Why One Doctor Says 'No' to Many Screening Tests

Cholesterol screening for healthy adults at no special risk of heart disease? A waste of time and money. Annual mammograms for women at average risk of breast cancer? Not worth it. Exercising solely because you think it will help you live longer? No way—far more important are your job satisfaction and socioeconomic position. Those are some of the controversial viewpoints Nortin Hadler airs in Worried Sick: A Prescription for Health in an Overtreated America. (Various experts disagree with him on those three points and others. The U.S. Preventive Services Task Force, for example, advises cholesterol screening in average-risk men over 35 and says there's "fair" evidence that mammography significantly cuts breast cancer mortality. And the U.S. government recommends 30 minutes of moderate aerobic exercise most days of the week.)

Hadler, a professor of medicine and microbiology and immunology at the University of North Carolina-Chapel Hill and an attending rheumatologist at that university's hospitals, is a longtime critic of what he calls the "culture of medicalization," which he says threatens to turn every malady into something that must be treated by doctors and every person into a patient. U.S. News talked to him about the issues he raises and how he interprets the research. Excerpts:

What's the crux of the problem?
We are the most medicalized of countries, with a belief that there's a technical or a biotechnical solution to all of our problems. Instead of demanding that solution, patients should demand a detailed explanation from doctors of the upsides and downsides of everything they suggest we do. There's this notion that we are all walking disasters waiting to happen, and yet the stories in the newspapers that talk about epidemics of heart disease, obesity, cancer, and diabetes are on the same page as stories talking about the graying of America.

You say that humans probably have a natural lifespan of about 85 years, give or take several years, and that we should focus more on getting there in a functional state.
Yes. I care far less what kills me than when I die. I don't care how many diseases I have when I'm 85 as long as the journey was fulfilling.

I write a lot about exercise and eating a healthy diet. A waste for everyone involved?
You don't want to be morbidly obese or feeble, but I don't mind if people are chunky or prefer reading to running. You want people to feel good in their own skin. How we set up a society to promote that sense of well-being is the key to the health of the public in a resource-advantaged country. To tell people who have been working in a factory all day that they should take the stairs and not the elevator is missing the point. I ride my bike because I love to. I wish every American had the time and resources to enjoy such recreational releases.

Let's wade into the mammography morass. Why don't you think they're useful for women who aren't already at some higher risk of the disease?
The Malmö study followed thousands of Swedish women who had screening mammograms and thousands who did not. Screening did not save lives. You'd have to screen 250 people starting at age 55 to prevent one death from breast cancer, and for every one you save, you will be treating two unnecessarily for breast cancer that never would have killed them before something else did. As far as I'm concerned, one in 250 is too rare to measure reliably or to base a public health agenda on. As a screening modality, mammography is a terribly blunt instrument. I'd love to have a good test, but it isn't clear that there is one for breast cancer.

So what's the alternative? Just wait for symptoms?
If you have a question—if you find a lump, or there's a peculiar shape to the nipple—go to the doctor and ask if you have something to worry about. In all likelihood, there won't be a lethal breast cancer. Proving that may start with a mammogram—a mammogram for diagnosis, not for screening.

And what about colonoscopy, which we're urged to get once we turn 50? There's never been a trial that shows it saves lives, after all.
Colonoscopy is the most defensible of the more controversial screening tests for cancer. It must be done carefully, and it's not a perfect test. Lesions are missed and complications occur. Colon cancer is a disease of later life, with rare exceptions, that grows and spreads slowly. If I develop colon cancer in my 80s, don't tell me about it because something else is likely to kill me. If I develop it in my 70s, don't tell me about it either. In my 50s and 60s, it may well stand between me and my 85th birthday. Screening younger people is futile because the disease is so rare that complications from doing the test will overwhelm any benefit. If the colonoscopist doesn't find cancer at 50 or later, you probably don't need another one. And as I've argued for ages, most of the complications come from snaring and removing the polyps. The time it takes polyps to become cancerous is considerable, decades. Stop snaring them!