing any attempt to combat them. A key driver is technological change itself. As Black described in 1998, the ability to detect smaller abnormalities axiomatically tends to increase the prevalence of any given disease.5 In turn this leads to overestimation of the benefits of therapies, as milder forms of the disease are treated and improvements in health are wrongly ascribed to treatment success, creating a “false feedback” loop fuelling a “cycle of increasing testing and treatment, which may eventually cause more harm than benefit.”5

The industries that benefit from expanded markets for tests and treatments hold widereaching influence within the medical profession and wider society, through financial ties with professional and patient groups and funding of direct-to-consumer advertising, research foundations, disease awareness campaigns, and medical education.8 Most importantly, the members of panels that write disease definitions or treatment thresholds often have financial ties to companies that stand to gain from expanded markets.20 Similarly, health professionals and their associations may have an interest in maximising the patient pool within their specialty, and self-referrals by clinicians to diagnostic or therapeutic technologies in which they have a commercial interest may also drive unnecessary diagnosis.

Avoidance of litigation and the psychology of regret is another obvious driver as professionals can be punished for missing the early signs of disease yet don’t generally face sanctions for overdiagnosing. Quality measures focused on doing more may also encourage overdiagnosis in order to meet targets for remuneration incentives.47

An intuitive belief in early detection, fed by deep faith in medical technology is arguably at the heart of the problem of overdiagnosis. Increasingly we’ve come to regard simply being “at risk” of future disease as being a disease in its own right. Starting with treatment of high blood pressure in the middle of the 20th century,48 increasing proportions of the healthy population have been medicalised and medicated for growing numbers of symptomless conditions, based solely on their estimated risk of future events. Although the approach has reduced suffering and extended life for many, for those overdiagnosed it has needlessly turned the experience of life into a tangled web of chronic conditions. The cultural norm that “more is better” is confirmed by recent evidence suggesting patient satisfaction flows from increased access to tests and treatments, even though more care may be associated with greater harm.49 50

What can we do about overdiagnosis?

Building on existing knowledge and activity, the international conference on overdiagnosis http://www.preventingoverdiagnosis.net/ provides a forum for learning more, increasing awareness, and developing ways to prevent the problem. Research on overdiagnosis is now recognised as part of the future scientific direction of the National Cancer Institute’s division of cancer prevention in the United States.51 The international overdiagnosis conference provides researchers working in this field with the chance to share and debate methods and further advance research agendas. As to education, the development of a range of curriculums and information packages could help raise awareness about the risks of overdiagnosis, particularly associated with screening.52 In association with the BMJ, a series of articles about the potential for overdiagnosis within specific conditions is being planned. And at the level of clinical practice new protocols are being developed to bring more caution in treating incidentalomas.3 Similarly, some are urging that we consider raising the thresholds that define “abnormal”—in breast cancer screening, for example—and evaluate methods of observing changes to some suspected pathologies over time, rather than intervening immediately.53 As we’ve seen, early studies of how to safely undiagnose or de-prescribe are starting to emerge.

At a policy level, reform of the process of defining disease is urgently required, with one model coming from the National Institutes of Health in the United States, where people with financial or reputational conflicts of interest are disqualified from panel membership.20 Dispassionate assessment of evidence may result in disease definitions being narrowed, as has been seen with the recent tentative proposals to raise thresholds for high blood pressure that could demedicalise up to 100 million people.54 Processes for defining disease may also benefit from an attempt to synthesise the evidence from clinical medicine with literature on the wider social and environmental determinants of health. Other policy reforms could review the permanency of some diagnostic labels, address calls for increased independence in the design and running of scientific studies,55 and adjust the structural and legal incentives driving overdiagnosis.

Concern about overdiagnosis does not preclude awareness that many people miss out on much needed healthcare. On the contrary, resources wasted on unnecessary care can be much better spent treating and preventing genuine illness. The challenge is to work out which is which, and to produce and disseminate evidence to help us all make more informed decisions about when a diagnosis might do us more good than harm.

References

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17. Kaplan R, Ong M. Rationale and public health implications of changing CHD risk factor definitions. Annu Rev Public Health 2007;28:321-44. Full Text
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22. Hodgkinson J, Mant J, Martin U, Guo B, Hobbs F, Deeks J, et al. Relative effectiveness of clinic and home blood pressure monitoring compared with ambulatory blood pressure monitoring in diagnosis of hypertension: systematic review. BMJ 2011;342:d3621. Abstract/Full Text
23. Winearls C, Glassock R. Classification of chronic kidney disease in the elderly: pitfalls and errors. Nephron Clin Pract 2011;119(suppl 1):c2-4. LINK
24. Biesheuvel C, Barratt A, Howard K, Houssami N, Irwig L. Effects of study methods and biases on estimates of invasive breast cancer overdetection with mammography screening: a systematic review. Lancet Oncol 2007;8:1129-38. LINK
25. Morrell S, Barratt,A, Irwig L, Howard K, Biesheuvel C, Armstrong B. Estimates of overdiagnosis of invasive breast cancer associated with screening mammography Cancer Causes Control 2010;21:275-82. LINK
26. Kalager M, Adami H, Bretthauer M, Tamimi R. Overdiagnosis of invasive breast cancer due to mammography screening: results from the Norwegian screening program. Ann Intern Med 2012;156:491-9. LINK
27. Tan G, Gharib H. Thyroid incidentalomas: management approaches to nonpalpable nodules discovered incidentally on thyroid imaging. Ann Intern Med 1997;126:226-31. LINK
28. Davies L, Welch G. Increasing incidence of thyroid cancer in the United States, 1973-2002. JAMA 2006;295:2164-7. LINK
29. International Association of Diabetes and Pregnancy Study Groups. Recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care2010;33:676-82. Full Text
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31. Cundy T. Proposed new diagnostic criteria for gestational diabetes—a pause for thought? Diabet Med 2012;29:176-80. LINK
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If you are a copyright holder, or a director, officer, owner, employee, agent, supplier, licensor, contributor, service provider, website hosting company, trade partner, heir or assign of a copyright holder and feel that you or anyone you are engaged in any form of relationship whatsoever may have rights to data as part of this site or related sites, your agreement with the terms of use constitutes the following agreement, which is mandatory in order to access the data contained on this site.

I do hereby declare, understand, agree and warrant that I am a copyright owner, or an authorized representative of a copyright owner of film, print, slide, movie, video, artwork, digital image, negatives or any other material in any format whatsoever (hereafter referred to as “COPYRIGHTED DATA”) which I believe to be, known to be, or suspect to be contained on the drfarrahcancercenter.com website.

I hereby freely grant a non-exclusive license to drfarrahcancercenter.com and its agents to reproduce these COPYRIGHT DATA in perpetuity, and I represent and warrant that I have the legal right and authority to grant such a license. I may at my discretion ask to be credited for my contribution or the contributor I represent to the drfarrahcancercenter.com site as a contributor whether this occurred with or without my knowledge, but even if I or the contributor I represent remains uncredited, this agreement shall survive since participation in the free flowing of information for the public at large is a paramount responsibility we all should share. Therefore, in the best interest of free-flowing information for the public at large, I am freely undertaking this agreement, and clearly warrant that I have the authority to do so. I agree to indemnify and hold harmless drfarrahcancercenter.com and any of its directors, officers, owners, employees, agents, suppliers, licensors, contributors, service providers, website hosting companies, trade partners, heirs and assigns from any and all liability, damages, and expenses (including reasonable actual attorney’s fees) that may incur as a result of use and publication of said material, including any claims brought by any person claiming an interest in the COPYRIGHTED DATA or their subject matter. I agree and warrant that anyone containing any format of data from drfarrahcancercenter.com contained in any medium outside of the drfarrahcancercenter.com website itself, is bound by this agreement, since acceptance of this agreement is the only way to legally access such data. In addition, I understand and agree that accessing or storing any format of data contained in any medium outside of the drfarrahcancercenter.com website where it is hosted, constitutes a violation of the copyright laws of Panama against the offending party. I understand and agree that if I copy, contain, possess, or transmit any such data from the drfarrahcancercenter.com site in any format outside of the website itself, that my possession of such materials is a violation of Panamanian laws, and I agree to destroy such data forthwith.

 

SECTION 3 – ACCURACY, COMPLETENESS AND TIMELINESS OF INFORMATION

We are not responsible if information made available on this site is not accurate, complete or current. The material on this site is provided for general information only and should not be relied upon or used as the sole basis for making decisions without consulting primary, more accurate, more complete or more timely sources of information. Any reliance on the material on this site is at your own risk.

This site may contain certain historical information. Historical information, necessarily, is not current and is provided for your reference only. We reserve the right to modify the contents of this site at any time, but we have no obligation to update any information on our site. You agree that it is your responsibility to monitor changes to our site.

 

SECTION 4 – MODIFICATIONS TO THE SERVICE

We reserve the right at any time to modify or discontinue the Service (or any part or content thereof) without notice at any time.

We shall not be liable to you or to any third-party for any modification, change, suspension or discontinuance of the Service.

 

SECTION 5 – OPTIONAL TOOLS

Any use by you of optional tools offered through the site is entirely at your own risk and discretion and you should ensure that you are familiar with and approve of the terms on which tools are provided by the relevant third-party provider(s).

We may also, in the future, offer new services and/or features through the website (including, the release of new tools and resources). Such new features and/or services shall also be subject to these Terms of Use.

 

SECTION 6 – THIRD-PARTY LINKS

Certain content, products and services available via our Service may include materials from third-parties.

Third-party links on this site may direct you to third-party websites that are not affiliated with us. We are not responsible for examining or evaluating the content or accuracy and we do not warrant and will not have any liability or responsibility for any third-party materials or websites, or for any other materials, products, or services of third-parties.

We are not liable for any harm or damages related to the purchase or use of goods, services, resources, content, or any other transactions made in connection with any third-party websites. Please review carefully the third-party’s policies and practices and make sure you understand them before you engage in any transaction. Complaints, claims, concerns, or questions regarding third-party products should be directed to the third-party.

 

SECTION 7 – USER COMMENTS, FEEDBACK AND OTHER SUBMISSIONS

If, at our request, you send certain specific submissions (for example contest entries) or without a request from us you send creative ideas, suggestions, proposals, plans, or other materials, whether online, by email, by postal mail, or otherwise (collectively, ‘comments’), you agree that we may, at any time, without restriction, edit, copy, publish, distribute, translate and otherwise use in any medium any comments that you forward to us. We are and shall be under no obligation (1) to maintain any comments in confidence; (2) to pay compensation for any comments; or (3) to respond to any comments.

We may, but have no obligation to, monitor, edit or remove content that we determine in our sole discretion are unlawful, offensive, threatening, libelous, defamatory, pornographic, obscene or otherwise objectionable or violates any party’s intellectual property or these Terms of Use.

You agree that your comments will not violate any right of any third-party, including copyright, trademark, privacy, personality or other personal or proprietary right. You further agree that your comments will not contain libelous or otherwise unlawful, abusive or obscene material, or contain any computer virus or other malware that could in any way affect the operation of the Service or any related website. You may not use a false e-mail address, pretend to be someone other than yourself, or otherwise mislead us or third-parties as to the origin of any comments. You are solely responsible for any comments you make and their accuracy. We take no responsibility and assume no liability for any comments posted by you or any third-party.

 

SECTION 8 – ERRORS, INACCURACIES AND OMISSIONS

Occasionally there may be information on our site or in the Service that contains typographical errors, inaccuracies or omissions that may relate to product descriptions, pricing, promotions, offers, product shipping charges, transit times and availability. We reserve the right to correct any errors, inaccuracies or omissions, and to change or update information or cancel orders if any information in the Service or on any related website is inaccurate at any time without prior notice (including after you have submitted your order).

We undertake no obligation to update, amend or clarify information in the Service or on any related website, including without limitation, pricing information, except as required by law. No specified update or refresh date applied in the Service or on any related website, should be taken to indicate that all information in the Service or on any related website has been modified or updated.

 

SECTION 9 – PROHIBITED USES

In addition to other prohibitions as set forth in the Terms of Use, you are prohibited from using the site or its content: (a) for any unlawful purpose; (b) to solicit others to perform or participate in any unlawful acts; (c) to violate any international, federal, provincial or state regulations, rules, laws, or local ordinances; (d) to infringe upon or violate our intellectual property rights or the intellectual property rights of others; (e) to harass, abuse, insult, harm, defame, slander, disparage, intimidate, or discriminate based on gender, sexual orientation, religion, ethnicity, race, age, national origin, or disability; (f) to submit false or misleading information; (g) to upload or transmit viruses or any other type of malicious code that will or may be used in any way that will affect the functionality or operation of the Service or of any related website, other websites, or the Internet; (h) to collect or track the personal information of others; (i) to spam, phish, pharm, pretext, spider, crawl, or scrape; (j) for any obscene or immoral purpose; or (k) to interfere with or circumvent the security features of the Service or any related website, other websites, or the Internet. We reserve the right to terminate your use of the Service or any related website for violating any of the prohibited uses.

 

SECTION 10 – DISCLAIMER OF WARRANTIES; LIMITATION OF LIABILITY

We do not guarantee, represent or warrant that your use of our service will be uninterrupted, timely, secure or error-free.

We do not warrant that the results that may be obtained from the use of the service will be accurate or reliable.

You agree that from time to time we may remove the service for indefinite periods of time or cancel the service at any time, without notice to you.

You expressly agree that your use of, or inability to use, the service is at your sole risk. The service and all products and services delivered to you through the service are (except as expressly stated by us) provided ‘as is’ and ‘as available’ for your use, without any representation, warranties or conditions of any kind, either express or implied, including all implied warranties or conditions of merchantability, merchantable quality, fitness for a particular purpose, durability, title, and non-infringement.

In no case shall anyone affiliated with drfarrahcancercenter.com including our directors, officers, employees, affiliates, agents, contractors, interns, suppliers, service providers or licensors be liable for any injury, loss, claim, or any direct, indirect, incidental, punitive, special, or consequential damages of any kind, including, without limitation lost profits, lost revenue, lost savings, loss of data, replacement costs, or any similar damages, whether based in contract, tort (including negligence), strict liability or otherwise, arising from your use of any of the service or any products procured using the service, or for any other claim related in any way to your use of the service or any product, including, but not limited to, any errors or omissions in any content, or any loss or damage of any kind incurred as a result of the use of the service or any content (or product) posted, transmitted, or otherwise made available via the service, even if advised of their possibility. Because some states or jurisdictions do not allow the exclusion or the limitation of liability for consequential or incidental damages, in such states or jurisdictions, our liability shall be limited to the maximum extent permitted by law.

You understand and agree that no singular individual, group of individuals or entity in any form whatsoever is responsible or liable in any manner for any content generated on, for, or as a result of the existence of this site, since this is a community generated site. You understand and agree that as this is a community generated site, and as a result of this, there is no good way to control what users and contributors post on or through the sites and drfarrahcancercenter.com cannot be responsible for any offensive, inappropriate, obscene, unlawful, infringing or otherwise objectionable or even illegal user generated content you may encounter on the sites or, in connection with your use of the sites.

You understand and agree with the following statement made on behalf of drfarrahcancercenter.com, “We, on behalf of our directors, officers, employees, agents, suppliers, licensors, contributors and service providers, exclude and disclaim liability for any losses and expenses of whatever nature and howsoever arising including, without limitation, any direct, indirect, general, special, punitive, incidental or consequential damages; loss of use: loss of data; loss caused by a virus: loss of income or profit: loss of or damage to property: loss of life: claims of third parties: or other losses of any kind or character, or the inability to use, the site or the content even if we have been advised of the possibility of such damages or losses, arising out of or in connection with the use of this site or any web site with which it is linked.”

 

SECTION 11 – INDEMNIFICATION

You agree to indemnify, defend and hold harmless drfarrahcancercenter.com and our parent, subsidiaries, affiliates, partners, officers, directors, agents, contractors, licensors, service providers, subcontractors, suppliers, interns and employees, harmless from any claim or demand, including reasonable attorneys’ fees, made by any third-party due to or arising out of your breach of these Terms of Use or the documents they incorporate by reference, or your violation of any law or the rights of a third-party.

 

SECTION 12 – SEVERABILITY

In the event that any provision of these Terms of Use is determined to be unlawful, void or unenforceable, such provision shall nonetheless be enforceable to the fullest extent permitted by applicable law, and the unenforceable portion shall be deemed to be severed from these Terms of Use, such determination shall not affect the validity and enforceability of any other remaining provisions.

 

SECTION 13 – TERMINATION

The obligations and liabilities of the parties incurred prior to the termination date shall survive the termination of this agreement for all purposes.

These Terms of Use are effective unless and until terminated by us. You may terminate use of the drfarrahcancercenter.com site, but this Terms of Use shall survive in perpetuity.

If in our sole judgment you fail, or we suspect that you have failed, to comply with any term or provision of these Terms of Use, we also may terminate this agreement at any time without notice and you will remain liable for all amounts due up to and including the date of termination; and/or accordingly may deny you access to our Services (or any part thereof).

 

SECTION 14 – ENTIRE AGREEMENT

The failure of us to exercise or enforce any right or provision of these Terms of Use shall not constitute a waiver of such right or provision.

These Terms of Use and any policies or operating rules posted by us on this site or in respect to The Service constitutes the entire agreement and understanding between you and us and govern your use of the Service, superseding any prior or contemporaneous agreements, communications and proposals, whether oral or written, between you and us (including, but not limited to, any prior versions of the Terms of Use).

Any ambiguities in the interpretation of these Terms of Use shall not be construed against the drafting party.

 

SECTION 15 – GOVERNING LAW

These Terms of Use and any separate agreements whereby we provide you Services shall be governed by and construed in accordance with the laws of the Republic of Panama.

 

SECTION 16 – CHANGES TO TERMS OF USE

You can review the most current version of the Terms of Use at any time at this page.

We reserve the right, at our sole discretion, to update, change or replace any part of these Terms of Use by posting updates and changes to our website. It is your responsibility to check our website periodically for changes. Your continued use of or access to our website or the Service following the posting of any changes to these Terms of Use constitutes acceptance of those changes.

 

SECTION 17 – CONTACT INFORMATION

Questions about the Terms of Use should be sent to us at staff@drfarrahcancercenter.com

Upon agreeing to these terms and conditions, you gain access to the drfarrahcancercenter.com website and assume total responsibility for any and all actions undertaken by you as a result of your access to the drfarrahcancercenter.com website. You agree and understand that the terms of this agreement shall be binding upon you, your respective heirs, successors, assigns and legal representatives. You understand and agree that all provisions of this Terms of Use agreement that by their nature should survive termination shall survive termination, including, without limitation, ownership provisions, warranty disclaimers, indemnity, licensing in perpetuity and limitations of liability.