Screening Can Do Silent Harm
Nick Arroyo is a 65-year-old man without medical problems. He feels well and sees a primary care doctor every three years or so. He had a chest CT for lung cancer screening because he smoked a pack-a-day for 50 years and heard a radio advertisement that said that lung cancer screening would be helpful. The scan detected a 1 cm nodule. A PET scan was positive, and a biopsy diagnosed it as small cell lung cancer. After evaluation showed no cancer beyond the nodule, he underwent surgery followed by four rounds of chemotherapy (cisplatin and etoposide). Following the chemotherapy, mediastinal lymphadenopathy was detected.
Mr. Arroyo died a year after diagnosis but was grateful that the screening test had given him a chance to fight the cancer.
Joan Drake is a 70-year-old woman. She has always enjoyed good health, her only medical problem being hypertension. She takes amlodipine and atorvastatin. She was looking forward to her grandson’s wedding and decided to have a coronary artery calcium screen because she “wanted to dance without a worry in the world.” Her score on the exam was 125 Agatston units. The test was followed up with a coronary artery CT which revealed a 75% blockage of her mid LAD. She underwent a cardiac catheterization with stenting of the LAD lesion.
Joan enjoyed the wedding and danced without a worry in the world.
Andrew Kennedy is a 67-year-old man who was diagnosed with prostate cancer after his PSA was found to be elevated. His evaluation revealed favorable intermediate-risk disease (PSA 7, T2b, Gleason score 3+4, 20% of biopsy cores positive). Mr. Kennedy opted for prostatectomy as he “just wanted this out of him.” He underwent an uncomplicated surgery and his PSA at follow-up was zero.
Despite loss of erectile function and incontinence (2 pads/day) Andrew is thrilled about the outcome and advocates that all his friends get their PSA checked.
Nan Williams is a 55-year-old woman who has an abnormal mammogram. Biopsy reveals DCIS. Because her grandmother died of breast cancer (genetic testing is negative) she opts for treatment with bilateral mastectomy.
A year after her surgery, Nan participates in the “Race for the Cure” wearing a “Cancer Survivor” t-shirt. She convinces her two 40-year-old nieces to begin breast cancer screening immediately.
Bill Delgado is a 70-year-old man. He smoked for 40 years but managed to quit when he was 60. He says he owes his life to his primary care internist for helping him quit. He has seen that doctor for 25 years. He has hypertension and borderline diabetes (A1C ~ 6.5, on no meds). He takes hydrochlorothiazide and a statin. He goes out for a brisk walk for 45 minutes each day with his wife of 45 years.
Bill’s church offered “vascular screening”. Given his hypertension and diabetes, he was happy to participate. He had an EKG, carotid dopplers, and ankle brachial indices. His ABIs were abnormal. He brought the information to his primary care doctor who told him no further follow-up was necessary. He explained that the initial test was not indicated and that findings on lower extremity dopplers would not change their management.
After the visit, Mr. Delgado decided he needed to find a new doctor since it seems like his old one was no longer really interested in his care.
Photo by Ben White
Excellent thought-provoking case series on screening for disease!
The two cases of cardiovascular disease highlight the downsides of unenlightened testing.
The 70 year old asymptomatic lady with hyperlipidemia on statin therapy and a CAC score of 125 was a victim of overly enthusiastic downstream testing and received coronary stenting she didn't need. High CAC scores should in asymptomatic individuals should not trigger downstream testing. In this case, the higher than average CAC score should have just reassured the patient that she needed statin treatment and to consider more aggressive LDL-lowering goals.
In some situation it is reasonable to do CAC scores for this kind of patient, especially if they are having issues with statins or are questioning the value of therapy. A zero score in my practice in a 70 year old means they don't need lipid lowering therapy.
The patient who underwent (most likely Lifeline) screening sponsored by his church is a victim of marketing and got a test that could not possibly help him. I've written on these shoddy for profit cardiovascular screening mills (https://theskepticalcardiologist.com/2014/12/02/shoddy-cardiovascular-screenings-are-more-likely-to-cause-harm-than-good/ )
"the service is being performed by a “mobile clinic.” These types of mobile clinics typically exist to make as much money as they can. Quality control is not one of their goals. They seek high volume, rapid throughput, and minimal expenses. The mobile clinic is most likely utilizing the cheapest equipment, technicians and interpreters of these studies that they can get.
Cheap equipment and inexperienced or poorly trained technicians are more likely to yield studies that are difficult to interpret or introduce errors and artifacts. Artifacts in an imaging study are images that appear to be abnormalities but are not. The more artifacts in a study, the more inappropriate subsequent testing will most likely be performed."
Modern medicine takes a lot of heat from critics who claim that over-testing leads to over-medicalization.
But conventional Western medicine’s strongest aspect is its ability to diagnose a condition, even in the absence of symptoms.
Its weakest aspect, the function it flatly fails at, is preventing the ills and maladies that are entirely preventable (which is, by far, most of them).
Why is this?
Could it be the economic model? Is there more money and prestige to be earned by treating sick patients , rather than keeping them healthy in the first place?
Are we really in the sickness business — and merely calling it “healthcare?”
One wonders.