Preventive Care – An ounce of prevention is worth a pound of cure!
Prevention of disease is of primary importance to physicians. Unfortunately, it is usually the lowest priority for patients. “If it ain’t broke, why fix it!” is the mantra of the majority of people in the United States when it comes to getting preventive care. As it turns out, it’s a lot of easier to prevent diseases than to try to right the ship once it has already capsized!
So what preventive care should people get and when should they get it?
I’m glad I asked!
The list below is based on the most up-to-date recommendations from the U.S. Preventive Services Task Force. For any particular preventive screening, they have established its usefulness and graded each on the following scale, which I will be referencing. The web site (link at the bottom of the blog) has graded out preventive care procedures for, literally, hundreds, of possible interventions. I am going to talk about the most important ones for the general person. For people who are at high risk for certain other medical problems, it may well be that it behooves you to get preventive screening for that problem, while the general population would not benefit from it.
So why don’t we screen for everything? I mean, if we can, shouldn’t we? What is the harm of testing everyone for every conceivable medical problem?
Well, my friends, there are many many reasons why this is not done.
1. Cost – We would bankrupt the system if we screened every single person for every disease, including diseases they are highly unlikely to ever even hear about! Sure, there are people who absolutely need to be screened for Sickle Cell Anemia, but if we screened every person regardless of their risk, it would cost us hundreds of millions of dollars.
2. Outright harm – yes indeed. Screening can hurt you! How, you ask, incredulously? If you screen a low risk population, then most of the positive test results will be false positives. if you get a false positive, you will probably need follow-up testing to see if the screening test was real or not. This can lead to dangerous outcomes. I will give you 2 examples. In the past, we used to give “The Executive Physical” which was titled after high-power male executives at large corporations. This overly-complete exam usually included a stress test looking for heart disease. When you do stress tests on people who are neither having symptoms of heart disease, nor have many risk factors, the majority of your positive stress tests end up being false positives. Unfortunately, you cannot ignore a positive stress test (or only ignore it if you want to be sued to the moon when they have their heart attack!), so these people end up being referred for angiograms to see if they have real cardiac blockages. Unfortunately, about 1 in every 200 people who get angiograms have some kind of substantial complication during the exam (i.e. heart rhythm problems, puncture of the arteries or even death). So….we were taking young and healthy executives and we were killing them! Not so good, eh? Another fine example is when the state of Illinois demanded that all people asking for a marriage license get tested for HIV. You can tell that an illinois bureaucrat made that decision, and not a doctor! Again, when you take a low risk population and screen them for a fairly rare disease, most of the positive results are false positives. So what we had was thousands of people coming up with false positive HIV tests; all which required expensive follow-up testing to determine if the original test was accurate. The costs alone were catastrophic, but worse still were the thousands of people who were literally freaking out, waiting for the results of their follow up testing, right before they were supposed to get married. A few suicides later, the state of Illinois stopped the program! As you can see, screening for everything in everyone can end badly!
3. Failure to help – in most cases, screening programs for rare or unusual diseases does not improve the mortality rate from the disease. If it doesn’t grant some sort of survival benefit, there is rarely a reason to screen! This argument is the one that makes the general population angry and upset, since it is hard to understand. It makes “sense” to screen all smokers with a Chest X-ray, looking for early lung cancer, but every study ever done on this program has shown that once we find a cancer on Chest X-ray, it is usually too far advanced to save them, or even help them to live longer.
4. Low Yield – this is another common problem with screening tests that infuriates the public. For example, recently, they determined that Mammographic Screening for women between the ages of 40 and 49 did not make sense. The reason is that Breast Cancer is rare enough in women this age, that you have to do mammograms on tens of thousands of women in order to find enough early cancers to save the life of one woman. The cost was $56,000 per year of life saved, in this age group. For a 5-year survival (i.e. “cured”), this is $255,000 per life saved. Despite the high costs, the public wants mammographic screening to be available to all women of these age groups; partly because Breast Cancer is very exposed in the press and it is the 2nd most common cancer killer in women.
Ok, so let’s talk about the screening that makes most sense, with some basic discussion!
Blood Pressure Screening
I wrote an entire blog on Hypertension, and I welcome you to go back into the archives and read it. The short and snappy answer from the USPSTF (United States Preventive Services Task Force) is that all adults should be screened for high blood pressure at least every other year (if your blood pressure is “normal” on the first screening) or every year if it is borderline. It grants blood pressure screening a GRADE A on the scale noted above. It’s cheap, has no known complications and is saves lives in bucketloads. The screening and treatment of hypertension is amongst the most cost effective preventive measures you can take! Do it. Do it now.
Men, you can skip this one!
Pap Smears are done in order to screen women for Cervical Cancer. It is amongst the best screening programs we have. By this, we mean that it is cheap, saves lives and is relatively safe! The recommendation is that all women have their first Pap Smear done within 3 years of becoming sexually active, or age 21, whichever one comes first. Continued testing should be at least every 3 years as long as the results are negative, until age 65 (Grade A recommendation). Continuing Pap Smears in low risk individuals after age 65 is a GRADE D recommendation. Understand, that the recommendations of the USPSTF are not the same ones as your gynecologist will probably recommend. They are absolute minimum recommendations based on cost/benefit analysis. Most women, especially those who are not in continuing monogamous relationships, should probably get them yearly. There will also always be a change as soon as you have a borderline or positive test; then you are no longer under the auspices of these guidelines!
Prostate Cancer Screening
This is much more controversial. We do screening with the PSA (Prostate Specific Antigen) blood test every year beginning at age 40, and the rectal examination of the Prostate Gland yearly after age 50. However, the data regarding the PSA test is murky at best (Class I) and the Rectal Examination has actually never been proven to save lives at all (Grade C). The problem with the PSA test is that the false positive AND false negative rates are pretty high. Thus, you can have a positive test and probably not have the disease, or you can have a negative test and still have prostate cancer! Positive tests usually end up with prostate biopsies…a very unpleasant test with a small complication rate. The rectal examination is still offered, as there were some studies showing that a combination of PSA testing plus rectal examination seemed to slightly increase the chance of survival. It has also been a part of the exam of all men over the age of 50 for a long time, such that most men expect it and feel that doctors who do not do the test are shirking their duty! I personally suggest getting the PSA test, with the full knowledge that it is imperfect, and allowing the doctor-patient relationship to do the rest when discussing what to do with the results. The Task Force specifically states that patients over the age of 75, or men with a likely lifespan of less than 10 years, should not be screened. In these populations, it is far more likely that they will die of something other than prostate cancer, even if it was discovered, since it is usually a slow growing cancer and many never spread.
Screening for Colon Cancer
This is the one I have a hard time selling to patients, even though it is a slam-dunk! Colon Cancer screening can be done in several ways, but the highest grade is for Colonoscopy (a procedure where a fiber-optic camera is inserted through the rectum and pictures are taken of the entire colon. Yes, you are sedated for the procedure!). The best thing about colonoscopy is that if they find a pre-cancerous “polyp”, they can remove it right there on the spot! It’s both screening and cure, in one fell swoop! Screening colonoscopy for people age 50-75 is Grade A, ages 76-85 is Grade C and older than 85 is Grade D. The first test should be at age 50, and the interval determined by what they find (usually anywhere from 2-10 years depending on the kinds of polyps they might find, or if they find nothing at all!). Colonoscopy is an invasive procedure, so complications occur in 25 people out of every 10,000 (less than 1/3rd of 1%). In the 15 years I have been a practicing, I have seen 1 complication from a screening colonoscopy. Screening should occur at a younger age for people with colon cancer in their family. There are alternatives to colonoscopy, but they are not as good. Hemoccult Testing of the stool (looking for microscopic blood in the stool) has not been shown to improve mortality (i.e. once a cancer is bleeding into your colon, it is usually too late) and is Class I. CT Colonography has fewer risks (6 complications per 10,000 procedures) but you have to have follow up colonoscopy anyway if they find something! And, they find “something” in 16% of all tests! There is also radiation exposure from CT scans; enough to cause an one additional cancer of some type per 1000 people tested. People can also screen themselves with a Barium Enema combined with a Flexible Sigmoidoscopy (a scope passed into the first 60cm of the colon from the rectum). Doesn’t work as well, has a 3.4 in 10,000 complication rate…and you have to proceed to a full colonoscopy if they see something! All in all, you are best off with the colonoscopy. They are working on “Capsule Endoscopy” where you swallow the camera and they take pictures, but the data is not yet sufficient to make a recommendation. However, again, if they see something you will need a colonoscopy anyway!
Screening for Osteoporosis
Screening for low bone density, or “osteoporosis” is done by performing a very low radiation test called a Dexascan. There are ultrasound methods which look at your feet or fingers, but they do not work very well and are probably only good for screening high risk patients. Current guidelines suggest that screening women over the age of 65 is a Grade B recommendation, as finding and treating asymptomatic osteoporosis does save lives (the average lifespan of a woman after her first hip fracture from a fall declines dramatically and is less than 1 year if they can’t fix it due to high surgical risk). The real controversy is whether or not we should scan post-menopausal woman (age 50-ish to 60). Screening in this age group is a Class C recommendation. I recommend screening this lower age group in women who are at high risk (i.e. family history of osteoporosis or if they fit the “profile” for a woman who will get it: Small, Caucasean/Asian, female.) or if they have other risk factors (steroid use, chemotherapy, malnutrition, vitamin D deficiency, alcoholism, drug abusers). When to do follow-up screening is based on the findings at the first test. Men over the age of 75 also can be considered for screening.
Breast Cancer Screening
Screening women, ages 50-74, for breast cancer is a Class B recommendation. Screening before the age of 50 is a Class C recommendation. Over the age of 75 is Class I. The controversy about screening women age < 50 has been discussed earlier. Interestingly, the Task Force recommends against (Grade D) teaching Breast Self Examination. The data show that women who examine their own breasts are much more likely to find benign findings which require follow up testing (i.e. mammograms, ultrasounds or biopsies) than findings of a malignancy. Thus, the cost and suffering for these women is much higher, as well as exposure to interventions which might have complications. Although I think it would be a hard sell to encourage doctors not to teach breast self-exam because of all the publicity it has been given, it may well be that it does more harm than good for most women.
Screening for High Cholesterol
Another slam dunk!
Testing people over the age of 35 is a Grade A recommendation. No risk and tons of benefit. We can prevent strokes and heart attacks and save lives by finding high cholesterol early and treating it. I did an entire blog on high cholesterol, so please feel free to go back into the Archives and read more about it. Testing people age 20-35 is a Grade B recommendation (Grade A if they have any other risk factors, such as a family history of high cholesterol or heart disease). The task force actually did break down their recommendations into many sub-groups, dependent on risk, but it is far more complex than most people need to know. That’s why you pay your doctor!
I did a huge blog about the benefit of vaccines so please read it (and there are several follow ups, but the original blog was one of my first ones), and the Task Force bows to the superior data and knowledge of the CDC when it comes to determining the benefit of vaccines (and even provide a link to the CDC page).
Summary: Get your vaccines. Get them all. They extend lives and save lives more than every intervention listed in this blog, put together! Vaccinate yourself. Vaccinate your family. Vaccinate your children. Listening to any other advice about this is a critical misrepresentation of the facts and medical knowledge.
The Yearly Physical
A lot of people do not get their yearly physical. Again, they feel well, so they think it’s pointless! The fact is that if you get your yearly physical, your doctor will do all of the preventive care we talked about in the paragraphs above! There was a study that showed that people who got yearly physical exams from an Internist lived 7 years longer than people who did not. There was some problem with this study, in that you could argue that people who get yearly physicals are more worried and involved with their healthcare in general! All the same, the study did show a remarkable difference between people who saw their doctor yearly and those who did not. Apart from cost, there can be no argument against it, so I certainly recommend a yearly physical for all patients 40 and older, and at least every other year for patients under the age of 40 who have no significant medical problems and take no medications on a regular basis.
Website for the United States Preventive Services Task Force: