Consumer Directed Healthcare

Routine Medical Screenings May Not Deliver as Promised, One Doctor Says
OPINION by NORTIN M. HADLER, M.D.

Sept. 26, 2008-

Most of us believe that when a doctor orders screening tests, that’s a serious step toward keeping illness at bay. The screening test can find factors that place us at risk for diseases we might develop in the future or find hidden diseases. In either case, we will be treated.

Screening tests are considered a triumph of modern public health medicine. I only wish it was that straightforward.

It turns out that many of the commonly recommended screening tests fall far short on this promise. They fall so far short that no one should have them without first discussing them with their doctor.

If you are not convinced you will be advantaged by having the test, why bother?

Let me illustrate this with three of the commonly recommended tests. I will explain why I have never let anyone check my cholesterol or my PSA, and why I have submitted to colonoscopy once, and never again.

Blood Cholesterol
Blood cholesterol level is a risk factor for heart and other blood vessel diseases — but not much of a risk factor. If you have the worst LDL and HDL cholesterol we find occasionally in the population, you have a year or two of life expectancy at risk.

For nearly all who are told they have “high” cholesterol, the amount of time on earth that they are risking is measured in months. I’m not sure we can even measure such a small risk, or that I care.

But if you do, the next question is crucial. Can we do anything to my cholesterol that reduces the risk? That’s not the same question as can you lower the cholesterol? We can do that very well, and we do lower the cholesterol of millions of Americans thereby reducing the risk factor. But does that reduce the risk?

There are scientific studies asking this question. The treatment does not reduce the risk of dying from heart disease. The most optimistic analysis of these scientific studies leads to the following conclusion: 250 people who have not had a heart attack would have to swallow a statin drug every day for five years to spare a heart attack.

Do you believe we can even measure such a tiny effect? Is it worth your while to take these pills for years? Would it be worth it if you had to pay out-of-pocket?

PSA Testing
PSA stands for Prostate Specific Antigen. It’s a normal protein in the prostate. A small amount gets into the bloodstream normally.

Greater amounts get into the bloodstream if the prostate is inflamed by infection. Prostate cancer is another cause of more PSA getting into the bloodstream.

Prostate cancer is a normal part of aging; by age 70, essentially all men have prostate cancer. Furthermore, nearly all men will die with their prostate cancer and not from it.

The challenge for screening is not to find prostate cancer, but to find the prostate cancer that will kill a man before his time. That’s a tall order, and one for which PSA screening is a double-edged sword. After all, if you want to be sure you will not die from prostate cancer before your time, you will have to submit to a procedure, usually a major surgical procedure that offers a 15 percent likelihood of incontinence and more of impotence.

In a clinical trial in Scandinavia, a great number of aging men were divided into two groups. Those who were offered and opted for surgery for their elevated PSA gained very little for the experience compared to those who were not offered surgery. They gained too little for me to opt for the surgery if my PSA was elevated. Therefore, I won’t let anyone check my PSA. You need to have this discussion with your doctor before you opt to have a screening PSA.

Colonoscopy
A few rare families and rare diseases aside, colon cancer is another disease of the sunset years.

Like prostate cancer, it is slow to grow and slow to spread but it is far less common than prostate cancer. The treatment, surgical removal, has far less likelihood of complications than prostate surgery.

The screening is not a blood test; it’s hunting for the cancer directly. More and more, this is done by inserting a tube into the colon and looking inch-by-inch. It’s not a perfect test, requiring patience as much as dexterity.

And it has complications, many of which relate to the removal of polyps which are grape-like growths on a stalk that have very little potential for harm (if they develop into cancer at all, it takes decades).

So we are back to our critical question. The issue is not whether one can find a cancer and remove it, but whether one can find and remove the cancer that is likely to cost me time on this earth.

I don’t care if I develop colon cancer in my 80s; something else is likely to kill me long before it can. I don’t care if I develop colon cancer in my 70s either, for the same reason. Furthermore, screening me in my 40s is largely an exercise in futility; colon cancer is so very, very rare in 40-year-olds that the chances of a complication of colonoscopy far outweighs the chances of finding the rare cancer. It’s in the 50s and 60s that finding and removing the rare colon cancer is likely to be meaningful to that person and worth the risks to all those who don’t have colon cancer.

Hence, I had my one colonoscopy. In fact, I settled for a partial look (flexible sigmoidoscopy) because that was good enough risk assessment for me and the procedure is gentler and safer.

I am not alone in realizing the limitations of these tests and others such as mammography or even the annual physical examination. Many a researcher has been recruited to the task of improving screening tests. However, until we have much better screening tests, no person should be screened unaware of the limitations of the test.

Dr. Nortin Hadler is professor of medicine and microbiology/immunology at the University of North Carolina at Chapel Hill, and an attending rheumatologist at University of North Carolina Hospitals. He is the author of Worried Sick: A Prescription for Health in an Overtreated America and The Last Well Person.

 

Popularity: 15% [?]

Some argue an independent panel should gauge presidents and presidential candidates’ health
By Allison Van Dusen for Forbes.com

American presidents generally don’t like to talk about their health problems. Few people knew, for instance, that during their presidencies, Woodrow Wilson had suffered a massive stroke that left him partially paralyzed or that John F. Kennedy was taking as many as eight medications a day to deal with extensive back pain, digestive problems and the hormonal disorder known as Addison’s disease.

As the 2008 presidential race heats up, two University of Michigan medical historians argue in the June 4 issue of the Journal of the American Medical Association that given the poor track record of past presidents to share medical details and the already strong interest in the health histories of nominees Sens. John McCain and Barack Obama, Congress should appoint an impartial panel to evaluate presidents and presidential candidates’ health.

We asked one of the authors, Dr. Howard Markel, director of the Center for the History of Medicine at the University of Michigan, to explain the concept and who it will really help.

Howard Markel:  If you’re healthy, nothing. If there’s something slightly there, you don’t want to give your opponent or opponent’s spinner any kind of leeway to knock you down. With the era of the permanent campaign, instant communication and the 24-7 news cycle, no one wants to give out information that might hurt [his or her] chance to win an election. We have found out that anything can and will be used against them.

Should a president’s or presidential candidate’s health be of concern to the public?

Absolutely. The president is the most powerful person on the planet. Their mental, physical health and well-being, really does effect the global market, war, peace, political legislation–all sorts of things with the stroke of a pen. The caveat is that you really can’t predict based on a medical evaluation today what’s going to happen a year from now. You could be cleared as completely healthy and a year later have a debilitating heart attack. But it’s important for people to know. We make decisions based on where people go to worship, their income, where they went to college. From my perspective, as a physician and historian of medicine, this is a big piece of data we want to know.

Why do you think there currently isn’t a method to assure impartial, candid health evaluations for future presidents and presidential candidates?

It’s all about control. It’s only gotten worse with each successive campaign cycle. You have to control the information getting out that might hurt you, even information you don’t think would hurt you. Sen. [Barack] Obama smoked cigarettes. There’s no evidence he has lung cancer or heart disease. But in this era, smoking cigarettes is looked down upon much more negatively than when FDR was running for president and had a cigarette in his mouth.

Explain the method you propose.

Once somebody is president, he needs to be examined on a regular basis, annually or more frequently. We want nominees to be examined too. And it’s critical that they’re not examined by their own physicians. If I’m physician to the president I’m probably going to like that job. There’s a conflict of, do I do something that will get the president upset enough to fire me?

An independent panel would be appointed by Congress with all sorts of doctors, dermatologists, neurologists and cardiologists, so that [everything] is covered, but also other experts, such as lawyers and ethicists, to help in terms of publication of such a report. They would be independent umpires who don’t have a dog in the race.

It’s also critical that nominees and presidents are evaluated because the 25th amendment of the U.S. Constitution … is vague in how it defines disability. How it’s defined today compared to 1967, when the amendment was ratified, has changed markedly. We need clear definitions.

At the annual checkup, nominees could voluntarily say there are categories they want to opt out of disclosing. They may have a genetic screening and carry a trait … that they don’t want reported. They may say they want to talk about that with their children, but it has no bearing on their ability to govern.

What do you say to people who feel this is too big an invasion of the president’s or candidates’ privacy?

We offer patients confidentiality, and that’s critically important for regular patients. But let’s face it: The president of the United States and the nominees for president of the United States are the most public patients in the world. They have long since given up any elements of privacy. We know whether they like hot dogs or the Yankees. With health, it’s just too important.

What about those who might argue that disclosing information about the president’s health could affect global politics?

If the president has a serious illness, like let’s say a stroke, that’s serious. We need to know about that right away. The vice president needs to be put in place by the 25th amendment. If it’s a long-standing [health problem], you’ve got a little bit more leeway.

I would argue it’s a bigger threat to national security by hiding it than by disclosing it. Transparency is way better than opaque policies–that’s one thing history teaches us again and again.

Popularity: 13% [?]

There have been a series of articles that discuss deathrow inmates and their request for clemency due to the fact that they are obese.  The inmates claim an even greater risk of experiencing excruciating pain and suffering than other inmates due to the fact that they are overweight.

Similar lawsuits have been filed in several states which have led to the halting of executions in Texas, Delaware and New Jersey.

The men in these articles have tortured, raped and killed innocent people.  What gives them the right to life? They took a life, if not, several.  What about the rights of the victim’s family to see justice for the loss of a loved one?

What kind of message would we be giving criminals?  By halting executions, are we telling “would be” criminals to fatten up to commit heinous crimes so that they may not face the death penalty?  I don’t think the victims of these men had a choice in the way their lives ended so abruptly!

 

Here are the articles, if you would like to read them…   

http://www.cnn.com/2008/CRIME/08/25/death.penalty.fat.ap/index.html

http://abcnews.go.com/TheLaw/story?id=3684431

Popularity: 38% [?]