GETTING THE MOST OUT OF MIDLIFE
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, author of “Overdiagnosed: Making People Sick in the Pursuit of Health.”
“The biggest problem with over-diagnosis is it triggers over-treatment,” adds Welch, a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice. “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 scan also captures a portion of the lungs, revealing tiny nodules that could be from scar tissue, an infection — or possibly an early-stage tumor. The nodules are probably harmless, but the scan raises enough concern that the physician recommends a follow-up chest CT — the patient’s second dose of radiation 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 [ionizing radiation] 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.
Not to mention the patient’s new fear that he or she has cancer.
Reasons to test
Experts acknowledge that the fear of being sued can sometimes influence a doctor’s decision to order more tests. A patient may come in complaining of chest pain, and the doctor may be fairly certain it’s not heart-related. But then she 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 in Boston.
But in other cases, such as with cholesterol checks, pressure from patients can prompt doctors to order tests they might otherwise skip, Cannon 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, he says.
Yet another reason for excessive screening: It’s easy.
Consider the PSA test to screen for prostate cancer. Once considered routine, the American Cancer Society no longer makes a blanket recommendation that men get the test; the U.S. Preventive Services Task Force says there’s no good evidence either for or against the test for men younger than 75, and it advises men 75 and older to skip it. But patients may not realize this.
“It would take a lot longer for the doctor 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 because there’s going to be many more false positives than true positives,” Braunstein says. “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 measurable 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,” he says.
Hadler points to a Finnish study that 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 attacks and strokes doubled in workers who were not laid off but who were exposed to the stress of major downsizing (defined as layoffs of 18% or more), researchers reported in 2004.
Meanwhile, the definitions of what it means to be “sick” have shifted. Over the last two decades, the threshold for treating 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,” Welch says. For instance, the ceiling for what’s considered a healthy 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, the upper limit of what’s considered “normal” blood pressure shifted from 140/90 millimeters of mercury to 120/80 mmHg — 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,” Welch says. “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. He also 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.
But tests can still be valuable, he says. He cites 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.
In this model, the physician is the expert on the medical options and the likely outcome of those options, based on scientific evidence. But the patient is the expert on his or her own perceptions and values, says Dr. Michael Barry, professor of medicine at Harvard Medical School and chief of general medicine at Massachusetts General Hospital in Boston.
“A clinician and patient would work together to decide on what the right medical decision is,” Barry says. “This is becoming more and more recognized as the right way to build a preventive healthcare program.”