I was recently on vacation and my wife and I had a fascinating conversation with a couple from Texas. They were dot-com millionaires, owned three homes and were already retired at the age of 50. When they found out we are physicians they told us about an extensive physical they had gone through at a major university center on the east coast that will remain nameless. It included a nutritional assessment that was completely canned, scripted, uninformative rubbish but that is for another post. It also included a full history and physical with a physician and the kicker… a full body CT scan. Even before I said anything the couple already had the impression they had wasted a lot of money. I think they were hoping I would tell them they were wrong and they had gotten a great value… but if they were they were disappointed.
For profit clinics have been doing full body CT scans and MRI scans now for some time. They advertise that they offer piece of mind by catching cancers or other dangerous problems early so they can be fixed before they get beyond repair. However, these scans offer anything but piece of mind. For most people they will find what we in medicine call incidentalomas. That is a tumor, benign or malignant, that is found incidentally or by coincidence when you are looking for something else. Commonly this happens in medicine when for instance you do a CT scan of the lungs looking for a blood clot and instead find a small nodule that could be old scar tissue or could be a tumor. There is no way of knowing by looking at it on the scan so now you are pressed to either biopsy it or watch it by doing a follow up CT scan. But this nodule had nothing to do with why you did the CT scan in the first place and it was causing the patient no symptoms or problems.
When you do a full body CT scan you are basically guaranteeing anything you find will be an incidentaloma. Assuming you felt well when you went in for your body check up you now have found lesions or abnormalities that were causing you no symptoms. Best case scenario you find nothing. Then you really do get the piece of mind you were hoping for and you go on with your life.
What is not advertised is the 46% of patients where something is found and therefore needs follow-up studies. Usually these studies show the findings were nothing of significance. What much of the general public does not understand is there a large percentage of people carrying around benign tumors in their body that they do not know are there and are not causing them any problems and never will. Also, what even most physicians I know do not consider, is that your body forms cancerous cells hundreds if not thousands of times a day. However, your body has such wonderful defense mechanism to kill off cancerous cells that most of these will never make it past the microscopic phase. What has never been studied (and likely never will for obvious reasons) is if even small visible malignant tumors could also be killed off by the body if left alone sometimes. And this may be happening in the body often, we just don’t know about it because most of us do not get a CT scan unless we have symptoms.
There is no way for us as doctors to know if that mass we see on the scan is benign or malignant unless we biopsy or remove it and see what it is under a microscope. This sounds easy enough but it is not. Roughly 200,000 people die each year from medical mistakes. The more you submit yourself unnecessarily to procedures or medicines that are unneeded the more you increase your chance of being one of those 200,000. Biopsies carry a risk of bleeding, infection or even death depending on where they are. A biopsy of a lung mass can collapse the lung and require a chest tube to fix. Biopsies of adrenal gland masses have an extremely high risk of bleeding. Masses in the kidney are very risky to biopsy and often we cannot be satisfied that the biopsy ruled out cancer so often masses in the kidney lead to removal of that kidney.
More information is not always better. PSA blood test screening for prostate cancer is a prime example. Doctors and patients had assumed for years that by checking a PSA in the blood and possibly catching prostate cancer before it gets too big or metastasizes has to be a good idea. It was the standard of care for years but then studies showed it did not improve mortality or morbidity. It was of no benefit to patients at all.
Most are in agreement that yes, cancer is caught earlier with PSA screening but this benefit is offset by procedures and surgeries done on patients who had a cancer that would have never caused the patient any problems. In fact autopsy studies of men who died from other causes found prostate cancer in 30% of men in their 50s at autopsy and in 80% of men in their 80s. So this is why it is often said that prostate cancer is often a cancer someone dies with, not from. And the PSA screening that was supposed to be giving more information or piece of mind may actually just have been leading to unnecessary biopsies and surgeries for cancers that never would have caused any problems.
Somehow the message needs to get out that more medicine is not always better. Medical tests, procedures and medications all have benefit but come at a cost. Not only financial but risk wise as well. However, as long as our medical system is based on financial profit for each test done or medication sold the incentive will always be to play up the benefits and brush off the risks. This has to change.
* UPDATE- I spoke to the case manager mentioned above and got the OK to use her true name. Her name is Denise Wells and she can be found at her website Om Sweet Om Yoga. There you will find some of her story and her current yoga classes and teaching. Thank you again Denise for opening my eyes to this.