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To Test Or Not To Test? Comprehensive Information About Screening Procedures

Despite vast advances in medical technology, confusion reigns over when to apply many common medical tests. Here’s what you need to know about routine screening procedures.

Posted October 15, 2012 by Leslie Garisto Pfaff

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Dr. James Saidi
Communication is an essential part of health screening.
Photo by Colin Archer/Agency New Jersey.

Dr. James Saidi
Glen Ridge urologist Dr. James Saidi confers with patient Carl Gelormine of West Caldwell.
Photo by Colin Archer/Agency New Jersey.

Never in human history have there been so many ways to screen for so many diseases, from mail-order DNA tests to CT scans of the lung that can spot a tumor the size of a blueberry. Yet rather than making life easier—or even healthier—the testing boom has perplexed patients and engendered a kind of screening backlash. 

Take mammography: Should it be an annual test beginning at age 40, as the American Cancer Society recommends, or a biennial test starting at 50, per the latest guidelines from the government-funded U.S. Preventive Services Task Force (USPSTF)?

And what about PSA, the decades-old test for prostate cancer? The American Urological Association recommends a yearly PSA for men 50 and older; the USPSTF does not agree. 

To add to the confusion, the American Board of Internal Medicine Foundation, in conjunction with Consumer Reports, this spring recommended against the routine use of 45 common screening tests and procedures, including bone mineral density scans in women under 65 who aren’t at risk for osteoporosis and cardiac stress tests in patients without risk factors for heart disease.  But given that most of these tests save lives, why not just administer them?

The problem, says Dr. Alfred Tallia, professor and chairman of family medicine and community health at UMDNJ-Robert Wood Johnson Medical School, is that virtually all tests carry some kind of risk. The conflicting recommendations, he notes, stem from varying visions of “whether the results of screening outweigh the harms.”

False positives, for instance, can lead to anxiety, unnecessary and potentially harmful medical procedures like biopsies, and additional, often costly testing. In fact, the Institute of Medicine estimates that excessive testing, and the overtreatment it often leads to, costs the U.S. health system some $210 billion annually.
“We teach medical students to discuss the facts, including risks and benefits, about testing with each patient,” says Tallia, “and let him or her decide whether the potential benefits outweigh the risks.” 
To help make that decision a little easier, we’ve gathered opinions, pro and con, on the most common screening tests from experts around the state. 

The Annual Physical

The idea of a head-to-toe annual physical—complete with EKG, chest X-ray and  full blood workup—is actually a leftover from an old American Medical Association precept of the 1960s, says Tallia. By the ’70s, experts in family medicine were already recommending periodic health screenings targeted to a patient’s age, gender and health risks. Are you a man between 18 and 64 with no risk factors for cardiovascular disease? The National Institutes of Health (NIH) recommends that you get your blood pressure checked every two years and your blood cholesterol screened, starting at 35, every five. At those screenings, your doctor should also be monitoring your height and weight and screening for alcohol and tobacco use and depression. And as of 2013, she may also test you for HIV, as the USPSTF is expected to recommend later this year. What about that EKG? “Absolutely non-predictive,” says Tallia. And the routine chest X-ray? “Totally nonpredictive—even in smokers.” 

The takeaway: Until age 65, you probably don’t need an annual physical, but you should see your doctor for periodic health screenings—the appropriate interval should be based on your risk factors. You should also get a regular blood-cholesterol workup and blood pressure check.  For a complete list of NIH recommendations, go to nlm.nih.gov/medlineplus/ency and search health screening.

Bone Mineral Density Testing
The dual-energy x-ray absorptiometry scan (DEXA) can detect bone loss, usually in the lower spine and hips.  And screening matters, because fragile bones can lead, later in life, to painful and often disabling fractures of the hip and vertebrae.  The National Osteoporosis Foundation, the American Academy of Family Physicians and the USPSTF recommend that, absent risk factors, all women should get a bone density scan at 65, and men at 70. 

But doctors don’t always adhere to those guidelines.  Dr. Gina Del Giudice, a bone densitometrist and senior partner at the Rheumatology Center of Princeton, suggests that her patients get a baseline screening at perimenopause (the lead-up to menopause) because, she says, “the most significant bone loss is going to occur in the first three to five years after menopause.” And Dr. Gregory Heifler, a family physician in Montclair, adds that most of his female patients “have already had a DEXA scan one year past menopause.” 

That may be because osteoporosis and its precursor, osteopenia (defined as lower than normal bone density), have gotten extensive press coverage over the past decade.  And it may also be the result of a long list of potential risk factors, including early menopause, Caucasian or Asian extraction, low-body weight, short stature, sedentary lifestyle, insufficient calcium and vitamin D intake, smoking, alcohol, celiac disease, overactive thyroid, and medications like steroids, proton pump inhibitors, and SSRIs. Still, testing can sometimes lead to unnecessary or needlessly prolonged treatment—generally, with bone-building bisphosphonates—and that treatment carries its own risk, including the possibility of bone fractures.
But here’s a bit of good news to make your decision to scan (or not) a little easier: In 2008, the World Health Organization developed the FRAX questionnaire to help determine your 10-year risk of developing a major fracture.  (To see the test go to shef.ac.uk/FRAX/ and click on calculation tool.)  Should you repeat the scan?  A 2012 study from the University of North Carolina suggests that women whose scans don’t indicate significant bone loss may be able to wait 15 years for a follow-up.
 
The takeaway: Women without risk factors for osteoporosis should have a DEXA screen at 65, men at 70; talk to your doctor to see if you’re at risk and might need earlier screening.

Cardiovascular Screening
When screening for cardiovascular disease, should your doctor go low-tech (blood pressure and blood-cholesterol tests), higher tech (an exercise stress test that monitors heart rate and blood pressure while you work out), or highest tech (a nuclear stress test that images blood flow)? According to Dr. Marc Klapholz, director of cardiology at UMDNJ-New Jersey Medical School, low tech wins the day. “In the absence of cardiac symptoms,” he says, “stress testing isn’t recommended.”  In addition, says Klapholz, your doctor should monitor you for signs of diabetes, itself a risk factor for cardiovascular disease; for overweight or obesity; and, especially, smoking.

The takeaway: Have your blood pressure and blood cholesterol screened regularly, and make sure your doctor is monitoring you for diabetes, obesity and smoking. For an individualized guide to when and how often these tests should be administered, go to nlm.nih.gov/medlineplus/ency and search health screening.

Mammogram
If you’re confused about mammograms, you have good reason. The test, which uses low-energy X-rays to examine the breasts for cancer, has been hailed as a lifesaver and held up as an example of everything that’s wrong with our medical system, including inefficiency, excessive cost and  overreliance on technology.

The ACS has long recommended that women at normal risk begin mammography at 40 and continue with annual mammograms as long as they’re in good health. In 2009, however, the USPSTF concluded that, until age 50, the decision to start mammography should be between a woman and her doctor, and that from 50 to 74, the test should be done every two years. Dozens of studies conducted over more than four decades have yielded conflicting results, but one of the most recent—a 2011 Swedish study—found that starting mammography at 40 rather than 50 resulted in a 26 percent reduction in breast cancer mortality.
Dr. Nancy Elliott, a breast surgeon and founder of the Montclair Breast Center, suggests that women “sit down with a specialist and assess risk.” That’s important, she says, because some of the most common risks for breast cancer are just that—common; they include increasing age, overweight or obesity, having a first child after 29 (or never having children), sedentary lifestyle and living in the Northeast. “I believe you should have a yearly mammogram starting at age 40,” says Elliott, who feels that “the advantages of early detection are significant, and not just in terms of survival—sometimes the advantage is that you don’t need chemotherapy.”

Women should also find out whether their breast tissue is dense, since cancer is harder to find in dense breasts (but can often be picked up with a breast ultrasound).  In fact, this year a bill requiring radiologists to inform women if they have dense breast tissue was introduced into the New Jersey legislature. Four other states have passed a similar law.

Elliott believes strongly that women should consult with and have their mammograms done by breast specialists, noting that specialists who read mammograms day in and day out are more likely to find cancers.  “If you’re going to have a mammogram,” she advises, “then make it count.”

The takeaway: If you’re between 40 and 49, consult with a doctor (ideally, a breast specialist) about when and how often to get a mammogram; start mammography at age 50 if you haven’t already, and speak with your doctor about whether it should be done every year or every other year thereafter. And find out if you have dense breast tissue.

Testing for Colorectal Cancer
There’s little debate about screening for colorectal cancer and polyps: Colonoscopy—an examination of the colon with a small camera on a flexible tube—“is considered the gold standard,” says Dr. Steven Peikin, head of the Division of Gastroenterology and Liver Diseases at Cooper University Hospital.  And virtually every medical organization, from the ACS to the USPSTF, recommends that men and women without risk factors or symptoms have their first colonoscopy at 50.  (African-American men and those with a family history of colorectal cancer should begin at 45.)  After that, says Peikin, the test should be administered every 10 years “if you’re at normal risk.”

Other tests that screen for both cancer and polyps are flexible sigmoidoscopy, double-contrast barium enema, and virtual (or CT) colonoscopy, but they’re not as effective as colonoscopy.  A variety of stool tests also screen for cancer, but not for polyps.

The takeaway: If you’re at normal risk, have your first colonoscopy (or other colorectal screening test) at or by age 50 and every 10 years thereafter until age 76.  Talk to your doctor about the risks and benefits of colonoscopy versus other tests.

Dental Exams
Regular dental exams can save more than your teeth.  In addition to checking for tooth decay, Dr. Jay S. Schuster, a Morristown dentist, says, “your dentist should do an oral-cancer screening and check for periodontal [gum] disease”—a condition that’s been associated with heart disease, stroke, diabetes, osteoporosis and low birth-weight babies.  Like Schuster, the Mayo Clinic recommends getting an exam twice a year.  “But people with serious dental issues, like periodontal disease, may need an exam every three months,” Schuster notes.

Though there are no hard-and-fast guidelines for dental X-rays, the American Dental Association does issue recommendations to be used in conjunction with your dentist’s judgment, among them that new patients get a full set of X-rays. “As a rule, I like to take posterior bitewing X-rays, which show decay between the teeth and can also monitor bone loss, once a year,” says Schuster, an interval in sync with the ADA’s recommendation of every 6 to 18 months in patients with previous decay or who are at risk for decay.  (If you’re one of the lucky few with no cavities, the ADA suggests that bitewings be taken every two to three years.) Whether you’ll need more frequent X-rays or a repeat of that full set depends on your overall dental health.  (For information on the radiation risks of various screening tests, see “The Fallout of Medical Testing,” below.)

The takeaway:
Make sure your teeth are examined regularly and that your dentist also checks for oral cancer, generally every six months. Speak with your dentist to determine the interval best for you.
  
Testing the Eyes
Many of us don’t trundle off to the eye doctor until we hit 40 and discover that reading is no longer the breeze it used to be.  Does that mean we’ve been neglecting our eyes? For those without vision problems, the answer is probably not.  The American Academy of Ophthalmology recommends that patients with normal vision and no risks for eye disease (like family history or diabetes) get a baseline exam at 40.

“That’s when we start to get concerned about glaucoma,” explains Dr. Linda Hsueh, an ophthalmologist with the Summit Medical Group, who notes that the disease, which affects the optic nerve and is marked by increased pressure within the eye, is often  without symptoms until it progresses to a more serious stage.  After 40, she recommends routine exams every year or two until 65, and then every year thereafter.  (If your eyes are less than perfect, you should probably have an exam every two to three years before age 40, Hsueh suggests.)

You may need to be seen more often if you have a strong family history of glaucoma or a past eye injury (which can predispose you to glaucoma), if you’re taking medications that can affect the eye, or if you suffer from hypertension or diabetes. Diabetes is a special concern.  A 2012 study out of Johns Hopkins University found that incidences of diabetic retinopathy (damage to the retina that can cause blindness if left untreated) increased 89 percent over the past decade.  The good news:  “A thorough, dilated routine eye exam,” says Hsueh, “will probably pick up most problems.”

The takeaway: If you have normal vision, get a baseline exam at 40.  If you have diabetes or vision problems or are at risk for glaucoma, have your eyes checked periodically before then.  After 40, talk to your doctor about the need for routine exams.  

The Gynecological Exam
Like the annual physical, the yearly gynecological exam is largely a relic.  “Unless a woman has symptoms that need to be checked out, she can have a gynecological exam every two to three years,” says Dr. Meena Devalla, an obstetrician/gynecologist in Belleville. A host of venerable organizations, including the USPSTF, the ACS and the American Society for Colposcopy and Cervical Pathology, agree. The visit, Devalla says, should include a full pelvic examination and, when appropriate, a Pap test, which examines cells taken from the cervix to check for cervical cancer and HPV infection (which can cause cervical cancer). The doctor also should screen for sexually transmitted diseases such as chlamydia.

Guidelines issued in March by the aforementioned groups recommend that women (including those who’ve gotten the HPV vaccination) have their first Pap test at 21 and every three years thereafter.  The exception: If your doctor is co-testing for cervical cancer with both a Pap test (which can find cancer and precancerous cell changes) and an HPV test (which detects HPV infection, sometimes before precancerous cell changes occur), you can wait five years between screenings after age 29 (co-testing isn’t recommended for women under 30).

Routine screening for ovarian cancer using the CA-125 blood test (which detects a substance found in high amounts in women with ovarian cancer but also in women with other conditions, including liver disease and pregnancy) has been abandoned by most doctors for healthy women with no special risk factors. And in September, the USPSTF issued a final recommendation against routine screening with the CA-125 test as well as ultrasound, since both screens can result in false positives, which can lead to potentially harmful procedures such as unnecessary surgery, including removal of the ovary.

The takeaway:  If you’re 21 or older, see your doctor for a routine GYN exam every two to three years.  Have your first Pap test at 21; find out which testing methods your doctor uses, and schedule regular screenings accordingly (for guidelines, go to cancer.gov/cancertopics/factsheet/detection/Pap-HPV-testing). And talk with your doctor to see if risk factors make you a candidate for ovarian-cancer screening.

The PSA
Some of Dr. Robert Weiss’s patients claim that PSA stands for Promoting Stress and Anxiety, and Weiss, a urologist in New Brunswick, gets it.  He notes that an elevated score on the test—which measures the amount of a molecule called prostate-specific antigen in a patient’s blood to screen for the presence of prostate cancer—doesn’t necessarily mean that cancer is present, only that it might be. If the PSA score is between 4 and 10, the patient and his doctor have to decide whether to biopsy the prostate or wait and rescreen down the road. Given that only 20 percent of men with elevated PSAs actually have prostate cancer, a lot of men with positive results are getting unnecessary biopsies or experiencing unnecessary anxiety.

That alone might convince you to take a pass on the test.  Then last year, the USPSTF, after finding no evidence in the scientific literature that PSA screening kept men from dying of prostate cancer, issued a recommendation against the test for all men in all risk groups.  That elicited a concerned response from many urologists, as well as the American Urological Association, who believe that while the test is clearly not perfect, the research data was flawed.  “The problem with the data [which followed patients with prostate cancer for up to seven years] is that you need to follow patients for at least 10 years, and probably 12 to 15 years, because of the slow-growing nature of prostate cancer,” says Dr. James Saidi, a urologist in Glen Ridge.  He adds that there’s been a significant decline in prostate cancer mortality since 1992, six years after the U.S. Food and Drug Administration approved the PSA.  “That’s a strong indication,” says Saidi, “that screening may work.”

So what to do?  Neither Weiss nor Saidi order the test automatically; instead, they educate their patients about its benefits and risks and let them decide for themselves, emphasizing that certain men—African-Americans and those with a family history of prostate cancer—are at higher risk for the disease.  “I explain that the PSA isn’t an exact test,” says Weiss, “but it’s the only way we have to detect prostate cancer.”  The PSA is generally done in conjunction with a digital rectal exam (DRE), which allows the doctor to detect abnormalities in areas of the prostate that can be reached manually.  The PSA can find cancer throughout the entire prostate and at an earlier stage, but the DRE can sometimes pick up cancers even when a PSA is negative, which is why doctors prefer to combine the tests. 

The takeaway: Starting at age 50 (or at 45 if you have risk factors for prostate cancer) talk with a urologist about the potential risks and benefits of having a PSA, along with a DRE.

Skin Cancer Screening
When it comes to finding potential skin cancers, the screening tool of choice is still the human eye—not only your doctor’s, but your own.  “Everyone should be doing a monthly self-exam at home,” says Dr. Cheryl Fialkoff, a dermatologist in Liberty Corner and Somerville. The procedure, in theory at least, is simple: Check your body, head to toe, for anything that looks or feels abnormal and, if you find something suspicious, seek prompt medical evaluation.

Of course, knowing what’s abnormal isn’t always easy, which is why the American Academy of Dermatology offers a “body mole map” that includes skin-cancer visuals, a guide to self-examination, and a place to chart results (go to aad.org and search body mole map).  It’s also why Fialkoff and other experts recommend that a baseline full-body exam—which can identify moles and other irregularities that should be monitored for changes—be performed by a dermatologist or other health care practitioner, and that you discuss the need for additional periodic full-body scans with your doctor.  (Your risk factors—like fair skin, freckling or moles, sun exposure, history of sunburn, previous skin cancers, and family history of melanoma—will help your doctor make a determination.)

These simple tests aren’t without controversy.  In 2009, the USPSTF concluded that there wasn’t enough research to determine whether full-body exams and self-exams were either beneficial or harmful.  The report did note that there was “fair evidence” that full-body exams were “moderately accurate” in detecting melanoma—the deadliest form of skin cancer—though no such evidence existed to justify self-exams. But it also stated that a paucity of studies made it impossible to conclude that early detection actually reduced deaths from skin cancer.

“Research is ongoing,” notes Fialkoff, who cites a 2012 German study showing that skin cancer screening has the potential to save lives. “While any systematic recommendations will come from further studies,” she says, “an individualized approach is the best way to determine the proper course for each patient.”

The takeaway:  Talk to a dermatologist about the efficacy of self-exams and in-office full-body scans, especially if you have risk factors for skin cancer.

Leslie Garisto Pfaff frequently writes about health for New Jersey Monthly.

***********************

The Fallout of Medical Testing

Advances in radiology have rendered most imaging tests far safer today than they were in the past, yet concerns remain, in part because of the potential dangers of cumulative exposure.  A single dental X-ray, for instance, delivers .005 millisievert (mSv) of radiation, roughly one-sixth of what you’d be exposed to on a cross-country flight, while a typical mammogram puts out .4 mSv, equivalent to 13 of those flights. (In case you’re wondering, the Federal Aviation Administration estimates that airline crewmembers—who are officially classified as “radiation workers”— have a 1 percent increased lifetime risk for radiation-induced cancers.)

Taken alone, neither of these tests poses much of a risk; unfortunately, when your doctor orders a test, he or she isn’t likely to ask about the other tests you’re getting or the ones you’ve had in the past.  That means that, depending on the number of tests you’ve had over a lifetime, your cumulative radiation exposure could pose a risk for cancer.  Consider that the use of radiological imaging procedures has increased sevenfold since the early 1980s, and that a CT scan of the colon, for instance, delivers 10 mSv (the equivalent of 333 cross-country flights), and you start to understand why some experts are wondering whether we’re getting too much of a good thing.

That doesn’t mean we, as consumers, should refuse these tests, many of which have replaced less effective and more invasive screening and diagnostic procedures.  “Some risk has been attributed to procedures involving ionizing radiation, and this should be weighed against the potential medical benefits that the procedures provide and the relative risks associated with alternate procedures,” notes Roger Howell, chief of radiation research at New Jersey Medical School.

While there hasn’t been sufficient research to determine how much radiological testing is too much, it’s certainly worth talking to your doctor about your imaging history and asking if that screen she just ordered really justifies the potential risk.  (For a list of radiation doses from common procedures, go to hps.org/documents/Medical_Exposures_Fact_Sheet.pdf.) —L.G.P.


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