Routine Medical Screenings: When, Who, Why or Why Not?
With contributions by Dr. Barbara Pierce, MD
What are some common health screenings men and women should have done routinely?
How often? What criteria must patients meet? Can these screenings be done through a Primary Care Provider (PCP)?
There is actually controversy regarding the benefits of an annual physical exam. There have been studies and reviews done that don’t show that they provide any benefit in reducing hospitalizations, time off from work, or death.
However, the United States Preventive Services Task Force has developed an evidence-based list of screenings as well as some therapies, which may be done at the frequency of yearly to once a lifetime. Tests include screening for hypertension, screening for colon cancer, and screening for abdominal aortic aneurysms.
There are also recommendations from the Centers for Disease Control regarding immunizations in adults with a recommended schedule of vaccinations throughout our adult life span. These include a shingles shot for ages 60 and up, and two pneumonia shots (the PCV 13 and Pneumovax 23) given a year apart at the age of 65 and up. Tetanus shots should be given every 10 years, and we still recommend a yearly flu shot for almost everybody in the U.S. Although evidence does not necessarily show proven benefit, there are quite a few people who would still benefit from an annual physical exam.
For example, people who are anxious about their health and want reassurance they are doing the right things for their health benefit from a yearly visit with their physician. People with a strong family history of diabetes, high cholesterol or heart disease, or hypertension, benefit from yearly exams and monitoring on a regular basis their blood pressure, cholesterol, and blood sugar. We want to find high cholesterol and treat it; find a slowly advancing blood sugar and treat it before we end up with a heart attack, cardiovascular disease, or full-blown diabetes. As we become older and a little frailer, we may benefit from a yearly screening of our memory, any signs of depression, and risk for falling. In fact, Medicare now has an annual wellness physical for Medicare recipients that is not a physical exam as much as it is a screening for these things.
Frequency of screening of women for cervical cancer has actually decreased– our guidelines now state that if we have co-testing of a Pap test with HPV testing and both results are normal, we can go up to every 5 years between Pap tests, with discontinuation at age 65. Mammograms can be done every 1-2 years, with discontinuation at age 75. Prostate cancer testing for men is still controversial, and patients and their physicians should have a discussion on risks versus benefits of testing for PSA. We still do colonoscopies every 10 years as a screening for colon cancer, between the ages of 50 and 75.
There are a couple of other screenings that are available specifically for smokers, including a one-time abdominal aortic aneurysm screening for men who have smoked and are now between the ages 65 and 75. There is also a yearly low dose CT screening for lung cancer in a specific age group between 55 and 80 that have a 30-pack-year history of smoking and are still smoking or quit within the last 15 years.
All of these guidelines set specific testing intervals to avoid over testing. Sometimes there are screenings that patients request that have poor evidence of benefit; such as when a woman comes in and asks for a CA-125 test for ovarian cancer, which is a terrible screening test in a woman who is at low risk, or has no symptoms. Sometimes a patient asks to be tested for every kind of cancer, which is basically impossible to do.
Why is it important to have these routine screenings done?
What do these screenings tell patients? Does insurance cover them? Should patients get a second opinion?
Screening tests are meant to detect the presence of a condition that can be treated while it is still in its early stages, before it can cause any significant or long-term damage. For example, in a colonoscopy we want to find polyps that can be removed and prevent their developing into cancer. We want to treat high blood pressure before it can cause heart failure, chronic kidney disease, or stroke.
Not all insurance has covered screenings in the past. Lung cancer screening is still not always covered by insurance. The Affordable Care Act, however, has mandated that most insurance cover a set of preventative services and immunizations that does include most of the testing we discussed.
Getting a second opinion on abnormal test results is up to the patient based on the severity of the diagnosis, and how much they trust the person who provided the screening for them. For example, when a mammogram is abnormal there could be several things that have caused this, usually a second more thorough mammogram has been performed, and recommendations are made on whether not to leave this alone and monitor it, or biopsy, or perform surgery. If a person is not convinced the recommended plan is best for them, it is probably good to go get a breast specialist who can review the mammograms, perform an examination, and give a second opinion on treatment plan.
Most screening tests will be ordered by a primary care physician, though, and most that come back abnormal we will then be referred to the appropriate specialist for further work-up and management. Of course, it is important for a patient to understand that if they have a screening done and the results are abnormal, they have to want to pursue further workup. Otherwise, it was not worthwhile to get the test in the first place. I have had patients with abnormal mammogram results and abnormal colonoscopy results that refused to have further workup or treatment done, and basically because I would request each time I saw them to have further evaluation – eventually they would stop coming in and both then died shortly thereafter. Screening tests and the knowledge we received from it was stressful and not useful in those cases.