When your doctor recommends a new medication, you know to ask about its risks (side effects) and benefits. But did you know that you should also ask about the risks and benefits of no treatment? In other words, what would happen if you just let the condition or disease run its course?
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What Is Natural History?
"Natural history" is the course a condition or disease will take if you don't treat it. Many symptoms and diseases get better without treatment. That is, they are "self-limited." For example, the common cold usually gets better on its own with time. Even so, treating its symptoms — sore throat, fever, congestion and that miserable feeling — can make you feel better even if it won't make the infection go away any sooner.
Natural history varies for most diseases. The natural history of prostate cancer, for example, depends entirely on how aggressive and advanced the tumor is when it's diagnosed. A tiny, non-invasive tumor in an elderly man may not need any treatment, because he is much more likely to die of something other than prostate cancer. But advanced or aggressive prostate cancer may require aggressive treatment, especially in a middle-aged man, to prevent his premature death.
Other diseases may have a grim natural history that treatment won't change. For example, most people diagnosed with pancreatic cancer die within a year. The natural history of amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease) is such that most people with the condition die of complications within three to four years. Knowing this can help when considering risky or experimental treatments. The risks might be acceptable given the risks of non-treatment. Or the dismal prognosis for these conditions may shift the focus away from treatment toward comfort measures.
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Why Natural History Gets Overlooked
Doctors and patients may overlook natural history for several reasons:
- They may assume that a particular condition always needs treatment. For example, most people think that cancer always requires treatment. Yet, there are situations in which people with small, non-aggressive cancers (including certain prostate or breast cancers) are better off without treatment.
- They overestimate a treatment's benefit. Pneumonia that is caused by bacteria can be cured by antibiotics. In fact, the disease may be fatal without them. But people are often given antibiotics for suspected viral infections. In such cases, the antibiotics may be given credit for a condition that was going to get better with no treatment at all.
- They underestimate treatment risk. Taking vitamin C in the midst of a cold seems harmless enough. But taking antibiotics for a cold — which aren't needed — can be risky. Ask anyone who has suffered a severe allergic reaction to them or developed a medication-resistant bacterial infection because of overuse of antibiotics.
- Direct-to-consumer drug ads (prescription and over-the-counter) may contribute to the idea that most problems can be fixed with a pill or other treatment. It's rare that a print, television or Web-based advertisement will mention the option and potential benefits of no treatment.
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Common Conditions That Don't Need Treatment
Here are some common examples:
- The common cold - There is no highly effective treatment for the common cold virus. Fortunately, a cold is gone in a few days. And options to treat symptoms make them easier to endure.
- Otitis media and sinus infections - Inner ear infections and sinusitis are often treated with antibiotics. However, a number of studies suggest that most people with these conditions improve without them. Decongestants or sinus irrigation may provide relief, however.
- Headache - Most headaches run their course and do not resolve any faster with treatment. (Migraine headaches, which can be prevented or shortened by treatment, are an exception.) Pain relievers can make the condition more bearable, but non-treatment is a reasonable option for many headaches.
- Back pain - The most common types of back pain, such as muscle spasm and strain, do not require specific treatment, such as surgery or cortisone shots. Most won't get better any faster with treatment. Supportive care, including pain relievers and heat, may make the discomfort more bearable, but, in the short run, doing nothing is a valid option to consider. (Persistent pain, or pain with "red flag" symptoms, such as fever or leg wekness, should not be ignored. Seek prompt medical evaluation.
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The Bottom Line
The knowledge that a disease or symptom may improve without treatment is helpful in many situations and many be underappreciated. Sometimes the best medical care a doctor can offer is to get out of the way and let nature take its course.
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Robert H. Shmerling, M.D. is associate physician at Beth Israel Deaconess Medical Center and associate professor at Harvard Medical School. He has been a practicing rheumatologist for over 20 years at Beth Israel Deaconess Medical Center. He is an active teacher in the Internal Medicine Residency Program, serving as the Robinson Firm Chief. He is also a teacher in the Rheumatology Fellowship Program.