October 2014

The Medicine

Looking for trouble

By Karen Hitchcock
Does medical screening do more harm than good?

I’ve had a mammogram request slip folded into the side pocket of my purse for two years. My GP gave it to me when I turned 40, telling me the time had come to start being screened. I put it in my purse and mostly forgot about it, feeling a slight tug of anxiety whenever it emerged in a wad of receipts. I’ll get to it soon, I’d think. Plan made. Every now and then, in the middle of the night, I’d worry: Maybe I have a cancer in me somewhere, growing quietly, waiting to burst into my bloodstream, spraying metastases to bone, liver and lung. I’d better get that mammogram. And then I’d fall asleep. So I was relieved when I started reading papers in major medical journals that claimed mass screening for breast cancer caused more harm than good. Off the hook.

Screening is a thing doctors do to healthy people, people without symptoms or signs of disease. The aim is to detect disease early so that it may be treated, and death or debility may be averted. It’s pretty hard not to be comforted by a good screen. We get screened for skin, cervical, breast, bowel and prostate cancer. We get screened for diabetes, osteoporosis, high blood pressure, and cholesterol. Newborns are screened for phenylketonuria, cystic fibrosis and hypothyroidism. There have been calls to screen people for dementia, for pre-diabetes, for obesity. I see my dermatologist once a year and get her to hunt my skin for melanomas. When I leave her office with the all-clear, I feel a sense of deep relief at having escaped death once again. Unfortunately, this is not the best way to detect skin cancer. The best way is to know your own skin and watch it vigilantly for deviations yourself. To the heavily freckled this proposition is laughable.

Some forms of population screening seem unambiguously good. The neonatal program causes little harm and saves lives. Whereas screening for “early dementia” is probably a bad idea, given that should your doctor detect it there’s nothing you can do except dread the future, and watch your family question your decisions and start speaking to you really slowly. Being searched for disease can be injurious.

In Australia, more than 3000 men die each year from advanced prostate cancer. However, a large proportion of men who live long lives will die with their prostate harbouring a cancer that is neither symptomatic nor a contributor to their demise. Public health organisations in most countries, including Australia, no longer recommend mass screening (using the prostate-specific antigen, or PSA, blood test) among asymptomatic men. This is because the program has been repeatedly shown to cause far more harm to the healthy than benefit to the “sick”. The data vary, but the most positive figures show that for every 1000 men tested for ten years, two men will avoid dying from prostate cancer, two will avoid cancer that spreads around their body, 87 will have a biopsy due to a falsely positive test, 28 will be diagnosed with a cancer that would never harm them during their lifetime, and 25 will have their prostate removed or irradiated unnecessarily.

A man can live without his prostate gland. If you tell people they have cancer in an organ they don’t need, most opt to have it removed. The problem is that removing it leaves a large number of men impotent, incontinent or both. An 80-year-old man in my clinic started crying. “They didn’t tell me it could happen,” he said and looked down at himself with disgust. “What’s the point of living now, like this, useless?” Before you get the simple, painless, free blood test, it’s important that you know the facts: you are ten times more likely to be rendered impotent than to have your life saved.

This year the Swiss Medical Board recommended that Switzerland’s breast cancer screening program cease. The board’s reasoning was based on American data showing that for every life saved (about 1 per 1000 women screened), between 70 and 100 women screened have an unnecessary biopsy, and between 3 and 14 women are treated with surgery, radiation and/or chemotherapy unnecessarily. The recommendation caused an uproar: it was against international consensus guidelines; it might “upset women”.

Mobile health-screening vans have started popping up all over the place in Australia. They do the rounds of churches and RSLs, setting up shop for a day like Girl Guides cookie sellers. They are advertised heavily, quoting statistics like “80% of strokes can be prevented”. That is true, but they are prevented by things like exercise and avoiding smoking, not by paying a private company to perform a single ECG and a Doppler ultrasound of your neck arteries from a van in a church car park. In the US, these health-screen businesses work with private hospitals that lend their name and logo for legitimacy. When the tests show something abnormal you are directed to the hospital, an institution that will be rewarded financially for doing things to you: fancier tests, appointments, interventions, treatments. This may or may not act as a disincentive for doctors to tell you the truth, which is that you should go home and stay away from privately operated mobile health-screening vans.

It’s easy to convince people that a check-up is a good idea. Who knows what bad things might be happening in your body without you knowing? But screening for disease is not the passive, completely benign process it appears to be. Some screens confer a sense of security that may be illusory. Some may lead you to harm, while others save lives. Before you consent to being screened for anything, ask about the benefits and the risks given your particular medical history. What might you lose if you sign up for years, waiting to see if you’re the one in a thousand? 

Karen Hitchcock

Karen Hitchcock is a doctor and writer. She is the author of a collection of short fiction, Little White Slips, and the Quarterly Essay Dear Life: On Caring for the Elderly.

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