Why One Doctor Says 'No' to Many Screening Tests

Ignorance is not bliss

I've noticed my US colleagues have a LOT of screening tests and invasive exams annually, but don't really know why...."it's to be healthy", "you'd be reckless not to"...

Yet the rest of the world doesn't have this degree of medical intervention and we're doing just fine - our rates of cancer are no higher.

I'm sure your rate of false positives and unnecessary follow-up must be high (it is for cervical and breast cancer)

Routine pelvic, breast and rectal exams - not done in my country. I was really surprised to hear women usually have these complete checks from about 18 and then present annually...

In Australia these exams are considered unnecessary in asymptomatic women and in fact, can be harmful. (false reassurance, false positives, discomfort and anxiety, unnecessary follow-up)

Annual cervical screening means 95% of women will have a colposcopy and biopsies in her lifetime, yet only a tiny number will have any sign of malignancy.

Most countries around the world offer screening 3 to 5 yearly and some countries like the UK, Netherlands and Finland start later - 25 or 30 to contain the harm to young women, who have a high chance of unnecessary follow-up treatment for changes that usually resolve on their own.

Most women have no idea of these risks and most have no idea of the REAL benefit of this Testing.

RM De May published an interesting article in the American Journal of Clinical Pathologists in 2000 - of the 1% of women who get cervical cancer, one third will have received one or more false negatives, so screening may have disadvantaged them with false reassurance and a later diagnosis - so that leaves 0.66% of women who'll benefit...

Apply your risk profile and the benefit to you may not exceed the risks of testing or might mean less frequent testing - at the moment most women are not in the position to make that call...

Dr Angela Raffles (cancer screening expert) released some figures - 1000 women need regular testing for 35 years to save ONE woman from cervical cancer.

It saddens me that fear and ignorance fuels so many of these Tests and exams.

I think patients need to be aware and do their homework before agreeing to cancer screening and routine exams.

Mammograms are also, a controversial topic - read anything by Prof Michael Baum, breast cancer surgeon. False positives, unnecessary surgery, new research that suggests mammograms may increase the risk of cancer, they suspect the bruising of the breast tissue and the discovery of ductal carcinoma in situ (DCIS) a slow moving cancer that usually doesn't bother a woman, but once biopsied, it can become invasive and once diagnosed, usually means surgery.

Men - beware of the PSA blood test - there are many doctors very concerned about this screening test.

Why is this happening? Screening tests are vote winners - also, preventive medicine might avoid law suits, but the main reason IMO is MONEY. Lots of people are getting rich on all these unnecessary tests and exams.

When an opinion is not enough

While Dr. Hadler has some legitimate points regarding old age, what concerns me is that he is very quick to put his oar in on issues where he has done no research, sees no patients and generally is unable to provide objective proof of his psychosocial theories. Which essentially relegates his input to nothing more than opinion. I prefer competent doctors who can do better than a subjective opinion. If I want a subjective opinion I can poll people behind me in the line at the grocery store.

When UnumProvident a large insurance conglomerate, which was successfully sued by the attorney generals of several states for their refusal to pay disability claims or tried to make them out to be stress disorders or psychiatric disorders so they only had to pay for two years instead of a lifetime, hires self proclaimed experts like Dr. Hadler so they don't have to pay legitimate claims there is something badly wrong with our system. Doing pharmaceutical research isn't the only conflict of interest journalists and the public need to watch the big business industry of health and disability just as carefully.

timely

Knew the author, very knowedgable and bright individual. As a fellow physician, I embrace his perspectives. Unfortunately, he challenges a social consciousness that has become so ingrained it has religious status.

Always fun to read a point of view that agrees with yours--

--especially when it is controversial.

I am much more interested in quality of life than quantity. As soon as we are diagnosed our quality of life decreases. Just "knowing" is a negative of its own, and on top of that there will be surgery or chemo or drugs with nasty side effects or endless trips to doctors offices,hospitals and labs.

This is not how I want to end my days, but being treated for disease has become the way of life for so many elderly.

I have a wonderful 91-year old friend who has not seen a doctor in 6 years. He has had 2 bypass surgeries, but is on no medication. I think he is on to something. HE decides when he has a problem that needs to be treated.

last post on cost issu

To the author of DR. Don't need it post.

Have you done the math? Do you know how many people need to do these tests to help one cancer early? Do you know that cancers spread at different speed, some are so slow-growing that they would never spread in person's lifetime if remain undetected; some spread a little faster but still slow enough that they are still treatable if detected early, some are so aggressive that they will kill you no matter how early they are detected. Screening helps in a small subgroup of cancers - those that spread slow enough that they can be detected by screening yet aren't so aggressive as to kill you anyway.

There is no way to say if you prostate cancer would've ever spread if remained undetected. You cannot predict the future either. There is also no evidence at all that PSA even makes a difference, but it sure increases the number of detected cancers. So maybe PSA saved your life and maybe it caused you to be treated for something that wouldn't have ever spread in your lifetime. There is no way to say. Even if you are in the former category, for every one whose life is safe several may be treated unnecessarily and suffer from incontinence or impotence as a result.

Plural of anecdotes isn't data. "My cancer was detected early and I am still alive" doesn't mean a thing: you could've still been alive without it or it can still come back. This is why there are studies.

"The overeaters and counterpart underexercisers cost this country extreme dollars, not those of us who are fitness and wellness oriented and use these "unnecessary tests" as benchmarks for fitness and life expectancy. "

This is just wrong. You have no clue about actual data or statistics. There is no evidence at all that people who do more tests live longer. There is very small evidence for reduction of desease-specific mortality, but no evidence at all for reduction of all-cause mortality. As to the cost- do your math. Even in best case, you need to test hundreds, even thousands to make a difference in one case. Each test has false positives that lead to more invasive tests that have risks and cost money. There is overdiagnosis, so more people are treated than without tests. You may save millions, but spend billions.

good article

"this writer must really hate women, sad."

Why? I am a woman. He agrees with papa smears. As to mammograms, here is an optimistic statistics for you - from studies and using absolute numbers not meaningless relative numbers (30% reduction of mortality, 30% of what number?). For every 1000 women screened for 10 years, 2 less may die from breast cancer (not overall - no proof of all-cause mortality reduction). During the same time, 50% of these women will have at least one false positive, about one forth of these false positives will end in biopsy. Don't you think this extra anxiety may have some negativie result on blood pressure and heart? Then there is an issue of overdiagnosis - detecting early leisions that may never spread in woman's lifetime if remained undetected, yet when detected - they are treated, and you may suffer from side effects of this treatment for life, maybe even die earlier. If you still want to be screened - fine, but stop presenting it as an obligation. It is a choice.

"Women in this country live years longer than men. Why? They go to the doctor more often."

Hello? Women have always lived longer than men, even before 19th century and before curative medicine. They also live longer than men in other countries. Also, while there are slightly more boys born then girls, more boys die in infancy. A premature girl has bettter chance than premature boy. Maybe we are just stronger. Correlation isn't the same as causation.

Listen to this man

This is an opinion that should be listened to--his point about treating for unnecessary breast cancer for example, This is called the NNT--number needed to treat. There's an obverse number called number needed to harm. With many tests, you expose more people to rotten and dangerous side effects than you an ever possibly "save". Medicine is all about statistics, folks, and if you want to play by "risk" factors, then you should learn enough mathematics to understand what you are reading about the disease du jour. One way to think about "risk" factors, is to assess the number of people with a risk factor that do not get the disease. Also, risk factors are derived for populations and population math is not completely relevant or translatable to individuals, unless there is a direct causality---not a risk factor.

Statins for cholesterol are an excellent example. They are not indicated for persons w/o heart disease, have been shown to not be effective (they reduce cholesterol, but not heart disease), do not extend life in persons without heart disease, and produce debilitating pain and memory loss in many. But they sure do lighten the wallet. These tests have risks of their own and they are not very accurate. CT scans and mammograms are fancy X-rays. Sure the doses are lower than they used to be, but how many more over a lifetime are you getting? Which photon is causing a mutation.

DR. Don't need it.

This Dr. is one of an increasing number who are setting the table for reduced medical care in the U.S. We are a county which overeats and underexercises. The overeaters and counterpart underexercisers cost this country extreme dollars, not those of us who are fitness and wellness oriented and use these "unnecessary tests" as benchmarks for fitness and life expectancy. Because of a PSA test, my prostate cancer was detected at an early stage, which allowd the medical community to eliminate it. This guy can live to 85 if he wants--being the world's oldest living human is my goal.

My suggestion for the good Dr. is for him to emmigrate to Canada or some other socialist nation whose medical systems are woeful.

response

Katherine Hobson

For Ben T. in FL:

Your doctor may have some reason for ordering up another colonoscopy in five years. But it can't hurt to print this out and take it to him, or follow the link at the bottom of the Q&A with Dr. Hadler to my previous story about questions you should ask your doc before getting a screening test.

hada colonoscopy 2004

I was 83 then and was told to have another in 09.After reading your article on the subject I do not think I will.Got to die of something!