How much medical testing is too much?
Midlife brings with it a host of health concerns — the risk of heart disease, high cholesterol, high blood pressure, diabetes and osteoporosis, to name a few. So as people reach middle age, they’re bombarded with an overwhelming number of recommendations for screenings, tests and to-be-on-the-safe-side preventive measures.
But patients and doctors alike are reconsidering screenings once thought to be must-haves for everyone — even mammograms and prostate cancer screenings.
The American Cancer Society recommends that women begin yearly mammogram screenings at age 40, but the U.S. Preventive Services Task Force doesn’t believe regular screening is necessary for women younger than 50.
Both the organization and the task force are more nuanced in their approach to prostate cancer screenings. Until 2010, the organization recommended that all men begin screening for prostate cancer at age 50; it now recommends that most men simply talk to their doctors about screening at age 50, or at 45 45 for men at higher risk. The task force says there’s no good evidence for or against regular screenings for men younger than 75 and that men 75 and older should skip it.
Mammography costs the U.S. about $5 billion annually, and the bill for prostate cancer screening is estimated to be $3 billion a year.
Other common tests have their own pros and cons: colonoscopies, CT scans, cardiac stress tests, thyroid tests, bone density tests, calcium scores and carotid artery ultrasounds
When it comes to screening and early intervention, we apparently can have too much of a good thing.
“As our technology gets more sensitive and is able to see more things, and as we test more often and we change the rules of what’s abnormal, we now recognize that we all harbor abnormalities, and our tests are increasingly able to find them,” says Dr. H. Gilbert Welch, a physician and professor at Dartmouth Medical School in Hanover, N.H., and author of “Overdiagnosed: Making People Sick in the Pursuit of Health.”
“The biggest problem with over-diagnosis is it triggers over-treatment,” adds Welch. “It’s a side effect of our relentless desire to find disease early.”
Take, for instance, a patient whose physician recommends a CT scan of the coronary arteries to screen for heart disease. The X-ray also captures a picture of the lungs, which reveals tiny nodules in the chest from scar tissue or perhaps an old infection. The nodules are probably harmless, but the scan raises enough concern that the physician recommends a follow-up CT scan — the patient’s second dose of X-rays in six months.
Once physicians start down the pathway of looking for disease, “you get a lot of unnecessary X-rays and imaging, with a lot of exposure to X-rays that probably is more dangerous than any information that you’re going to get from those X-rays,” says Dr. Glenn Braunstein, an endocrinologist and chairman of the department of medicine at Cedars-Sinai Medical Center in Los Angeles.
And, of course, as a backdrop is the patient’s new fear that he or she has cancer.
Reasons to test
Experts acknowledge that the fear of being sued by patients can sometimes influence decisions. For instance, a person may come in complaining of chest pain, and a doctor may be fairly certain it’s not heart-related. But then the doctor may think, “ ‘Well, there’s a 0.1% chance that it is, and what if I didn’t do the stress test?’ ” says Dr. Christopher Cannon, a cardiologist at Brigham and Women’s Hospital.
But in other cases, such as with cholesterol checks, the external pressure from the patients themselves is more likely to sway doctors into a test that they might not otherwise do, he says. In many cases, “the tension is more the demand of the patient, of ‘I want to know, do I or don’t I’ ” have a certain condition, says Cannon.
Yet another reason for excessive screening: It’s easy.
“It would take a lot longer for the doctor to spend the 15 minutes to go over the data for why screening with a PSA in his age group is not a very effective approach for picking up prostate cancer or because there’s going to be many more false positives than true positives,” says Braunstein. “That’s a 15-minute discussion, whereas it’s one minute to write the order for a PSA. And if you don’t write the order for a PSA and that’s what the patient wants, then you’ve got an unhappy patient.”
Dr. Nortin Hadler, a rheumatologist at the University of North Carolina and author of “Worried Sick: A Prescription for Health in an Overtreated America,” estimates that only about 20% of our health and life expectancy is based on risk factors for disease; the other 80% can be boiled down to quality of life, which Hadler sums up with two questions: “Are you happy in your socioeconomic status, and do you like your job? It’s very powerful.”
Hadler points to a 2004 study in Finland in which researchers examined health effects on municipal workers during a severe recession that took place from 1991 to 1996. The number of deaths from cardiovascular events such as heart attack and stroke doubled in populations of workers who were not laid off but who were exposed to the stress of major downsizing (defined as layoffs of 18% or more).
Defining ‘sick’
Meanwhile, the definitions of what it means to be “sick” have shifted. Over the last two decades, the threshold at which we treat a number of conditions, including high blood pressure, high cholesterol, diabetes and osteoporosis, has been lowered.
“We’ve always changed it in a consistent direction to label more people as abnormal,” says Welch. For instance, the ceiling for total cholesterol has dropped from 300 to 240 to greater than 200. The change from 240 to more than 200 instantly created 42 million “new cases” of high cholesterol, Welch points out. Likewise, what’s considered “normal” blood pressure shifted from numbers below 140 over 90 to numbers below 120 over 80 — a change that affected millions of Americans.
“As we get down into people with milder and milder changes in these numbers, we’re dealing with people with extremely low risk of developing the feared outcome,” says Welch. “That means we’re treating a lot of people who are never destined to develop the problem at hand. But they can be harmed by treatment.”
Still, other experts say it is important to not make blanket generalizations for or against screening.
Cannon acknowledges that if a patient is at extremely low risk for heart disease, that person may not be helped by treatments aimed at lowering his or her cholesterol. But he emphasizes that a single total cholesterol number should never be a determining factor for treatment and that family history and other risk factors should be taken into account.
He also points to recent studies, including an April study in the Journal of the American College of Cardiology, showing that calcium scans to detect cholesterol buildup in the arteries have been very effective at managing heart disease.
A joint effort
Rather than relying on over-generalized guidelines, which can be contradictory, doctors are increasingly erring on the side of “shared decision making” between the patient and physician.
“Instead of the older paternalistic model of clinicians or an expert panel recommending what someone should and shouldn’t have, this would be a process where using scientific evidence, a clinician and patient would work together to decide on what the right medical decision is,” says Dr. Michael Barry, professor of medicine at Harvard Medical School and chief of general medicine at Massachusetts General Hospital.
In this model, the physician is the expert on the medical options and the likely outcome of those options. But the patient is the expert on his or her own perceptions and values, he says. “This is becoming more and more recognized as the right way to build a preventive healthcare program.”
READ MORE: Midlife and What to Do About It
