Opinion

A Tyee Series

Do You Really Need that Medical Test?

Today begins a series on hidden risks of medical screening, and how its benefits can be oversold.

By Alan Cassels, 20 Jun 2011, TheTyee.ca

Alan Cassels

Health researcher Alan Cassels: When screening leads to 'overdiagnosis.'

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Also in this series:
What You Should Know about Medical Screening

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If you feel like you have something wrong with you, don't delay, go to your doctor and get it checked out.

But if you are healthy and otherwise feeling fine, should you go to your doctor and ask for tests to see if your body is harbouring some kind of disease or another? Everywhere you turn it seems there is someone or some group urging you to you to get tested for something to stay healthy.

Last week, for example, was Men's Health Week, whose aims include prodding men into seeing their doctors to get that check-up and the tests that almost inevitably result.

But it's important to realize that whether it's a cholesterol test, a check of your bone density or a probe of your prostate, the modern medical testing juggernaut wants to "screen" you for disease not just to protect you but because it gives doctors lots of business, and puts dollars in the pockets of big pharmaceutical corporations.

Still, how could that be a problem, you might ask. After all, you never know if Alzheimer's disease, bipolar disorder or low testosterone is lurking around the corner, so it's better to be safe than sorry, right?

Wrong. Or should I say, "mostly wrong." There are a few reasonable instances where screening entire populations of healthy people to find diseases before they can cause harm makes sense. The problem is that most of us don't know that much of the routine screening of your blood, your bones or your organs for disease are great for creating busywork for you and your doctor, but are often little more than exercises in futility in healthy people.

And they can also be deadly. Americans are world leaders in hunting down disease, and get scanned by high tech CT scanners about 70 million times per year. Sounds good right? Not if you consider that about a million children per year have unnecessary CT scans and about 29,000 cancers per year in the U.S. are actually linked to the overenthusiastic use of CT scans.

Similarly, what if other high-tech disease-hunting expeditions end up leading us into fatal quicksand?

Those concerns have prompted me to search out the worst examples of medical screening, and I'll be sharing those in articles to come.

'Get It Checked!'

Q&A WITH ALAN CASSELS

What drives your focus on medical screening?

"Lots of books have been written on screening. Hardly anyone has read them. I'm trying to make it easier to understand that much of what we do in the way of screening apparently healthy people is harmful, not beneficial."

Why would any doctor recommend a test that's not needed?

"Most testing is done with good intentions, but based on one axiom: Test Early and Test Often. The TETO principle is never sufficiently challenged by the medical orthodoxy. And it should be. Much of what will be discovered will be benign, but lead to other tests, some invasive. The patient can become obsessed and have unnecessary anxiety. For very few medical screening procedures is there scientific proof of their benefit."

Do you worry someone might avoid screening that would save his or her life?

"I'm not saying do it or don't do it. I'm saying do it with your eyes open. And it depends on the test. It's probably a good idea, for example, for a woman to have a pap smear."

Is there a screening test you won't get, despite pressure to do so?

"I would never undergo a cholesterol test. I know what would follow. The findings would be either normal or high. If high, the doctor would want to give me a statin. And I know they don't much help people who have never had a heart attack. And there are risks associated with using a statin. And that most people who have heart attacks have normal cholesterol."

What was your approach to researching this issue?

"I started by looking at the marketing. Who is pushing what kind of screening? So then I look at what does the science say? What do the experts say? And that's where the story is, the gap between the marketing and the science.

"I've spent 15 years looking at the pharmaceutical industry and have written two books on the marketing of illness. In this case I'm focusing just on the screening aspect. That's a big gateway into a lot of medicalization of normal human health."

My bottom line is this: If you are willingly exposing yourself to a medical screen, you need to do so with your eyes wide open.

This series is intended to help open your eyes to the results-based data about various forms of screening, and their potential risks as well as the rewards.

That's the sort of context you'd probably want if, for example, you were a guy who, heeding the call of Men's Health Week, got your hands on a checklist provided by the Men's Health Network based in Washington D.C. Their "Get it Checked! Guide" contains 15 different screening exams men should be getting, while asserting that "regular checkups and age-appropriate screenings can improve your health and extend your life."

This is a refrain on the Test Early Test Often gestalt of our times. But is it really as simple as getting a rectum probe, a testosterone or PSA reading or an examination of our stools? Are we to accept at face value the implicit message: Get tested now, or die?

Getting screened is a lot easier than changing one's diet or exercise regimen. So when campaigns like Men's Health Week knock on our doors, heading off to the doctor is the simplest way to check off the 'do something' category. Compared to hitting the gym, much easier to let your doctor get your bone density checked or see if your testicles and cholesterol levels are in the right place.

Health promotion could mean not only urging fitness or nutrition, but leveling a sharp critique of the unhealthy way of life built into the way we produce food, structure our workplaces, and fail to deal with poverty. But because screening is big business, in the upside-down world of health promotion the easiest way to prevent disease is to arrange to have someone look for it even harder.

Unfortunately, while screening for disease seems risk free, as new research emerges we are starting to see that such testing can produce a form of collateral damage called "overdiagnosis."

The widening net

To understand what "overdiagnosis" can look like, take the two most thoroughly studied types of medical screening: mammography for breast cancer and PSA testing for prostate cancer. Regardless of the faith we hold in both these screening paradigms, no one refutes one single fact: as new research comes to light, the experts promoting them change their minds on who should be tested, and why.

Despite the indignity of a rectal probe (Note to editor, this is the right time to insert a rectal exam joke, such as: Q: Why did the doctor use two fingers to do my prostate exam? A: He wanted a second opinion. Bad-dum-bum) and the uncertainty of a PSA test, the simple fact remains most men will eventually get prostate cancer in their lifetime, and most will die from something else. About 60 per cent of men in their 60s have some form of prostate cancer, but have a lifetime risk of dying from it of about three per cent.

The point I'm trying to make here is that as screening casts a wider and wider net, it captures more and more patients, many who are perfectly healthy. And that has its own downside, to be explored in more depth as this series unfolds.

If more and more screening means more overdiagnosis, do we discard all screening because it leads to overdiagnosis? Of course not. Striking the right balance is the challenge we face in an age of rising medical costs and more and more screening procedures coming on line.

As I said earlier, if you are willingly exposing yourself to a medical screen, you need to do so with your eyes wide open. I'm looking forward to continuing this discussion in the coming weeks. [Tyee]

Alan Cassels is a drug policy researcher at the University of Victoria and is co-author of Selling Sickness. This and more articles in this series to come are drawn from his forthcoming book The ABCs of Medical Screening: Looking for Sickness in 26 Wrong Places.

17 Comments:

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  • Perry

    48 weeks ago

    Universal health care is a myth

    Great to see more of Alan Cassels' important perspective on health care. One issue that arises from this constant pressure to be tested is the anxiety it causes for those who have no family doctor and cannot access the medical system. For those people, something like 5 million Canadians without a doctor, hearing that many of these tests are not necessary is a welcome message.

    It really irks me when I hear media doctors like Dr. Art Hister, and other medical reporters exhort their listeners to go see their doctor. People who do have a doctor don't need to be told that, and those who don't have a doctor and cannot access one through a drop-in clinic, for example, are just made more anxious by that constant message.

    One thing that confuses me in this article is Cassels' comments that the TETO principle is designed to give doctors lots of business. With 5 million people without a family doctor, it seems to me that doctors are not lacking business, but just the opposite, patients are lacking doctors. In some towns there are no doctors taking new patients so I don't see how the call for more testing gives doctors more business when most are already too busy and turning away prospective business.

    Doctors are now in a position to pick and choose their patients. I know personally of cases where a doctor simply refused to continue seeing a patient after an initial visit because that patient asked too many questions or wanted to be an active part of their medical care, not just patronized and lectured too. The doctors could do that, refuse to treat people, because they knew there was a long line of people waiting for their chance to access the system.

    And it is a question of accessing the medical system, because if you cannot access a GP then the only recourse is to go to the nearest hospital emergency ward, and as far as I know, you cannot just walk in to an emergency ward and ask for a medical test. In one of those cases I mentioned above, my friend was kicked out of the doctors office after her second visit for questioning the doctor's attempt to prescribe a powerful pharmaceutical. That meant she now had no doctor so her only recourse was to self-medicate. When she later developed a problem with her ear she was hesitant to go to the hospital's emergency ward because it never seemed to reach the level of an emergency. So, she suffered for a year before finally getting desperate enough to go to emergency. Within a few minutes the doctor discovered her ear was seriously blocked with ear wax causing various symptoms. It was removed and almost instantly her symptoms suffering ended. Is that really what emergency wards are intended for, and how much more does that cost the system?

    Our medical system is a disgrace. Universal health care in Canada is a myth.

  • dave0ferg

    48 weeks ago

    Looking forward to rest of series

    Dr Gabor Mate MD (When the Body Says NO) makes a convincing case that stress is a very important factor in the progress of cancer.

    Scenario 1: I go to the doc for prostate exam; oops something funny up there; need more tests immediately. My stress level goes up. Ten weeks later, get more tests; something funny not so funny now; need chemo, radiation and surgery immediately. My stress level goes way up. Ten weeks later get nuked, zapped and cut; immune system trashed; stress goes over top. I die; stress zero.

    Scenario 2: Don’t get test; no sweat. Cancer muddles along slowly for 31 years when I get shot by a jealous husband at age of 99 years. No sweat; no birthday card from King Billy.

    Looking forward to rest of series.

  • b-anonymous

    48 weeks ago

    Sometimes testing works and saves lives

    I get your point, and I'm sure you will get a lot of positive comments, HOWEVER...
    My wife (now in her young 50s) recently went for her regular every-two-year mammography scan and they discovered breast cancer. The medical system kicked into high gear and we're now very optimistic that she will be cured. BC has the highest survival rate for cancer in the world. Part of this is due to a great breast cancer screening program. If you test positive, you get a biopsy. It's painful, yes, but if it turns out to be cancer, and if your life is saved, or even extended by 5 - 20 years, you will thank your lucky stars that you live in BC and you took advantage of the free breast cancer screening service.
    I'm just afraid that many of the comments elicited by this article will somehow denigrate the system. I'm here to say that the system works. Medical screening saved my wife's life. OK? That's pretty huge as far as I'm concerned. Not to mention her.

  • b-anonymous

    48 weeks ago

    Correction to comment above

    When I said "BC has the highest survival rate for cancer in the world" I meant breast cancer. Sorry for any confusion.

  • snert

    48 weeks ago

    If you really want to gamble cheap

    just don't bother going to see the doctor at all. I mean that's gotta work for some of us, right?

  • Perry

    48 weeks ago

    build more fences

    b-anonymous, I'm glad your wife is ok and the system worked for her, but the point of my first comment was that the system does not work for everyone, millions in fact. What do you want them to do, just remain silent and not criticize or expose the failures in the current system? They want access to health care just like your wife, but can't get it.

    snert, it is only a gamble if a person has the option to go to a doctor and doesn't. Millions across Canada do not have that option. In one small B.C. town of 35,000 there are no doctors taking new patients, there is no walk-in clinic, and around 3,000 people have no doctor. I'm sure that's a common situation across the province and country.

    So what are people to do who cannot access our supposedly great medical system that only works for some people? Is it really a great system when it denies so many people basic care, forcing them to wait until their condition worsens to a true emergency? Wouldn't it be far cheaper to build fences at the top of cliffs instead of hospitals at the bottom of them?

  • Skywalker

    48 weeks ago

    One problem

    Sometimes the test are repeated three, four times by different doctors. No doctor seems to be able to rely or access the tests prescribed by another. The repetition costs and is wasteful. In the computer age there is no reason the information is not accessible. I have also discovered that most doctors are so busy they really have no time to listen to the patient. You go in with a simple query and before you know it they have you down for some serious tests to determine everything except what you stopped in to see them about. This is needless bleeding of the system.

    Doctors are paid by the quantity not the quality and that is backwards.

  • snert

    48 weeks ago

    Perry

    Quote:
    it is only a gamble if a person has the option to go to a doctor and doesn't. Millions across Canada do not have that option. In one small B.C. town of 35,000 there are no doctors taking new patients, there is no walk-in clinic, and around 3,000 people have no doctor. I'm sure that's a common situation across the province and country.

    Seems to me that's a different problem altogether which may or may not be mitigated by reducing the number of tests.

  • snert

    48 weeks ago

    Skywalker

    Quote:
    Sometimes the test are repeated three, four times by different doctors. No doctor seems to be able to rely or access the tests prescribed by another. The repetition costs and is wasteful.

    Without going into great detail personal experience tells me otherwise. With the advent electronic patient records coordination is really very simple as long as you request it.

    The following link even allows individuals to get certain medical test results as quickly as the doctor requesting them does. You may even read them before he/she does.

    https://secure.myehealth.ca/Login.aspx

    Part of the problem with tests is that people can become intimidated by their doctors and may not wish to challenge them.

    The one thing that really scares me about the changes that have been made is the reliance on hospitalists for treatment of longer term patients. There is huge potential for a lack of continuity in treatment.

    One thing that really pisses me of is that you can no longer be admitted to hospital by your GP, at least in Fraser Health. It's either admission by a specialist or self admission via emergency department. This just leads to swamping emergency services.

  • Skywalker

    48 weeks ago

    Why should you have to request it?

    You have access to Medicare and hold a card. If a doctor wants and needs your history to treat you, they should be able to access the information. They ask you all kinds of questions about your history when you are admitted but never ask if you mind them accessing your file. That tells me they don't have access and couldn't get it even if you gave permission. The frequent tests by different doctors was in the same hospital region in facilities not 30 miles apart.

  • snert

    48 weeks ago

    Skywalker

    Depending on the time frame test results may not always be available.

    There is some patient responsibility to make sure each doctor is fully informed. This can be nothing more than a simple reminder or it can take the form a direct challenge. "I or he/she just had that test. What gives?"

    Nothing is perfect and things can certainly be a lot better, IMHO Improvements are being made however. I've had occasion to see some of them happen over the last couple of years.

  • OwlRol

    48 weeks ago

    Family doctors, private clinics

    My favourite family doctor went back home where the practice paid an equivalent to here but the system provided a much lower stress level in practice.

    Got a new family doctor. Pointed out the inconclusive results of some screening tests. Thank you.

    Had an emergency situation. Doctor's appointment not available for two weeks. Went to clinic. Misdiagnosis and useless prescription. Desperate. Two days later lucky spot on specialist appt. list. Treated and remission.

    Incident a year later. Resolved. Now very familiar with symptoms and treatment.

    Went for checkup. No problem? Four days later, possibly sparked by checkup procedure, full flare up.

    In those four days I travelled out of province. Requested prescription refill. Can't do between provinces. Advised to go to clinic.

    Waited at clinic for several hours. Showed doctor the prescription. Wouldn't touch it (nothing to do with opiates, pain killers, stimulants or other mood affecting drugs, this is very specific). Sent to emergency.

    Waited for several hours. Informed doctor of the condition and required prescription. Supposedly had to be tested. Waited more hours. Equipment failure.

    Eventually doctor trusted me on my own judgement for, what was roughly a once a year, serious, repeated condition. I was the medical expert now.

    Got my prescription after wasting nearly 24 hours. Problem solved, for now.

    Told by specialist that no one knows what causes or triggers this condition.

    This ongoing experience showed me that the private medical clinics are pretty much useless for anything but colds, cuts and minor ailments. Fear of litigation makes them send anything else to be treated, after long waits, in emergency.

    Moved. Looking for a new, local, family doctor. No luck yet. Meanwhile, tests, ha, ha.

  • SCR

    48 weeks ago

    Tests provided by private labs

    This link connects to Private Labs : A Cautionary Tale by Ross Sutherland.

    http://www.canadian-nurse.com/index.php?option=com_content&view=article&id=469%3Aprivate-labs-a-cautionary-tale&catid=10%3Athe-last-word&Itemid=42&lang=en

    His article covers how private labs have lobbied against publicly funded labs in hospitals and have now corraled 80% of the diagnostic market. This shift has profited those providers, $4 billion a year, but has it been a less expensive alternative ?

    The Conference Board of Canada is plumping these for-profit labs as the "alternative" to public funded medicare. However CBOC has ignored significant evidence contradicting their assumptions. (Again)

    Sutherland's well written and brief synopsis is well worth following up.

  • jwstewart

    48 weeks ago

    Questions

    If this "research" is so valuable why isn't in publish in peer reviewed medical journals?

    In fact there is a debate occuring right now about prostate/colon screening and what is the best screening protocol, no mention of it here.

    Given that this "research" results in books for sale at a profit, shouldn't this be in the book review section?

  • snert

    48 weeks ago

    SCR

    If it ain't broke don't fix it. The private labs are one of the few things that work well in our medical system.

  • Chatterbox

    48 weeks ago

    Assumptions - post hoc ergo propter hoc

    We assume a lot about health care, including that every diagnosis of and treatment for cancer--if one lives--was lifesaving. Similarly, if one dies during aggressive chemo or radiation therapy, no one questions whether or not the cancer was the cause of death.

    Both assumptions represent a well-known logical fallacy of correlation-not-causation, also known in short as a post hoc error.

    The fact is that cancer, which describes any unregulated cell growth, is not necessarily or even often life threatening. Nearly everyone has experienced that odd but passing growth, bump, or discolouration, and even clinically diagnosed cancers may often be benign. As Alan Cassels so correctly points out, a malignant cancer may progress so slowly that something else kills the patient first. There are also now genetic tests that claim to spot predispositions to cancer, so now you don't even need to be diagnosed with a disease to become convinced you need treatment.

    Now, I am not preaching willful neglect of one's body, but in fact true and valid caution.

    Too many glibly say what's the harm, anyway? What's going to happen from a simply visit to my doctor, a clinic, or a hospital? They are there to help, right? It is in fact their hypocratic oath.

    Tens of thousands of Canadians die under the care of their doctor every year, and not from the disease for which they sought that care.

    They have a name for this grim statistic: iatrogenic mortality. The prevalence of iatrogenic mortality is also on the increase, right alongside our striking medical advances. The power to save a life is also the power to kill one, nature's cruel balance.

    Try not to be a victim, and maybe this series will provide a real cure.

    - A Masters Graduate in Health Care Administration and Epidemiology

  • snert

    48 weeks ago

    Chatterbox

    Quote:
    As Alan Cassels so correctly points out, a malignant cancer may progress so slowly that something else kills the patient first.

    To start with you need a damned test to determine if that is going to be the case.

    You're comparing apples and pomegranates or detection and treatment.

    Sooner or later blood work will be able to detect all diseases either through genetics or blood chemistry. When that day arrives the testing should be available to everyone and done on a regular basis. Once the system is in place it need not be prohibitively expensive unless you live in the US, of course.

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