Get Your Checkup!

But at what Cost?

The “Checkup” has become a common theme In General Practice and Primary Care.

Men are exhorted with blokey slogans like “get your grease and oil change” to have their regular checkup or they will suffer all sorts of dire consequences

Women are prompted with signs in public conveniences to have their regular PAP smear.

It seems an intuitively attractive idea that if we look for disease and detect it early we are more likely to be able to cure it and outcomes will be improved.

In particular the spectre of Cancer is kept at bay.

But what is the evidence?

Screening for disease

Many examinations and tests have been proposed over the years to look for occult disease – ie disease that has not yet presented with symptoms or signs.

The RACGP Red Book lists many recommended procedures and a further 15 that it says are not supported by evidence.

Health Screening is the process of looking for disease in people that are well in order to detect a disease or classify them as likely or unlikely to have a disease.

The aim is to detect early disease in apparently healthy individuals. Case finding is a more targeted approach to an individual or group at risk of a particular condition

Screening for disease in asymptomatic people is also termed “Primary Prevention”.

To be valid, a screening test or procedure must pass three evidence tests.

The test must reliably detect an important health condition before it would otherwise present.

There must be a treatment for the condition.

The outcome must be improved as a result.

Very few screening procedures pass these tests when they are rigorously applied.

Those that do have surprisingly weak evidence to validate them.

PSA (Prostate Specific Antigen) as a screening test

The debate about PSA has raged for years and seems further than ever from being finally resolved.

We regularly see in social media and TV items exhorting men to have a checkup and all will be well

But when we apply the 3 tests above to PSA as a screening test it falls short.

(1) Does it detect prostate cancer reliably?

The figures are debated but roughly 20% of men with prostate cancer have a normal PSA, ie its sensitivity is 80%.

Conversely 80% of men with a high PSA do not have cancer (low specificity). However a high result invariably results in more investigation including biopsy which has its own risks and errors.

(2) Is treatment of prostate cancer effective?

Various treatments have been proposed – radical surgery to remove the cancer completely, curative radiotherapy or hormonal treatment

All have significant failure rates (not curing the cancer) and side effects are almost universal. Impotence is likely, incontinence is possible and significant side effects such as radiation proctitis (inflammation of the rectum) are common.

Moreover many men with prostate cancer die from other causes – the cancer may never affect their lifespan. The 10 yr survival disadvantage of men with prostate cancer is only 2%

(3) Is the outcome improved?

A large German meta analysis concluded:

The benefits of PSA-based prostate cancer screening do not outweigh its harms. We failed to identify eligible screening studies of newer biomarkers, PSA derivatives or modern imaging modalities, which may alter the balance of benefit to harm. In the treatment group, 2 of 1000 men were prevented from dying of prostate cancer by treatment. But all-cause mortality was similar in both screening and control groups. In the screening group there was a significant burden of morbidity associated with investigation and treatment side effects. For every 1000 men screened, 220 suffered significant side effects or harm.

Once the diagnosis is made, there may be some differences in subgroups and risk can be stratified. There can be a discussion with the individual about the best treatment in their particular circumstances.

But the initial decision to screen by necessity is based on population data. A discussed above, PSA screening in this situation is not supported by the data.

The Evidence for Secondary and Tertiary prevention

Secondary and tertiary Prevention describe activities which manage known risk factors for disease (secondary prevention or “case finding”) or even the disease itself to prevent recurrence of events or worsening of the disease (tertiary prevention). Examples of this are managing risk factors for Ischaemic Heart Disease (Hypertension , Cholesterol, smoking) in a client who has suffered a heart attack or Hypertension in patients with impaired renal function. In this situation the evidence for benefit is much stronger than in Primary Prevention.(ref)

But to achieve this benefit the health service must maintain a clear summary of the client issues and ensure that a program of regular relevant interventions is delivered. There is reasonably good evidence that a programmed series of interventions (a “Care Plan”) effectively reduces hospitalization and complications of known Chronic Disease.

Here a good EHR (electronic Health Record) system with logical business rules is important. But many of the current EHR systems in use suffer from poor “data visibility” ie important data about a client such as past history is difficult to find. This is due to poor program design and “noise” due to unnecessarily complex dialogs and administrative information cluttering the record.

(see my previous articles Poor Administration – a Health Hazard? and Software Design in Health – TjilpiDoc )

The General Checkup

A “General Checkup” has not been shown to improve outcomes in the general population.

A large meta- analysis of nearly 200,000 subjects failed to show benefit in outcomes (mortality or morbidity) (ref)

There were more diagnoses and treatment, however.

In the Indigenous population the idea of a checkup seems intuitively attractive because of the high rate of ill health generally.

However there does not appear to be research supporting this assertion.

The Checkup as a Safety Net

The Checkup in its various forms seems to be implicitly regarded as a “safety net”.

However, the studies of a General Checkup and the effects on outcomes (minimal) would suggest that this is not so.

Indeed it is my anecdotal experience that known issues are often ignored and new disease is rarely found on a routine checkup. Most new issues present as an acute illness or event.

The Commercial Value and cost of the Checkup

The Checkup is a relatively low risk activity legally and can be performed by less sophisticated clinicians to a large extent as it is a scheduled and programmed activity. It does not require highly developed clinical acumen and there are usually no difficult decisions. In spite of the lack of evidence, it is well remunerated by Medicare. It has become a commercially attractive option for Primary Care practices. But it generates significant system costs in addition to the checkup itself. There are oncosts for pathology and imaging generated – this is attractive to providers of these services. In spite of all this extra cost to the system the research quoted above would suggests that there is no improvement in outcomes.

Primary Care, Imaging and Pathology Providers have a vested interest in performing these services, even though the evidence for them is poor.

Why the disconnect between evidence and practice?

The PSA question continues to be debated even the though the evidence is clear. A regular “General Checkup” continues to be promoted in spite of the lack of evidence of benefit and significant cost.

Is this similar to the Climate Change debate where vested interests prevent real action? I would argue commercial vested interests are causing this disconnect. In fact much of our practice in Health is driven by commercial interests and much of our evidence has become corrupted by commercial drivers. As we struggle to deliver Health services and General Practice is apparently in crisis it is time in my view to review our whole basis of Health Service delivery and explicitly address these issues.

References

Assessment of prostate-specific antigen screening: an evidence-based report by the German Institute for Quality and Efficiency in Health Care

Ulrike Paschen, Sibylle Sturtz, Daniel Fleer, Ulrike Lampert, Nicole Skoetz, Philipp Dahm

First published: 07 May 2021

https://doi.org/10.1111/bju.15444

Citations: 4

BMJ. 2012; 345: e7191.

General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis

Lasse T Krogsbøll, doctor,Karsten Juhl Jørgensen, doctor, Christian Grønhøj Larsen, doctor, and Peter C Gøtzsche, professor, director

Effect of evidence-based therapy for secondary prevention of cardiovascular disease: Systematic review and meta-analysis

PLoS One. 2019; 14(1): e0210988.

Published online 2019 Jan 18. doi: 10.1371/journal.pone.0210988