General health check-ups have long been popular in the US, where they are often carried out yearly. By contrast, they have only recently been introduced in the UK, but to be done every five years, and this latter check-up is mainly focused on reducing the risk of heart and circulatory diseases. Doctors measure blood pressure, cholesterol levels and body mass index and give some general health advice. If any abnormalities are found, then follow-up evaluations and/or treatment should be done at the advice of the physician.
Having a regular yearly check-up for someone who is basically healthy sounds like common sense – the ultimate in preventative medicine – but this is surprisingly controversial. That’s because this is a form of screening – in other words, looking for illness in people who have no symptoms. And screening has a nasty habit of doing more harm than good, especially in the absence of evidence to prove its worth in reducing disease and mortality. The most recent trial, and one of the largest ever, looked at nearly 60,000 Danish people who were offered annual checks for five years. Five years after this period, there was no effect on heart attacks or overall death rates.
The potential downsides of screening are that it can worry people unnecessarily, offer false reassurance, or trigger unneeded tests and treatments. That has been shown for certain kinds of screening (see below).
Now routine pelvic exams for women are meeting the same skepticism. A recent study published in a leading internal medicine journal (Annals of Internal Medicine) has arrived at the conclusion that this type of examination should be dropped from routine care if it is performed on symptom-free women who are not pregnant. The study was based on a review that found no studies supporting the pelvic exam for finding ovarian cancer or any other serious disease. Exceptions to this recommendation are the periodic obtaining of so-called “PAP smears”, i.e. sampling of cells from the cervix to detect early cancer, but this test can be done every three years. Of course if any woman has any symptoms pointing toward this area, such as pelvic pain, abnormal bleeding, sexual dysfunction or other troubling complaints, more frequent examinations are usually needed.
This worthwhile procedure is capable of detecting, preventing, and curing colon cancer. In most individuals not at high risk for such cancers, colonoscopy should begin at age 50 and repeated periodically at intervals advised by the physician performing the test. In general, repeated testing is done every five years until the age of 75. If no cancer or precancerous polyps are found initially, however, one can usually wait for 10 years for the next test. After age 75, testing usually is discontinued. For adults over 75 who have not previously been screened, decisions about first-time screening is usually made in the context of the individual’s health status and competing risks. For persons older than 85 years, competing causes of mortality preclude a mortality benefit that outweighs the harms, and, therefore this procedure is not indicated.
For the average woman, the U.S. Preventive Services Task Force recommended (2009) mammography every two years in women between the ages of 50 and 74. The Canadian Task Force on Preventive Health Care (2012) and the European Cancer Observatory (2011) recommends mammography every 2–3 years between 50 and 69. After the age of 74, testing is optional and best done at the advice of your physician. These task force reports point out that in addition to unnecessary surgery and anxiety, the risks of more frequent mammograms include a small but significant increase in breast cancer induced by radiation. Most studies do not find an effect of mammography screening on total cancer mortality, including breast cancer, after 10 years. Thus when such information is offset by the fact that many women with “positive” mammography results will be suspected and treated unnecessarily for benign conditions and experience psychological distress including anxiety and uncertainty for years, we must conclude that universal screening is of questionable value at best.
In high risk groups, such as those with a strong family history of breast cancer, screening does make sense. In women who are otherwise healthy, screening with mammography is probably optional, but most data suggest that this is best accomplished when augmented by careful palpation of the breasts done by self examination or by a medical professional. When both examinations detect an area of increased density, then more intensive evaluation is justified and is more likely to yield a significant reduction of long-term mortality.
PSA is a blood test designed to detect early prostate cancer in men, and it too is falling under increasing scrutiny. A growing consensus suggests that it’s usually not necessary, but considerable disagreement persists. My take on this subject is that men should not routinely get this test, especially if they are younger than 50 or older than 74. If, however, you are between those ages, talk with your doctor about the risks and benefits of the test, and your risk factors, such as being African-American or having a strong family history of this disease.
Lung Cancer Tests: Only for long-term smokers
A recent study found that annual low-dose CT lung scans could cut the risk of death from cancer by 16%.in long-term heavy smokers. At present, Medicare refuses to cover the cost of this test, but they should! Thus the test should be employed in those between ages 55 and 80 who smoked a pack per day for 30 years or two packs for 15 years, provided that they currently smoke or stopped within the past 15 years.
I might conclude by offering the following general advice: One should always designate a personal physician (usually a family physician or general internist). An initial visit should be scheduled to include a physical examination, a general blood profile that includes cholesterol and other markers for cardiovascular risk and diabetes, an electrocardiogram, and a chest X-ray. This should be followed by advice about life-style issues such as exercise, diet, and others as needed. After that, follow-up examinations can be performed on an as-needed basis, depending primarily on the initial assessment. If no abnormalities are found to warrant closer follow-up, for men, a regular five-yearly interval to measure blood pressure and focus mainly reducing risk of heart and circulatory diseases would be quite sufficient. As noted above, women should be followed in a similar fashion, but need a bit more attention, at least with regard to PAP smears at three-yearly intervals, and for those over the age of 50, mammograms every two years are probably OK, but stay tuned regarding this later recommendation. Colonoscopy, lung scans, and PSA testing have been covered above.