Preventive Screenings Could be Harmful to Your Health

Consumer Reports, which has been rating everything from cars to coffeemakers for the past 75 years, evaluated a different kind of item earlier this year: heart screening tests.

The unprecedented move came after the magazine discovered that more than 40 percent of its subscribers had undergone unnecessary heart testing, reported John Santa, director of the Consumer Reports Health Rating Center.

“We had not realized how ill-informed healthy people are about screening tests,” said Santa, whose center found that 44 percent of subscribers with no heart disease risk factors had unnecessarily subjected themselves to such screenings as electrocardiograms, exercise stress tests, and C-reactive protein blood tests. “Something needs to be done to rein in the spending and testing spree by patients and their doctors,” he said.

The new Consumer Reports’ rating, complete with its trademark red and black dot evaluations, is only the latest effort by health experts to rouse Americans out of their blind devotion to preventive screenings. In January, Dartmouth Medical School professor H. Gilbert Welch and two colleagues released their acclaimed book, “Overdiagnosed: Making People Sick in the Pursuit of Health,” which argues that the biggest problem posed by modern medicine is overdiagnosis, the process of detecting medical abnormalities that will never cause actual health problems. Similarly, the National Priorities Partnership, composed of 48 respected health care organizations, declared in 2008 that lab testing was one of the four worst areas of medical overuse.

Medical screenings may seem like benign rituals, often giving the public a dose of reassurance that they are taking charge of their health. But many are completely unnecessary, wasting people’s time, creating unnecessary anxiety, and driving up health care costs.

Nearly a decade before Welch published “Overdiagnosed,” he discovered that 10 million women had been screened for cervical cancer in one year, even though they had no cervixes. They all had undergone total hysterectomies, so their chances of having cervical cancer were virtually nil. Even the U.S. Preventive Services Task Force, an independent group of medical experts who make recommendations for physician practice, had declared that doctors need not give such women Pap smears.

Many terminally ill patients continue to undergo medical screenings, too, even though test results will have no impact on their life expectancy, researchers at Memorial Sloan-Kettering Cancer Center found. In a study published in the Journal of the American Medical Association last year, the researchers concluded that 15 percent of terminally ill men had prostate cancer tests and nearly 9 percent of terminally ill women had mammograms.

The U.S. Preventive Services Task Force recommends only a handful of routine screenings for healthy adults with no risk factors, including tests for three cancers (cervical, breast, and colon cancer) as well as exams for two heart-disease related issues: blood pressure and cholesterol. Medical experts say other tests, such as annual EKGs and chest x-rays, are a total waste. “What’s going on is a waste of our resources,” Santa said.

People may undergo other tests, thinking even if they are not necessary, there’s no harm. But just like drugs, screening tests have risks as well as benefits.

“There’s never not a downside,” said Virginia Moyer, chair of the U.S. Preventive Services task Force.

Radiation may well be the worst side effect of screening, with as many as 29,000 people developing cancer from CT scans each year and 15,000 dying from them, a 2009 study in the Archives of Internal Medicine estimated. PSA tests for prostate cancer, meanwhile, can lead to so many false positives and needless treatments that Otis Brawley, chief medical officer of the American Cancer Society, has said the tests are “50 times more likely to ruin your life than it is to save your life.” Prostate treatment can cause incontinence and impotence.

Many tests may not have such dire side effects, but their consequences can still be insidious. Preventive screenings typically result in many false positives, so when people who don’t need certain tests in the first place wind up with troubling results, they may embark on a “cascade of unnecessary, costly and in some cases risky follow-up tests and treatment,” Santa said.

Santa recently heard about a stressed-out middle-aged woman whose doctor decided to order an angiogram “just to make sure” she had no heart problems. The test showed she was fine, he said, but when the catheter was pulled out of her heart, her coronary artery got torn—and suddenly she had a significant heart issue. Such a situation is rare, he said, but it does happen.

In another instance, an older woman on her way to a mammogram appointment she didn’t need slipped on ice near the doctor’s office, breaking her hip, said Rosemary Gibson, author of the book, “The Treatment Trap,” and the “Less is More” series in the Archives of Internal Medicine.

So, given the growing alarm over unnecessary screenings, why do so many such tests still occur?

An unwieldy mix of factors—some cultural, others financial—seem to have created a perfect storm that keeps all the testing machinery in overdrive. Not only do doctors work in a system where thoroughness is prized, but they also must worry about malpractice suits and “pay for performance” plans, which can grade them on the screening tests they order—tests which may not be appropriate for every patient. Add to that people’s curiosity about newfangled tests and the American belief that more is better, and it’s no wonder that the testing frenzy is hard to contain.

And that doesn’t even account for the relentless advertising by hospitals and drug companies, which have huge financial motives to push screening. Brawley, who used to be a medical school professor at Emory University, said that he and his colleagues once calculated that if 1,000 men at a local mall participated in a free screening, Emory could bill Medicare and insurance companies $4.9 million for subsequent tests, biopsies and prostatectomies.

Indeed, The HealthFair Solution advertises its screening vans to hospitals on the Internet, saying “with patient revenue being down as much as 30 percent in some specialty physician groups, a partnership. . .can bring tremendous value to you.”

Drug companies also use testing to create demand for their products. In the 1990s, Merck essentially created the industry of bone mineral density testing in order to sell its osteoporosis drug, Fosamax, an investigation by National Public Radio discovered. The company figured out how to make cheap density testing machines, wound up buying out a medical device company, and convinced Congress to pass a law that allowed Medicare to pay for the bone scans, NPR found.

The machines produced tri-colored reports, with green meaning healthy bones, yellow meaning osteopenia, or bone thinning, and red meaning osteoporosis. It didn’t take long before droves of women were getting their bones scanned. And not only were women with osteoporosis taking Fosamax, but those with osteopenia were clamoring to get help with thinning bones—even though it wasn’t a disease. Merck had exactly the right prescription: a lower-dose version of Fosamax.

Now, debates over heart screening are taking center stage. The Society for Heart Attack Prevention and Education, SHAPE, a little-known nonprofit group, managed in 2009 to convince the Texas legislature to make insurance companies pay for CT coronary artery calcium scanning as well as carotid ultrasounds in men between the ages of 45 and 76, women between 55 and 76, and others at risk of developing heart disease.

SHAPE founder Dr. Morteza Noghavi, also director of American Heart Technologies in Houston, argues that the legislation reflects the medical community’s increased ability to understand and detect heart disease. But Consumer Reports gave the carotid tests its worst rating, while neither the American Heart Association nor the American College of Cardiology has recommended routine CT scans for patients without symptoms.

With the legislation, an estimated 2.4 million Texans are now eligible for these tests, potentially costing the state $480 million, said Dr Amit Khera, a Texas medical school professor, in a recent report in the Archives of Internal Medicine paper. His article was accompanied by a brief commentary by the journal’s editor, Rita Redberg, who declared: “When Texas leads the nation in the percentage of residents without health insurance, it is remarkable that Texas has chosen this path.”

The Florida legislature is now considering a similar bill.

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Contributing Writer Rochelle Sharpe is a Pulizter Prize-winning journalist with more than 25 years of health writing experience. Sharpe’s bi-monthly news feature for the Health Policy Forum focuses on issues related to health, wellness, and prevention. As a leading nonprofit health care research and consulting institute dedicated to improving human health, Altarum encourages open discussion and debate about the many challenges in health care today. All postings to the Health Policy Forum (whether from employees or those outside the Institute) represent the views of the individual authors and/or organizations and do not necessarily represent the position, interests, strategy, or opinions of Altarum Institute. Altarum is a nonprofit, nonpartisan organization. No posting should be considered an endorsement by Altarum of individual candidates, political parties, opinions, or policy positions. Read more.