Are Doctors Overdoing It?
Jackie Lahey is a model patient. She never misses her yearly physical, gyno appointment or mammogram. "I do everything right," says Jackie, of Maplewood, New Jersey. But a few years ago, her proactive approach to her health resulted in a scare that still haunts her. At age 42, she had just gotten a mammogram and was waiting for the results, when the radiologist walked into the exam room with a grim look on her face. "She said they had found a suspicious area on my chest wall," Jackie remembers. "I asked if it was cancer, but she hedged and said they needed to do further tests."
Jackie learned that she had a tumor, which had been designated BI-RAD 5, or "highly suggestive of malignancy." (The BI-RAD system designates breast cancer risk based on mammogram findings; 1 is cancer-free and 6 is cancer). "I was a wreck," she says. "All I could think about was what my kids would do if I died."
Finally, a week and a needle biopsy later, Jackie got word that the growth was actually benign. But the saga still wasn't over: The breast cancer surgeon recommended that she have the lump removed anyway; he wanted the entire thing biopsied "just in case." Jackie scheduled the surgery, which confirmed that she did not have cancer. "I was so relieved!" she says. "But now, every time I get a mammogram, I wonder if I'll have to go through all that again."
A growing number of physician groups, public health experts and medical task forces say that stories like Jackie's illustrate a major problem with today's health care system: Americans are overscreened, which can lead to false diagnoses and needless surgical procedures. Of the nation's $2.7 trillion annual health care bill, as much as $325 billion went to unnecessary medical care, a 2009 study found. Currently, 39 physician specialty groups are calling on their member doctors to stop reflexively ordering some 200 tests or procedures, including ovarian cancer screenings and MRIs for back pain, that are routinely performed but have been found to be largely pointless. And the U.S. Preventive Services Task Force (USPSTF), an independent panel of experts that releases medical recommendations, has advised against routine mammograms for women in their forties because the risk of false-positive results is so high.
"In the last 50 years, we have developed a very prevention-oriented culture," says Carolyn Westhoff, MD, a FITNESS advisory board member and professor of obstetrics and gynecology at Columbia University Medical Center. "But we're learning that we can do many of the screening tests less often and that some of them are useful only when a person has certain symptoms."
Yet most doctors still aren't heeding that message. Many are reluctant to give up tests, for reasons ranging from the well-intentioned (they truly want to search out and treat any condition that could harm you) to the self-serving (they want to cover their butts and avoid medical malpractice suits). According to one study, 93 percent of physicians in specialties with a high risk of litigation, such as ob-gyn and orthopedic surgery, said they practice "defensive medicine," meaning they order tests and perform diagnostic procedures out of fear of being sued. And some doctors may be influenced by the fact that the more they do, the more they get paid by insurance companies. To be fair, Dr. Westhoff says, many docs are simply creatures of habit, practicing what they were trained to do.
The medical system has trained patients to follow certain rules, too. Two-thirds of adults, for instance, believe that an annual physical is a must. Turns out, it's not. "Our culture believes that early detection is always good and that more is better," Dr. Westhoff says. "But it is often worth pulling back and doing a little less."
So how can you avoid subjecting yourself to unnecessary medical exams and tests but still protect your health? Here's what every woman needs to know.
No More Yearly Checkups
You know the annual physical drill: Blood pressure — check! Eyes, ears, throat — check! Blood test (ouch) — check! But the surprising truth is that "many of these tests don't help promote health or prevent disease," says Miriam Alexander, MD, the director of the general preventive medicine residency program at the Johns Hopkins Bloomberg School of Public Health in Baltimore. "They're just what we've always done."
In fact, a research review concluded that routine medical tests failed to reduce rates of disease, hospitalization, or death. What they can lead to, however, is further testing. "When you run tests, you raise the risk of false positives. That means more tests or trips to a specialist even though there was no reason to run the test in the first place," Dr. Alexander says.
That's not to say you should ditch your doc altogether. It's important to have a physician for when you get sick, and there are certain screenings and vaccinations that you do need over the years. So some experts are calling for a "periodic well visit" instead of an annual checkup. Your doc would focus on preventive behaviors like eating right and exercising and on helping you eliminate disease risk factors such as smoking and weight gain. The two of you would discuss your family's medical history and which tests you truly need to check for heart disease, diabetes and various cancers. Patients with particular risk factors would see a doctor more regularly.
The bottom line: Until periodic well visits become the norm, experts say that if you do opt to get physicals, you may not need to go every year.
So Long, Stirrups!
Imagine going to your gyno and not spending the appointment staring at the ceiling with your knees in the air. "Until the Pap test was introduced, a woman didn't go to the ob-gyn unless she was pregnant or had symptoms like pain or bleeding," Dr. Westhoff says. When the Pap became standard in the late 1940s, so did the yearly gyno exam. But in 2012, based on new research, the American College of Obstetricians and Gynecologists (ACOG) told its members to dial back on the Pap test and give it every three years; for women 30 and older who combine it with a test for human papillomavirus (HPV), the recommendation is every five years.
The reason: Although the Pap can be a lifesaver, there is no benefit to screening on an annual basis, because cervical cancer is slow growing. "If you do Pap smears frequently, you'll get some results that are 'not normal' but aren't cancer," Dr. Alexander says. "Patients might then be ordered to have uncomfortable additional testing, which causes anxiety and can, in rare cases, lead to severe complications."
As for annual pelvic exams, women simply don't need them, research has found. The exams are not necessary to screen for ovarian and uterine cancers or sexually transmitted infections, and they don't need to be done before a woman starts taking oral contraceptives. "Gradually, more and more ob-gyns are realizing that the pelvic exam doesn't have to be done so frequently," Dr. Westhoff says.
The bottom line: The ACOG still recommends an annual gyno visit, but unless you have a medical problem or new symptoms, you probably don't need a pelvic exam between Pap tests, Dr. Westhoff says.
The New Thinking on Mammograms
Many women are squeezing their breasts into the mammo machine when they don't need to, some experts believe. In 2009 the USPSTF set off a firestorm when it said that research did not support annual mammograms for women in their forties and that average-risk women in their fifties could get one every other year. The reason for the shift, the organization says, was that mammograms don't save enough lives to warrant the risks. Although the screenings reduce the breast cancer death rate by 15 percent, mammograms can also cause harm, according to the USPSTF. One review found that women in their forties who had annual mammograms for 10 years had a 56 percent risk of having a false-positive result, which led to further testing for something that turned out to be harmless.
False positives can cause considerable emotional distress, a number of studies found. Such results also lead to unnecessary procedures, like biopsies or the surgical removal of a lump — or both, as in Jackie Lahey's case.
But that's not the worst of it. Because mammograms tend to catch small slow-growing cancers — some of which might never cause a problem — women may undergo radiation therapy, chemotherapy and surgery they don't need. Mammograms even pick up precancers. Recently an advisory group to the National Cancer Institute (NCI) recommended that the word carcinoma be removed from conditions like ductal carcinoma in situ (DCIS), a precursor to breast cancer, so that women aren't frightened into getting aggressive treatment, such as surgery, for something that may never become malignant. "DCIS is quite varied; some are more serious, others less so. The majority of DCIS cases progress very slowly, perhaps over a decade," says Laura Esserman, MD, an expert on the NCI panel.
However, those in favor of annual mammographies counter that we don't yet know which cancers will be slow growing rather than aggressive and that, hey, 15 percent of lives saved is a lot of lives. Plus, a new study of women who died from breast cancer found that 65 percent of the deaths occurred among those who never had a mammogram; half the women diagnosed with fatal cancer were under age 50. But the study, Dr. Esserman points out, merely proves that if you have an aggressive cancer, you're more likely to die from it. "There is no proof that if screened, those who died of breast cancer would somehow have survived," she says.
The bottom line The USPSTF recommends mammograms every two years starting at age 50, while the American Cancer Society still advises annual mammograms for women 40 and over. "I advise women to follow the USPSTF guidelines, but if you're at high risk or have dense breasts, you should get a screening every year, starting at 40," Dr. Esserman says.
Originally published in FITNESS magazine, April 2014.