Can you have too much a good thing in health care? Most definitely. Too many tests is never a good thing, which new providers learn fairly quickly as they struggle to follow up results that likely will have no impact on the patient’s health but now must be dealt with. Which can lead to more unnecessary tests, invasive procedures, added expense and patient anxiety, which is never benign.
Many people don’t know when it is recommended to stop certain screenings. While some screenings for cancer are pretty innocuous in terms of the actual examination, i.e., a PSA blood test or a skin cancer screening, there are others that are well, a bit more unpleasant. I’m talking about pap tests, colonoscopies and mammograms. Yet these are the very tests many people faithfully have on a regular basis, without thinking about whether they are still needed.
Before I go further, I must stress that these are decisions that you should be making with your health care provider, based on your individual state of health, family history and attitude towards testing. More about that later. But feel free to read on and bring any questions you may have to your next appointment. Or me, if you’d like to engage that way.
The pap smear is a familiar but antiquated term for the screening test for cervical cancer. Antiquated because cells are no longer smeared onto a slide but instead, mixed into a liquid medium. Pap test is more descriptive. The Pap test is the poster child of preventative screenings, its use having resulted in a remarkable reduction in the incidence of and death from cervical cancer worldwide. But today the pap, which examines the cells of the cervix, is no longer the only test for cervical cancer. Once the link between the Human Papilloma Virus (HPV) and cervical cancer was clearly established, a test was developed to check for it, and a vaccine (the HPV vaccine) was developed to prevent it in the first place. OB/GYNs are the providers most people think of as performing pap tests, but so can nurse practitioners, physician assistants, and Family Medicine doctors. In fact, any practicing doctor can perform it but most non-gyn specialists do not, nor do most internists, I guess by choice and subsequent lack of supplies. I am always intrigued by the unwillingness of internists to do an internal exam. But I digress.
First, be aware these guidelines only apply to asymptomatic women without any known risk factors or prior abnormal paps. In fact any test called a screening is by definition intended for those with no symptoms. Depending on the guidelines used (I tend to use the United States Preventative Services Task Force (USPSTF), which has a community health focus) the tests should be initiated at either age 21 or 25 (the American Cancer Society (ACS)), regardless of sexual activity or vaccination status. For ages 21-29, pap tests every 3 years. For age 30 and above, a pap test every 3 years, a pap test/HPV test combo every 5 years, or an HPV alone test every 5 years. The HPV test alone is not widely available yet but can easily be added to the same sample from a pap test, which becomes the combo. The reason testing for HPV is only initiated after age 30 is because many women under 30 have benign HPV infections which could clear without treatment, and additional testing/biopsies are avoided this way. When to stop pap/HPV testing? For asymptomatic women who’ve been tested regularly and the last 2 Pap/HPV tests have been normal and have never been diagnosed with pre-cancerous lesions or cervical cancer, the age is 65.
Continuing with women’s health, the advice about mammograms also varies depending on which guidelines you use. The USPSTF advises, for asymptomatic women without known risk factors or family history, a screening mammogram every 2 years starting at age 50. The American Cancer Society advises starting at age 45, doing a mammogram every year until age 55 and thereafter every 2 years up through age 74. The consensus for stopping in asymptomatic women without risk factors is 75, unless the patient has a greater than 10 year life expectancy at age 75. With all these screenings, they are deemed worth doing if your life expectancy is 10 years or more. As much as people loathe these tests, it’s not easy hearing that you don’t need them anymore. So cancer could go undetected? That’s a frightening thought for most people. It’s more like it’s not the cancer that will kill you so why go through testing and treatment, when you are more likely to die of something else. Mortality is concept most of us can’t truly grasp or accept, surely a topic for another post.
For male-specific screening tests, we are talking prostate cancer. Here, it is all about shared decision-making because there is no clear consensus about the benefits of screening asymptomatic men at average risk for prostate cancer across a population. Most guidelines say if you choose to do it, start at 50 in men without a family history of the disease, and discontinue at age 70. The dreaded digital rectal exam (DRE) is not recommended for screening because it has not proven to lessen mortality. What is shared decision-making, exactly? It’s when you and your provider discuss pros and cons of testing, including false positives (which lead to unnecessary biopsies and other tests and of course anxiety), false negatives (missing a cancer that is present), and overdiagnosis.
Overdiagnosis is a problem inherent in many cancer screening tests, not just prostate, and most notably mammography. It occurs when a cancer is detected, but it is so slow growing it will not affect life expectancy if left untreated. But because it is very difficult (the technology is just not there yet for some cancers) to determine that a cancer is harmless, if you will, once it’s found, the push is to treat it. With prostate cancer, there is the option of watchful waiting, also called active surveillance for certain men (it depends on age, frailty, comorbidities and life expectancy) whose cancer is found to be, through biopsy, imaging and DRE (the digital rectal exam is employed in risk stratification of the cancer), very low-grade. Even in this case, many men, knowing they have prostate cancer, will opt for treatment to avoid the anxiety of close follow-up and repeated testing. And with treatment often comes morbidity (illness to the layperson), expense, possible loss of employment, and anxiety. There is no getting around anxiety with a cancer diagnosis no matter what you do.
It could be argued that of all the screening tests, the colonoscopy is the most dreaded. It takes up at least two days of your life, what with the prep and the actual procedure and post-anesthesia recovery of a few hours. The prep is probably most dreaded, when it’s just you and the awful tasting drink to cleanse your bowels. Cleansing the bowels, that doesn’t sound too bad, right? What it means is hours of diarrhea, where it is now just you and the toilet. And when it’s time for the procedure you are weak, and surprise! – at least mildly dehydrated, which usually makes the placing of the necessary IV line more difficult. But there is a silver lining. The drugs. Usually now it’s the same drug, propofol, which Michael Jackson got every night to sleep. And it works so well, you could almost understand his affinity. One minute you are in the hospital bed after the difficult IV insertion, the next in some zen paradise you most reluctantly emerge from to find yourself in that same hospital bed with a loved one or close friend staring at you worriedly. It was nice while it lasted.
Colonoscopy is not the only game in town but it is considered the gold standard because it not only can prevent death from colon cancer but it can prevent the cancer from occurring by removing precancerous polyps. And if yours is negative, you can wait 10 years to do it all again. Another way to screen is sigmoidoscopy, an office procedure where the most distal portion of the colon (so not the entire colon as in colonoscopy) is visualized and any polyps found can be removed and later biopsied This does not require sedation but does require some bowel prep. It is not a popular or promulgated choice because at that point, why not go for the colonoscopy and at least get the drugs?
The other options are stool-based, that you can do in the um — comfort of your own home. They are pretty good at detecting cancer but not so good at detecting precancerous polyps. Depending on the test, the suggested frequency is every one to three years. If any of these tests is positive or abnormal, of course you would need a colonoscopy. Same is true of the so-called virtual colonoscopy that uses a CT scan, which has fallen out of favor lately.
Screening for colon cancer is recommended starting at age 45 for asymptomatic individuals without any risk factors, since recently there have been more people under 50 diagnosed with colon cancer for unknown reasons. The stop point is 75 as long as life expectancy is 10 years or greater.
Lastly, there is skin cancer screening. And I must tell you I was most surprised that there is insufficient evidence to recommend that asymptomatic individuals get a yearly skin check by a dermatologist, especially to rule out melanoma, a skin cancer that can be deadly. Different guidelines support that providers counsel patients, especially those most at risk with fair skin, to avoid unprotected sun exposure, and to check their own skin for new or suspicious lesions. I know that as a health care provider, I do counsel sun protection and look at a patient’s skin for anything glaringly abnormal. But frankly there is so much to cover during a physical, and so little time. For those who can afford it, I advise a yearly skin check with a dermatologist, who will examine every inch of you under very good light, and I practice what I preach. For those who can’t, I tell them the general guidelines of size, color and change in lesions and if anything seems abnormal, to have it checked. Skin is an organ that should be checked from birth. As to when to stop checking, no consensus on that either. Maybe when you no longer feel the need to look in the mirror? That says more about life expectancy than anything else.
#healthcoach #knowingwhentostop #prevention