The Wellness Guide to Preventive Care
For: "Full-Body
Scans—Peace of Mind at a Price?" December 2002
A recent government study showed that more than half of
all Americans do not receive many of the important preventive services
they need—that is, immunizations, screening tests for early detection
of disease, and education about healthy habits and injury prevention.
Why not?
• Many Americans—44 million—have no health insurance.
• Many people do not get continuity of care. They may have to switch doctors as they switch from one insurer to another, making it hard to keep track of what services they've had.
• Patients may not insist on getting preventive services. They may be confused about which tests to ask for. They may not know that Medicare (and some other insurance plans) covers some of the pricier items, such as mammograms and colonoscopies, as well as the cheaper ones. They may not know that prevention is usually the most economical form of medicine—well worth budgeting for, even if insurance doesn't cover it.
• With tests for some cancers, there's the embarrassment factor. Some people may dread being tested for colon, prostate, or breast cancer and be relieved if the doctor fails to mention it. Some people would rather not know.
• Both doctors and patients may be confused by contradictory recommendations. What should a medical checkup consist of? Does everybody need an annual physical? Should all men get a PSA test? At what age should a woman start having mammograms? (See below for answers to such questions.)
• Doctors may fail to ask patients about smoking and drinking, not to mention exercise habits and diet. Some HMOs don't encourage their doctors to counsel people. Some doctors think their job is to treat illness, not prevent it.
• The watchword among insurers now is cost containment. Yet medical technologies and consumer demand for services are expanding daily. Thus, we all have to make choices. Will patients in a big HMO get more benefit from an additional MRI machine or from having their doctors take time to counsel them about exercise and a heart-healthy diet? The new MRI machine will be easier to justify, in terms of immediate, measurable benefits.
How about that annual physical?
It used to seem simple: people were advised to undergo a
standardized annual or biannual "complete physical." But in
the 1980s, at the request of the government, an independent committee
of physicians known as the U.S. Preventive Services Task Force reviewed
all evidence and evaluated the benefits and drawbacks of common screening
tests and came up with recommendations. (A similar group, the Canadian
Task Force on Preventive Health Care, does the same work in Canada.) That
head-to-toe physical exam has now been discarded for seemingly healthy
people, since it yields too few benefits for its cost. Over the long run,
it doesn't pay off in terms of better health and longer life.
Some tests that used to be routinely done, such as chest
X-rays, electrocardiograms (EKGs), urine tests, and complete blood counts,
are now reserved for people with symptoms or risk factors. In other words,
they are not general "screening" tests and are not done routinely
in everyone (and as such are not covered in this article).
The U.S. and Canadian Task Forces continue to update and
re-evaluate their advice, reviewing thousands of studies every year and
consulting hundreds of scientific reviewers.
Health care: your role
You are responsible, in large part, for managing your own
preventive care. Your primary-care practitioner should be your partner.
If you need any of the tests listed on the chart, ask about them. You
should, if possible, have a copy of your test results and records.
There are other important preventive measures not listed
on our chart—the kind of commonsense steps that could save millions
of medical dollars and prevent injury, illness, disability, and premature
death. Here's a checklist:
• Don't smoke, and avoid secondhand smoke.
• Maintain a healthy weight.
• Get regular exercise. Brisk walking for just half an hour every day can be a big factor in weight control and in staying healthy.
• Choose a diet low in animal fat and sodium, and rich in fruits, vegetables, whole grains, and low-fat or nonfat dairy products. Eat at least two servings of fish a week.
• Keep alcohol consumption moderate: no more than one drink daily for a woman, two drinks for a man. If you are a heavy drinker, seek counseling, and cut back or quit.
• Do self-exams of your breasts or testes, as well as skin.
• Fasten seat belts, see that kids ride in proper restraints, and obey the law. Drive sober and defensively.
• Brush and floss to prevent dental disease.
Medical experts may disagree about a lot of things, but
they all agree that good health depends on improved access to and increased
use of preventive services.
A test you don't need
Increasing numbers of readers ask us
for the lowdown on the so-called full-body CT scan—a flourishing
industry these days. It has even been featured on Oprah.
Symptomless people are signing up for these tests—not covered by
medical insurance—at a cost of about $1,000. For most people, results
are nil, unless you count a commodity called "peace of mind."
But peace of mind is really not something a full-body scan can deliver.
And if it could, how often would you have to get one?
According to the American College of
Radiology, the full-body scan is not the right way to screen for cancers
of the breast, prostate, colon, or lung—at least not without follow-up
tests. It cannot spot high blood pressure or diabetes. The American Cancer
Society discourages it as a waste of money, and a poor substitute for
the tests listed below.
Furthermore, if the scan does find anything
suspicious, you may simply be subjected to more (sometimes invasive) tests—and
it may well turn out to be a false alarm. Instead of peace of mind, you
get anxiety.
Finally, the FDA worries about needless exposure to radiation from a test
that's unlikely to do you any good.
Someday there may be one magic test that will accurately detect anything and everything. But the full-body scan is definitely not it.
Preventive Services for Healthy
Adults
These are the major screening tests (that is, routine tests
for people without symptoms) and adult immunizations. Our advice is based
largely on the recommendations of the U.S. Preventive Services Task Force.
Most HMOs and Medicare cover these services; fewer traditional insurers
pay for them. Infants, children, and pregnant women need other kinds of
preventive care not described here.
Blood pressure measurement (to detect
hypertension)
Who needs: All adults.
How often: Once every 2 years for those
with normal blood pressure.
Comments: More frequent monitoring for those
with readings of 130/85 or higher. See Wellness
Letter, May 1999.
Cholesterol measurement
Who needs: All adults.
How often: Once every 5 years. More often
if total or LDL ("bad") cholesterol is high, HDL ("good")
is low, and/or you have risk factors.
Comments: Those at high risk for heart disease
need medical advice about life-style changes and possibly drug therapy.
See Wellness Letter,
August 2001.
Pap smear (for early detection of
cervical cancer)
Who needs: All women with a cervix, starting
at age 18, or earlier if sexually active.
How often: If 3 annual tests are normal,
then once every 3 years. More often if you smoke or have multiple sex
partners or other risk factors.
Comments: Some experts advise that women
who have never had an abnormal result can stop being screened after age
65.
Breast cancer screening (mammography)
Who needs: All women 50 and over; those
40-49 should discuss risk factors with a doctor. See Wellness
Letter, August 2000.
How often: Annually. Medicare reimburses
for it.
Comments: Clinical breast exams are also
important—consult your doctor.
Colorectal cancer screening (fecal occult blood
test, sigmoidoscopy, colonoscopy)
Who needs: Everyone 50 and over; earlier
for those at high risk.
How often: Occult
blood test annually; sigmoidoscopy every 5 years or colonoscopy every
10 years.
Comments: Digital rectal exam and X-ray
with barium enema may also be done. Medicare now pays for colonoscopy.
See Wellness Letter,
December 2000.
Prostate cancer screening (prostate
specific antigen, or PSA, test; and digital rectal exam, or DRE)
Who needs: Blacks and men with family history,
DRE and PSA starting at age 40. For others, DRE, and possibly PSA, starting
at 50.
How often: DRE annually; PSA on professional
advice.
Comments: Usefulness of PSA screening for
all men remains controversial. See Wellness
Letter, November 2000.
Diabetes screening (fasting blood
glucose test)
Who needs: Everyone 45 and older; earlier
for those at high risk.
How often: Every 3 years.
Comments: Blacks, Hispanics, Asians, Native
Americans, obese people, and those with a strong family history need more
frequent screening, starting at age 30. See Wellness
Letter, October 1997.
Thyroid disease screening
Who needs: Women 50 and over; those with
high cholesterol or family history of thyroid disease.
How often: On professional advice.
Comments: Routine screening remains controversial.
Talk to your doctor about risk factors. See Wellness
Letter, June 2000.
Chlamydia screening
Who needs: Women 25 and younger, if sexually
active.
How often: Annually, or more often.
Comments: Men and women of any age who are
at risk for STDs (chlamydia, gonorrhea, syphilis, and HIV) should be tested.
See Wellness Letter,
October 1998.
Glaucoma screening
Who needs: People at high risk: those over
65, very nearsighted, or diabetic; blacks over 40; those with sleep apnea
or family history of glaucoma.
How often: On professional advice of eye
specialist.
Comments: Many eye specialists advise screening
all adults every 3-5 years, starting at age 39. See Wellness
Letter, September 2000.
Dental checkup
Who needs: All adults.
How often: Every 6 months, or on professional
advice.
Comments: Should include cleaning and exam
for oral cancer.
Tetanus/diphtheria booster
Who needs: All adults.
How often: Every 10 years.
Comments: People over 50 are least likely
to be adequately immunized.
Influenza vaccine
Who needs: Everyone 50 and over, people
with lung or heart disease or cancer, and others at high risk.
How often: Annually, in autumn.
Comments: Even healthy younger adults can
benefit and should consider getting the shot.
Pneumococcal vaccine
Who needs: Everyone 65 and over, and others
at high risk for complications.
How often: At least once.
Comments: Effective against most strains
of pneumococcal pneumonia; lasts at least 5-10 years.
Rubella vaccine
Who needs: All women of childbearing age.
How often: Once.
Comments: Avoid during pregnancy.
Hepatitis B vaccine
Who needs: All young adults, as well as
adults at high risk.
How often: On professional advice.
Comments: All newborns should be vaccinated.
Chickenpox vaccine
Who needs: Anyone who has never had chickenpox.
How often: Once. But above age 13 it requires
two shots.
Comments: Not recommended for pregnant women
or those with compromised immunity.
UC Berkeley Wellness Letter, November 2001
