Too much of the wrong kind of preventive care can actually get you in trouble. Examples abound in a system that punishes doctors for omitting tests, rewards them for ordering unnecessary ones, and creates dubious borderline conditions such as osteopenia—a step short of osteoporosis—that too often lead to treatment with expensive drugs. And while the test itself may not seem so bad, especially if it's an imaging test that isn't invasive, the consequences of an unnecessary test can be profound, even life threatening. Steven Nissen, chief of cardiology at the Cleveland Clinic, tells of one such case, involving a 52-year-old nurse who agreed to a routine imaging test as added reassurance that her heart was healthy. Tests, for cholesterol, artery inflammation, and rhythm disturbances were normal. But her doctor suggested she undergo an extra test, called catheterization, which would allow doctors to flood her coronary arteries with a dye that reveals blockages. The tube delivering the dye tore one of the heart's main arteries, causing a massive heart attack. A bypass operation to repair the damage ultimately failed. The nurse ended up needing a heart transplant. "I have five more cases like it," Nissen says.
Doctors have become so concerned about excessive testing—especially tests involving radiation-emitting CT scans—that nine medical specialty groups, including the American Board of Internal Medicine, the American College of Radiology, and the American College of Cardiology, have joined forces to try to curb it. As part of an effort called "Choosing Wisely," each one produced a list (available at www.choosingwisely.org) of "Five Things Physicians and Patients Should Question." Their lists include such “Don’ts” as “don’t do imaging for uncomplicated headache,” and caution doctors to try to dramatically reduce the number of CT scans they perform. Few experts think it's a good idea to undergo full-body CT scans to look for potentially cancerous spots in the lungs or for calcium build-up in the coronary arteries of the heart. "Thirty percent to 60 percent of CT scans are wrong, incomplete, or inappropriate," says radiologist and patient safety expert Chuck Denham of the Texas Medical Institute of Technology.
CT scans, even when appropriate, could potentially have a major impact on cancer rates nationwide. "We're now over 70 million CT scans being prescribed a year," says physicist Owen Hoffman, a radiation risk expert at a consulting firm called Senes Oak Ridge. Hoffman has estimated that, over time, these scans will actually cause 15,000 to 45,000 cancers in unwitting patients years after they were performed. Worse, Hoffman says, many of the scans could, and should, have been avoided.
CT scans aren't the only tests that raise concerns. The USPSTF task force has recommended against more than two dozen tests, grading them "D" for "Don't do it. There's zero net benefit or harm," says task force chairwoman Virginia Moyer, a pediatrician at Baylor College of Medicine in Houston.
One notable example is PSA testing for prostate cancer. One or two high PSA readings prompts many physicians to recommend a biopsy, a test to detect cancer cells that is uncomfortable, has risks of its own, and doesn't appear to significantly reduce prostate cancer deaths. Any benefit, the task force concluded, is outweighed by the risk that an incorrect diagnosis or unneeded procedure will lead to death or complications. About a third of men treated for prostate cancer end up with urinary incontinence, impotence, or both. About 1 in every 200 dies within 30 days from complications of surgery.
Another controversial example is screening younger women for breast cancer with mammography, which has many of the same drawbacks. In 2009, the government task force reversed long-accepted recommendations for screening women in their 40s, arguing that the benefits were outweighed by the risks of false diagnoses, biopsies, and unnecessary treatment. The task force now recommends screening every two years for women between the ages of 50 and 74.
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