Peace of mind -- but at a price

FIT, tan and significantly younger-looking than his 57 years might suggest, Garret Leahey still worries about the perils of getting older. Is he really as healthy as he thinks? He’s heard the horror stories, especially the guys who eat right, run every day and then have a heart attack during a jog in the park or while playing basketball with their kids. “I know things can change on a dime,” he says flatly.

So two weeks ago, the Los Angeles man decided to do something about it: He got a full-body CT scan. Cost: $800, all out-of-pocket.

Since arriving on the scene just a few years ago, elective CT scans -- essentially powerful, computer-aided X-rays once reserved for sick or high-risk patients -- have exploded in popularity with throngs of worried well who need to know they are OK. The number of CT scans reached 32 million last year, up 6 million since 1997, with a significant chunk of that gain coming from elective tests.

“This is fast becoming an integral part of people’s annual medical regimen,” says Bruce Friedman, president of Heart Check America in Los Angeles, where Leahey underwent his procedure.

Still, many doctors and medical associations balk at the trend. The Food and Drug Administration, the American Cancer Society and the American College of Radiology recommend against the exams for patients without symptoms. Many physicians say self-referred screenings aren’t worth the money, especially because most insurance companies won’t pay for screenings on a preventive basis.

Many also fear that elective scan results are riddled with false positives that lead to needless anxiety and possibly dangerous follow-up procedures.

Scan proponents often paint critics as little more than scaremongers, pointing out that the scans can detect problems other exams may miss. But a small and growing body of research seems to support some of the critics’ concerns.

Recent studies have shown that although more than a third of the people who get scanned find something abnormal enough to require a follow-up, as few as 1% ultimately discover anything meaningful. Other research validates different fears, such as high radiation exposure that in some cases can reach 250 times the level of a typical chest X-ray. Several states, including Texas and Pennsylvania, have passed laws banning patients from getting scans without a doctor’s referral.

“People see this like it’s ‘Star Trek,’ where we can take a swipe of a wand and find what ails them -- then another wand and fix them,” says Dr. Robert Smith, director of cancer screening at the American Cancer Society. “That isn’t the case. We are increasingly seeing the benefits of these tests don’t warrant the costs.”

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Scan centers on the rise

Even in tough economic times, the trend shows no sign of slowing.

Although some centers have encountered financial problems -- with some even closing their doors -- experts say that’s primarily because they expanded too quickly. Overall, the number of centers has continued to increase.

Southern California has an estimated 30% of all scan centers in the country. Radio commercials and print ads -- “These 15 minutes could save your life” -- abound. It’s also hard to ignore the sometimes-startling results.

Beth Henson, 56, of Camarillo, got her first full-body scan last summer. Since turning 50, she has tried a new test every year, including a bone density exam and an AIDS test. All turned out fine. But in her CT scan, doctors noticed that one of her ovaries was the size of a grapefruit, something her own doctor later said was impossible to detect with a typical pelvic exam. Henson had surgery, which showed that the growth was precancerous. She had her ovary removed and now says she is fine.

“All I can say is that this was worth its weight in gold for me. I believe it saved my life,” says Henson, who has recommended the test to many of her friends.

Elective CT scans initially were limited to the heart. But a major study, published in 1999 in the prestigious British journal Lancet, showed the positive benefits of scanning for early lung cancer -- a major killer. That, and public endorsements by celebrities such as Oprah Winfrey and Isiah Thomas, further ignited the industry. Soon companies began offering scans for more areas of the body including tests such as virtual colonoscopies and brain scans.

The scanning centers themselves fall under few regulatory guidelines. The FDA has approved the use of CT scanners for diagnostic use, but not for screening purposes. That means companies are using the machines “off label.” As long as they don’t include the names of specific machines in advertising, even the most erroneous claims are hard to stop. Still, proponents contend CT screens are going through the same struggles and criticism other screening technology had to endure before receiving broader approval.

Moreover, they say, the science behind other more accepted types of screening, such as mammograms and PSA tests for prostate cancer, remains controversial. Many often have high rates of false positives. Plus, certain tests notoriously fail to catch large percentages of people who are at high risk for disease. A high cholesterol score, for instance, clearly indicates a higher risk for heart attacks, but half of all people who have a heart attack don’t have high cholesterol. Isn’t it better to be safe than sorry, they ask.

“We shouldn’t wait 20 years to help those that can benefit from this if we know now this can save lives,” says Dr. Matthew Budoff, assistant professor of radiology at Harbor-UCLA Medical Center.

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A doctor’s obligation

Others see the issue as a bit more complex. After all, how does a doctor proceed with a terrified patient whose screening results have shown an abnormality? Dr. Douglas Souvignier, chairman of internal medicine at Camino Medical Group in Sunnyvale, says doctors have an ethical and perhaps legal responsibility to make sure nothing is wrong, even if they strongly believe there isn’t. That can sometimes involve invasive procedures, including potentially dangerous biopsies.

Souvignier recently had a patient who was “extremely upset” about a scan that showed a small spot on her kidney. After doing an ultrasound, he discovered it was just a benign cyst. It’s a scenario that happens several times a year in his department, which he estimates costs insurance companies thousands of dollars in unneeded costs. “These exams open up a can of worms, and almost always it’s for nothing,” he says.

Last year, researchers at UC San Diego questioned 1,192 patients, ages 22 to 85, who had undergone a scan. Nearly 46% of those studied had an abnormality (which is typical, doctors say) and more than a third were told to go for a follow-up with their own doctor. In one out of 10 cases, patients had a mass that could have been either a cancer or another life-threatening illness such as an aortic aneurysm. In the end, however, just 1% of them were believed to have a major life-threatening condition. A separate study on CT lung cancer screenings released by Johns Hopkins University in January, also found more costs than benefits arose from elective screens.

In July, a study by researchers at Stanford University Medical Center published in the Journal of Radiology called for increased regulations for scanning centers. One major concern: The study found radiation from CT scans could be as high as 2 rads, or 250 times that of a normal chest X-ray and 30 times more than a mammogram. While the chance of getting cancer from the radiation is relatively low, doctors say it’s possible. Radiation exposure is cumulative over a person’s lifetime, so the risk is higher for younger patients or those who’ve had many previous X-rays.

“These centers are proliferating very quickly, but most people don’t know or aren’t paying attention to the risks that are involved,” says Dr. Judy Illes, the study’s lead author and a senior researcher at Stanford University Medical Center’s department of radiology.

Still, doubts about certain CT tests, especially those that focus on specific organs rather than the whole body, increasingly fall on a sliding scale. Heart scans, for instance, are gaining more converts particularly if they’re performed with a newer type of CT scan known as EBT, or electron beam tomography. Both machines look alike, but the EBT scan is much faster (an all-important difference when photographing a beating heart) and therefore takes better images and emits less radiation than traditional CT scans.

A recent article in the New England Journal of Medicine suggested that preventive EBT scans might be beneficial for high-risk groups, such as smokers and those with a family history of heart disease.

Preventive lung scans are also moving onto increasingly solid -- though still somewhat shaky -- scientific grounds especially for those at high risk, such as current and former smokers. Several studies, including the 1999 Lancet study and others, have shown that CT scans may be better at finding early tumors than traditional X-rays because they can scan areas up to 10 times smaller than X-rays.

Beyond that, most other CT screening tests remain largely dismissed. Elective virtual colonoscopies and CT brain scans may ultimately prove beneficial, but for now they have relatively little research behind them, radiologists say. And CT images don’t work well on breast tissue or for spotting prostate cancer, so most doctors recommend staying away from scans in those areas. “Beyond [hearts and lungs], the science is extremely sketchy,” says Budoff of Harbor-UCLA.

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More study warranted

Before more doctors endorse CT scans, many are waiting for broader prospective studies that are the gold standard of medical research. Prospective studies, which the National Cancer Institute and the National Institutes for Health are currently performing on lung and heart scans, involve tracking two groups of people -- one that has had a CT scan, another that has not -- to determine who is at risk for certain diseases. But it could be another decade before the studies are complete.

There may be another problem even if those studies do prove CT scanning is ultimately a beneficial screening tool. Although common sense says knowing about a tumor or calcium lining your artery walls will help prevent problems, it’s not clear that’s the case. There is little research, doctors say, that catching something early actually lowers mortality. In other words, screening may be catching sick people earlier, but it may not ultimately save them.

That’s a major reason most doctors still suggest sticking with traditional methods of lowering risk for disease, like quitting smoking and losing weight. “You can never underestimate the value of a healthy lifestyle,” says Smith of the American Cancer Society.

Meanwhile, back in the Los Angeles screening center, Leahey sits in an office waiting to hear his results just 20 minutes after getting off the table. While he won’t know for sure until a radiologist reads the report and mails it to him and his doctor next week, an initial look appears to show he’s almost as clean as a whistle. One problem spot: calcium build-up on two arteries, but it doesn’t look like anything out of the ordinary for a man his age. Overall, the nurse practioner jokes, he’s got the body of a 40-year-old.

“That’s good news,” he says. “It’s exactly what I came here to hear.”