fitness · health

Testing, testing: how much preventative care and screening do we need?

Important note: as they say, I’m not a doctor (well, not an MD; my philosophy PhD really doesn’t count here). We all read, talk to people and make our own decisions about what to do based on our particular values and needs and goals and bodies and finances and time. So this isn’t advice, much less a medical recommendation. (Not that you’d think so, but I figured I’d say it anyway).

Okay, that said: I went to the gynecologist this week.

Oh joy!
oh joy!

I was there to deal with some menopausal symptoms (a topic for another blog post). During the appointment (my first with this doctor), she reeled off a big list of questions about screening, including mammograms, paps, etc. I tend to be a bit behind schedule according to American (but not necessarily other country) standards for various types of health screening. In this country, there’s a lot of variation among individual practitioners about screening, and they are sometimes at odds with national professional scientific panel recommendations (e.g. for mammography, see here the US Preventative Services Task Force recommendations).

My previous internist and I got into a heated argument about screening– she wanted yearly mammograms for me (luckily I have no family history of breast cancer nor is it likely I have genetic markers for it) and in response I cited the USPSTF results. She replied, “well, I don’t agree with them”. I asked what evidence she had to contravene those results. She had none. I changed doctors a bit later.

It turns out that I have some company in being resistant to and skeptical of many (although not all) medical screening. Barbara Ehrenreich (one of my author-essayist heroes; her classic book Nickeled and Dimed forever changed my view of labor justice) has published a new book called Natural Causes: An Epidemic of Wellness, the Certainty of Dying, and Killing Ourselves to Live Longer. I recently read an essay excerpt from the book here, which definitely makes me want to read the whole book (when I do, I’ll post a review).

Ehrenreich is reacting to two trends she sees:

  1. the technological new-toy enthusiasm in the medical establishment which pushes us to be examined, measured minutely, recorded and treated, just in case the barely registerable potential abnormality that we’ve been informed of will rise up to plague us;
  2. the identification of this tech-heavy but not obviously therapeutic process with normal health maintenance; resistance is seen as irresponsible and maybe even irrational.

I really like this example she gives of a medical encounter that perfectly illustrates 1):

I was struck by the professionals’ dismissal of my subjective reports—usually along the lines of “I feel fine”—in favor of the occult findings of their equipment. One physician, unprompted by any obvious signs or symptoms, decided to measure my lung capacity with the new handheld instrument he’d acquired for this purpose. I breathed into it, as instructed, as hard as I could, but my breath did not register on his screen. He fiddled with the instrument, looking deeply perturbed, and told me I seemed to be suffering from a pulmonary obstruction. In my defense, I argued that I do at least 30 minutes of aerobic exercise a day, not counting ordinary walking, but I was too polite to demonstrate that I was still capable of vigorous oral argument.

There are a bunch of questions that she raises here, and they are issues that I think about a lot in my professional life (as a public health ethics person) and in my personal life (as an aging, active, curious person). One of them is this: if I don’t have any symptoms, does it serve me to engage in high-tech explorations of my systems in search of something that looks amiss to the machine?

This is of course a very hard and controversial question. The whole issue of screening for diseases and risk factors and conditions and genetic markers for people who are asymptomatic is a huge area of health research for a lot of fields (mine included). I did find this interesting systematic review of meta-analyses and randomized trials (this means they looked at a ton of data at several levels using very fancy methods). It asks a very straightforward question: does screening for disease save lives in asymptomatic adults?

The straightforward answer is: for the most part, no. Here’s what their abstract conclusion says:

Among currently available screening tests for diseases where death is a common outcome, reductions in disease-specific mortality are uncommon and reductions in all-cause mortality are very rare or non-existent.

What does this mean? I can get various kinds of screening for diseases– mammograms, colonoscopies, blood chemistry, imaging and other tests for cancers, heart diseases, type 2 diabetes, etc. The researchers asked two questions:

  1. How likely are these individual screening tests to reduce my risk of dying from that particular disease?
  2. How likely are these individual screening testing to reduce my risk of dying for any reason?

In the case of 1), they did see some reductions in disease-specific mortality risk for four tests (including mammography under some protocols, and two less-invasive-than-colonoscpy tests for colorectal cancer). But they didn’t find those reductions for the other 15 screening tests they looked at (I won’t list them here, in part because their results are more robust for some than others based on availability of evidence). However, here are a few nuggets I found that put them in Ehrenreich’s camp:

A very large number of tests continuously become available due to technological advancement.One may be tempted to claim a survival benefit of screening based on observational cohorts showing improved survival rates, but these are prone to lead-time and other types of bias.

They conclude with this (edited by me for brevity):

One may argue that a reduction in disease-specific mortality may some times be beneficial even in the absence of a reduction in all-cause mortality. Such an inference would have to consider the relative perception of different types of death by patients (e.g. death by cancer vs death by other cause), and it may entail also some subjectivity… Screening may still be highly effective (and thus justifiable) for a variety of other clinical outcomes, besides mortality. However, our overview suggests that expectations of major benefits in mortality from screening need to be cautiously tempered.

In short: screening for serious diseases is medically useful for people under many circumstances. But for those with no symptoms, it is questionable whether it will extend their lives, and it’s not clear it will give them greater control over how and what they die from.

Lots of screening presupposes a very high-tech, very interventionist, and statistically low-yield approach to health. That’s fine if that’s your deal. You do you. But it’s important to know what you’re signing up for. And this is not one-approach fits all. Because of my medical and family history, I am committed to and feel like I need some types of screening, but not others. I try to stay informed and make evidence-based decisions, but my decisions are also based on what I think health is for me, what my biggest health worries are, and how I hope my life will go.

Have you had experiences with medical professionals about screening and health that you’d like to share here? I’d love to hear from you.

4 thoughts on “Testing, testing: how much preventative care and screening do we need?

  1. My experience was not anything anyone would want to repeat: I had a low grade brain cancer, and the testing question that eventually emerged was, what is the ideal frequency of MRI follow up. By this time, I was approaching 10 years with no recurrence (this is extremely rare, so there is no useful statistical guidance). One doctor thought 2 years, the other 6 months
    Hmmm. Quite a difference! So, I decided to ask each one what he/she would do if either one was in my situation, and why. They answered freely. The 6 month guy had recently had a patient go 2 years and come back with a recurrence that crossed the center line of the brain; he felt he could have improved the quality of her remaining life with earlier information. The 2 year woman said she thought symptom-free survival was the best quality of life.

    Anyway, my point is that many doctors are very willing to have very basic conversations to help us navigate these sometimes stormy waters. My choice, like yours, is to choose the doctor. Then, going forward, we can work together to choose among the seemingly endless testing options.

  2. As a psychologist in Australia, and an older woman, I am confounded by this problem on a daily basis. At present it seems that the big tests are all the go but smaller, mostly non invasive blood tests are not well used. There are a myriad of relatively easy to correct conditions that can drematically impact on mental health – eg low iron, celiacs disease. But if a client presents with mental health issues (particularly a woman) doctors seem relcutant to do further investigation. Finding a good doctor is certainly the key. My favourite question is – if this was your wife (mother, daughter) what would yuu recommend.

  3. This is such an interesting blog post. It is something I have been wondering about, and what I’m reminded of is how our consideration of health has changed. I cannot remember where I read this (the idea is not mine, but I am reminded of it with this post) but the idea is that once upon a time, for “healthy living” we would go about our lives until a symptom or something else came up, and then we would go to the doctor to figure out what (if) something was wrong. But now we have to do all this preventative work, even if we feel absolutely fine or we may face an accusation of not taking care of ourselves when faced with a diagnosis. I can’t speak from personal screening experience but I do work as a dietitian, so I often see people as a result of various blood tests, so it is interesting to consider this question.

  4. I had a hysterectomy almost a decade ago. I rarely go to the doctor but at my last visit, she argued I should get a Pap test, just to make sure everything is okay because sometimes stuff gets missed. The hysterectomy was completely unrelated to any cancer symptoms, but I have reluctantly agreed to get one done next year to celebrate my decade free of my other issues (and also because many many years ago I did have some pre-cancerous cells). OTOH, I am much more eager to have my next colonoscopy because having polyps removed at the first one scared the bejeebers out of me. I would never have done even the basic test that led to the colonoscopy without the annual screening program promoted by the provincial health authorities.

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