Take charge of your health: use medical check-ups wisely
The traditional medical check-up, as practised in the past few decades, was very extensive and reassured healthy people that they weren’t sick or about to die. In a typical physical exam the physical took the pulse, temperature and blood pressure, prodded the abdomen, made people stick out their tongues and say “AAAH”, peered into the ears, tapped the knees with a small hammer, listened to lungs, heart and neck (carotid artery), ordered a variety of blood tests and generally gave the person a thorough going over. Both the physician and those being examined firmly believed — given no evidence to the contrary, as the subject hadn’t been much studied until 15 years ago — that finding and treating disease at an early stage would prevent worse trouble down the road. Since Health News last discussed medical check-ups in 1984, the annual physical check-up for healthy, non-pregnant adults has been dramatically revamped and is largely being abandoned. While some physicicans still give their exhaustive, regular physical examinations, and although many people demand them, old fashioned medical check-ups — expecially “executive check-ups” — are slowly going the way of ancient practices such as leeching and cupping. In their place more streamlined and personalized of the periodic medical examination, together with lashings of advice, counseling and exhortations, are coming in for the 90s. It’s a touchy subject and there are probably as many opinions as there are physicians.
Many routine medical tests coming under fire
Several medical committees and task force have studied the benefits versus risks of annual check-ups. During the 1970s, as the cost of medical care soared and new technologies became widely available, Canadian and U.S. governments began to investigate the usefulness of routine medical examinations. The Canadian government commissioned and medical task force — the Canadian Task Force on the Periodic Health Examination — to study the health of Canadians and evaluate the tests usually done at routine check-ups. The aim was to decide which tests should be included, which omitted, and which done only for selec ted “at-risk” individuals. First reporting in 1979, the Canadian Task Force — made up of more than 40 scientists, clinicians and consultants spanning a wide range of disciplines — gave its verdict on 78 different conditions and medical procedures, suggesting which were worth doing, which not and which should be done only for certain “at-risk” groups. The Canadian Task Force is a world leader in preventive health care, highly influential and internationally recognized as the first to develop rigorous criteria to assess the value of routine screening tests. The Canadian Task Force (CTF) looked at every aspect of the medical examination: “hands-on” procedures such as skin and rectal exams; lab tests; X-rays; electrocardiograms (to detect heart abnormalities); preventive measures such as immunization and stool test (to detect colon/bowel cancer) as well as the usefulness of lifestyle counseling. Many of the procedures which were previously a ritualistic part of annual physical check-ups had never been scrutinized or questioned for their benefits in preventing disease nor for their cost to the health system. After reviewing the scientific reliability and quality of the evidence, the risks and benefits of the various procedures, their acceptability and cost, the available tests were either endorsed by the CTF for use at periodic medical check-ups, rejected, or recommended only for selected groups prone to certain disorders. The Canadian Task Force and several American health authorities now suggest that the routine “everything-and-the-kitchen-sink” approach to annual medical check-ups be abandoned. In its place they propose a lifetime health care plan based on a set of age-and-sex-related health protection packages. In essence the health-protection plan determines how often check-ups are needed and which tests are appropriate for the person’s sex, age and “risk” profile. Above all, the CTF stressed the need to each and ever office visit as an opportunity for counseling on practices that increase disease risks such as smoking, poor diet, failure to use seatbelts, lack of exercise or alcohol abuse.
According to the Canadian Task Force, routine annual check-ups for healthy non-pregnant adults should be replaced by tests geared to age, sex and individual health risks. The recommednations are to be regarded as the minimum necessary, given the balance of risks against benefits. They are not inexorable rules carved in stone but guidelines for medical practitioners who will adapt them and conduct their own version of the medical check-up, depedning on their experience and the risk profile of the person being examined. The CTF recommendations are re-evaluated from time to time in the light of new findings. In its recent updates, the Canadian Task Force has re-assessed the preventive usefulness for symptom-free people of several tests — such as those for thyroid function, prostate cancer, chlamydia (a common sexually transmitted infection) and testing for mental deficits in the elderly. The CTF stood by its recommendation against routine testing for these conditions. However, it stressed the need for thyroid tests in newborns, cystic fibrosis chekcks for persons with relative who have this disease, hearing tests for people frequently exposed to loud noise and the encouragement of b reastmild feeding for low birthweight babies.
Although the United States Preventive Services Task Force (USPFTF) agrees with most CTF guidelines, other health agencies — including the Canadian Cancer Society, the American Cancer Society and the American Medical Association — disagree with some of the Canadian Task Force recommendations, calling for more extensive tests (often based on less rigorous criteria). Thus, while there is broad agreement on the need to tailor tests to individuals, medical authorities disagree, sometimes widely, on the conditions to test for and which procedures should be used.
A few broad areas of agreement
Amid the controversy, there’s general agreement among most North American health authorities about giving up several procedures formerly done at check-ups, such as routine chest X-rays, electrocardiograms, many blood tests, examinations of the spleen and liver rectal exams (although some U.S. organizations promoted annual rectal examination for prostate cancer in men over age 40).
Most medical agencies agree on the need for:
* A thorough family medical history to determine individual health risks.
* Healthy weight maintenance and low fat diets (broadly shared goals).
* Routine blood pressure measurements once every two to five years and at each physician visit in all adults over 18 years old. (The CTF recommends that blood pressure be checked in all adults at least every five years and biannually if visiting the doctor for other reasons.) Treating moderately high to high blood pressure in all age groups is known to reduce the risk of stroke and heart attacks in the elderly.
* Childhood immunization is universally promoted against infectious disease such as tetanus, poliomyelitis, whooping cough, rubella, diphtheria, measles, mumps and meningities.
* Annual influenza shots are strongly promoted for the over 65s. Each year about 2,000 Canadians die of influenza and its complications, many of them elderly. With winter approaching and this year’s influenza viruses poised to strike, all seniors over age 65 and other risk groups (such as healthcare providers, people with lung ailments) are urged to get their flu shots now. Although experts are never entirely sure which influenza viruses will hit each season, they have a fair idea and can prepare vaccines ahead, ready for injection by late September/early October. Last year’s (1990/91) flu outbreaks in Canada were relatively mild but ths season’s could be worse. Influenza viruses continually mutate (undergo small alterations), so that each year’s vaccine contains slightly different components. The 1991/92 vaccine contains: A Taiwan (same as last year), A Bejing and B Panama strains. every now and then a genetic change in an “A” type influenza virus causes a killer epidemic (such as the 1958 Asian and the 1968 Hong Kong gloval pandemics). Yet, although vaccination prevents or lessens the severity of influenza, takes a minute, doesn’t hurt and has little if any after-affects, fewer than 30 per cent of the over 65s get their annual flu shots. This year, people deterred by fear of side effects might be persuaded to go for immunization as the new “split virus” vaccine introduced for Canadians by most provinces (already widely used in the U.S. and Europe) has been less side effects than the older “whole virus” vaccine. At most, influenza immunization causes slight malaise and muscle aches starting eight to 12 hours after injection, lasting just a day or two. It’s certainly worthwhile for those in danger to be vaccined!
Besides everyone over age 65, others advised to get annual flu shot include:
* residents of nursing homes or chronic care facilities;
* Anyone with ongoing lung disease (such as emphysema, bronchitis, TB, asthma);
* people with diabetes, cancer, chronic heart or kidney diseases;
* healthcare workers (e.g., physicians, nurses);
* persons who provide essential services (e.g., police and firemen);
* anyone else who wants to reduce their risks of getting influenza
* Clinical breast examinations by a competent healthcare professional is generally promoted for women over age 50, and Canadian health authorities also support mammograms (special breast X-rays) every two years for women aged 50-69.
* Papanicolaou or “PAP” tests to detect premalignant or cancerous changes of the cervix (opening of the uterus) are advised for women once they become sexually active or from age 18 onwards. All sexually active women should have regular Pap smears in order to catch cervical cell changes in time to prevent their development into full-fledged cancer. However, the recommended frequency of Pap tests remains in dispute. The latest recommendations from the Workshop Group, supported by the Canadian Health Service Directorate, the Canadian Cancer Society and the National Cancer Institute of canada, suggest that Pap smears be done every three years if two consecutive tests prove negative (show no suspicious changes). However, some physicians prefer to do annual Pap smears up to age 69-plus in all sexually active women. (For more on Pap smear screening see Health News October 1989 issue.)
Understanding the pros and cons of medical screening
In checking for disease, it is crucial to understand the difference between “screening” tests done on healthy symptom-free people to find signs of disease and “diagnostic” test used in those who complain of some definite symptom(s) such as pain or bleeding. Screening tests are not the same as diagnostic tests. Screening is done to detect so far unrecognized disease in otherwise healthy people. It entails large scale testing of symptom-free persons who usually have no known risk factors other than age or gender. (For instance, statistically, just being male and over 40 carries increased risks of heart disease.) By contrast, diagnostic tests are done to determine the cause of a noticeable symptom — such as stiffness, pain, fever, a lump, rash or other abnormality. “Selective screening” means testing symptom-free people known to be at speical risk for certain disorders (e.g., cholesterol tests on smokers at extra risk of heart disease). “Case finding” means using doctor visits as an opportunity to do specific tests for certain disorders.
To be worthwhile (given accurate, cheap, easily done tests), screening must not only detect disease early but also be done for disease where there’s an available treatment that’s effective at a pre-clinical stage, before detectable symptoms appear. The trick in deciding whether a certain test is justified is to balance the number of individuals that might benefit from finding and treating a particular disease at an early stage against the possible harm. Not surprisingly, there is an ongoing debate about which tests and procedures merit the possible cost, damage and anxiety created by widespread testing. In fact, there is hardly any area of medicine more controversial than screening tests. Different health and medical organiations, examining the same data, may arrive at different conclusions and draw up separate guidelines. In many medical areas where information is incomplete, health professionals can only make an educated guess in deciding which tests to do at routine check-ups.
Some drawbacks of widespread sc reening
High cost in one major drawback to giving all adults annual check-ups and screening the whole population to detect the tiny minority who are at elevated risk of certain conditions. Even if the tests turn up someone who has a higher-than-average chance of developing a disease — for instance a high blood cholesterol predisposing to heart disease — not all will take the necessary steps or alter their diets to reduce the danger. Besides the dollar cost, there’s always a chance that the tests which search for disease can cause damage. For example, certain tests produce many “false positive” results, suggesting that someone has a disease — such as diabetes, bowel or breast cancer — when it’s not present. The mistaken result can create unnecessary worry, perhaps labelling someone as “potentially sick.” A false positive reading can trigger a cascade or waterfall-like effect where one wrong result leads to a whole battery of needless tests with more and more invasive procedures ordered, some of which may be unpleasant and even risky. For instance, a false positive result of the test for occult (hidden or stale) blood in stool will be followed by further investigation for bowel cancer, including X-rays and perhaps a colonoscopy (examination of the colon via a long viewing tube) and surgical biopsy (tissue removal). The person is thu subjective to several anxiety-provoking procedures even though the occult blood test was wrong and there was no polyp (growth), cancer or other bowel abnormality present in the first place.
Highlights of some key issues in the
Through the years, Health News has dealt with several current controversies about screening tests. Discussions centre on their value, how frequently they’re needed and whether they’re worth doing. Some tests not recommended for average healthy persons are advised for groups at risk of certain diseases. The following is a brief recap and update on some screening debates already covered by Health News.
* The cholesterol dilemma: to test or not to test
Since the June 1988 issue of Health News covered the cholesterol story in depth, there’s still no universal agreement about whom to test for blood cholesterol, when, how often nor what the “safe” levels is. All agree on testing those with known cardiac risks, such as smokers, the obese, diabetics, hypertensive (with high blood pressure) and people with a family history of early heart attact. But health agencies are divided on the merits of screening all adults to permit preventive therapy and try to decrease coronary risks before people have a heart attack or disabling stroke. The U.S. Preventive Service Task Force, the American College of Physicians (ACP) and the National Cholesterol Education Program support nations-wide cholesterol tests for all U.S. citizens aged 20 to 74 every five years — a policy that’s been roundly attacked by several medical authorities. British experts oppose widespread cholesterol screening, instead promoting the “risk” approach — testing only those with known cardiac risk factors. Most Canadian health experts, including the Toronto Working Group on Cholesterol Policy (a highly regarded authority on the subject) promote regular cholesterol tests only for men aged 35-60 with one or more other coronary risk factors: smoking, a family history of hyperlipidemia (high blood lipids), diabetes, sedentary lifestyle, abdominal obesity and close relatives with early heart attack. The Toronto Working Group also recommends blood cholesterol tests for women aged 35-60 who have at least two of the cardiac risk factors listed above. Most Canadian experts consider mass cholesterol screening potentially harmful — straining health care resources, needlessly treating people who may never develop heart disease, possibly labelling symptom-free, healthy individuals with marginally elevated blood cholesterol as “almost sick.” Other arguments against cholesterol screening are: insufficient proof of its usefulness; the lack of standardized laboratory techniques; to few well-trained personnel to do the tests; to few registered dieticians to give cholesterol-lowering advice; the difficulty of altering entrenched eating habits and the uncertain pay-off in life prolongation. Many experts suggest that rather than mass cholesterol screening everyone should eat heart-healthier, cancer-preventing, lower fat diets.
* The cancer screening debate
While many U.S. authorities such as the American Cancer Association recommend extensive cancer checks (of the thyroid gland, testicles, prostate, lymph nodes, mouth, throat, skin) in everyone over age 20, the Canadian Cancer Society does not consider the evidence compelling enough to promote such intensive cancer surveillance. Against it, experts cite the incomplete data on the advantages of mass cancer tests, research still in a state of flux (new studies being started and old ones being updated) and the widely divergent opinions.
* Breast cancer screening controversy rages on
The June and August 1991 issues of Health News fully discussed the arguments over who should have regular mammograms (breast X-rays). While several U.S. health agencies promote regular mammography starting at age 40, most Canadian experts recommend it only from age 50 onwards. (For more on breast cancer see health News June and August 1991 issues.)
* Bowel cancer screening debate continues
Colorectal (bowel) cancer accounts for 15 per cent of all cancers and affects six per cent of women and five per cent of men. The question is whether to test the whole population over age 50 or only known risk groups. There are many problems in colon/bowel screening. Firstly, the fecal occult blood tests — which look for traces of blood in stool from bowel or colon growths — although cheap and easy to do are untrustworthy. They rely on the collection of three consecutive stool samples for analysis and, as one experts comments, “people don’t like to mess about with their stools, so many don’t comply.” Secondly, a positive test isn’t always followed up by thorough investigation. Thirdly, occult blood stoll tests yield many false results. A mistaken positive result may occur because of recently-eaten red meat, compounds in certain fruits, iron pills or gastric bleeding due to aspirin or other anti-inflammatory drugs. Somewhat risky procedures may then follow on the basis of a false positive reading, causing much aggravation and anxiety.
Besides false positives, false negative occult blood tests are an equally frequent danger which might wrongly reassure people and deter them from seeking attention for symptoms of real bowel disorders. (One physicians warns that “rectal bleeding shouldn’t automatically be ascribed to hemorrhoids as 16 per cent of colon cancer patients also have hermorrhoids”.)
Sigmoidoscopy, with a flexible viewing tube inserted via the rectum to look into the colon/bowel and colonoscopy (with a longer tube that sees further) are more accurate cancer detectors, but they’re expensive and require considerable skill to be safe. The American Cancer Society, the U.S. National Cancer Institute and some other health agencies recommend not only regular fecal occult blood tests for healthy adults over age 40, but also periodic sigmoidoscopy. This bowel screening advice counters the new U.S. Congressional Office of Technology Assessment view that “screening does not detect enough colon cancer to justify the cost.” There have been no good, large-scale studies to show whether screening by sigmoidoscopy or colonscopy can discover enough cancers at an early enough stage to save lives. Nonetheless, some experts advocate not only regular sigmoidoscopy but also the more invasive colonscopy, arguing that many cancers occur higher up the colon, beyond the reach of sigmoidoscopy. Looking for a disease that many not be there with colonoscopy carries considerable risks as it requires an anesthetic and can perforate the bowel (in about one per 750-1,000 cases). Given the weak data on its value, most Canadian health agencies do not recommend routine colonoscopy. The CTF, the Canadian Cancer Society, the International Union Against Cancer and the U.S. Preventive Services Task Force find the evidence “too inconclusive, the techniques too uncertain, too costly and too dependent on skilled expertise, to warrant regular occult blood tests or routine sigmoidoscopy in healthy, non-risk adults.” The suggest regular colon cancer screening only for people with a family or personal history of breast or colon cancer, ulcerative colitis or multiple bowel polyps at a young age. Ine University of Toronto specialist sums up the situation by saying that “we’re wishy-washy about making rules because there’s no hard data to go by. All in all, bowel screening adds up to uncertainty about its value.”
When all is said and done, given the many considerations, there’s not much left for the traditional annual check-up. Blind faith in the preventive properties of medical exams doesn’t bear up to scientific scrutiny. Average healthy persons, who have no risk factors that make them candidates for more intensive screening, probably have little reason to see a physician every year. But, whenever seeing a doctor for some problem, remember to use it as an occasion to ask about any tests needed, discuss health concerns and find out whether there are any preventive steps that might reduce disease risks. Building a relationship with the physician by regularly discussing health concerns may make diagnosis and treatment easier and quicker if somethin does go wrong. Finally, people might take pride in and be reassured by Canada’s leading role in preventive health care, a poineer in the field of medical check-ups. New evidence will doubtless resolve many current controversies. Meanwhile, the best idea is to take charge of your own health, promptly report any symptoms that do occur and modiy your lifestyle in ways that maximize health benefits.
Note: A detailed table comparing the Canadian Task Force recommendations for annual chekc-ups with those of several other North American health authorities is available from the Health News office by writing, or calling (416) 978-5411.
COPYRIGHT 1991 Strategic Inc. Communications Ltd.
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