Every so often, I get letters inviting me to sign up for “potentially lifesaving screening” tests offered by Life Line Screening.
The Ohio company sets up at a church in my University City neighborhood and offers five tests for $149 – a “savings” of $181 – to detect the risk of vascular disease, stroke and osteoporosis.
The company brochure warns that “your risk of stroke doubles every decade after age 55” and that “4 out of 5 stroke victims had no apparent warning signs prior to a stroke.”
People across the country get offers like these from Life Line and similar companies. They’re tapping into the anxiety many people feel about health problems that might not be detected early enough to be treated successfully.
It makes sense, doesn’t it? The earlier we detect problems, the better off we’ll be. Right?
Well, not always.
“My concern with these mass screening efforts is that they don’t talk about the harms of screening,” said Dr. Otis Brawley, chief medical officer for the American Cancer Society and author of “How We Do Harm.”
“We always have to ask, ‘Is the benefit greater than the harm?’” said Brawley, who’s based at Emory University in Atlanta.
One of the tests offered by Life Line – ultrasound screening of the carotid arteries – is not recommended by the standard-setting U.S. Preventive Services Task Force for routine screening of healthy adults.
Brawley said ultrasound can identify “small lesions” in the carotid arteries that, if left alone, would never cause problems. But once patients get positive test results, they usually seek further testing and treatment. That can lead to more expensive and invasive procedures, such as the implantation of stents or surgery.
We always have to ask, ‘Is the benefit greater than the harm?’
Dr. Otis Brawley, chief medical officer of the American Cancer Society and author of ‘How We Do Harm.’
“You have to look beyond the initial cost of the screenings,” Brawley said. “…The majority of all carotid artery lesions will never be clinically relevant.”
As might be expected, Life Line’s chief medical officer, Dr. Andrew Manganaro, objects to some of Brawley’s objections.
Manganaro said Life Line doesn’t test everyone who calls. He said each person is questioned about age and risk factors for cardiovascular disease – if they’re over 50, have high blood pressure or high cholesterol, are 20 pounds overweight – to find out if they’re appropriate candidates.
“It’s a misconception that we screen people willy-nilly,” Manganaro said. “That wouldn’t make any sense, and we don’t do that.”
Manganaro said he’s confused by Brawley’s criticism that screenings lead to more tests. “If you have something wrong, it’s best to know it,” Manganaro said. Further testing would not be ordered by Life Life, but by the patient’s doctor, “and they should only do it when it’s appropriate.”
Brawley is right that some carotid artery blockages don’t progress to become problems, Manganaro said, “but you don’t know” which ones are which. Just finding out about a blockage could prompt someone to stop smoking and choose healthier behaviors, said Manganaro, a cardiovascular surgeon in Dayton, Ohio, for 30 years.
Manganaro said he first heard about Life Line when a patient brought in a packet of results from the testing, which included an ultrasound to detect abdominal aortic aneurysm. The doctor had been up all night operating on a patient whose aneurysm had burst. Such patients have a 20 percent chance of survival, he said, compared to 95 percent for patients who have elective surgery on aneurysms detected earlier.
“The notion of screening people for these diseases made ultimate sense to me,” Manganaro said, “because I’m the one who sees the bad end of the stick.”
It’s a misconception that we screen people willy-nilly. That wouldn’t make any sense, and we don’t do that.
Dr. Andrew Manganaro, chief medical officer for Life Line Screening.
For abdominal aortic aneurysm, the Preventive Services Task Force recommends one-time screening for men ages 65 to 75 years who have been smokers and selective, rather than routine, screening” for men of that age who have never smoked. For women 65 to 75 who have smoked, the task force says evidence is “insufficient” to make a recommendation, but it recommends against routine screening for women who have never smoked.
Other tests in the Life Line battery are blood pressure measurements at the ankle and arm to screen for peripheral arterial disease, a bone density test of the heel to detect osteoporosis, and electrocardiogram of the arms and legs to identify atrial fibrillation, or irregular heart beat.
Brawley, who is an epidemiologist as well as an oncologist, said the value of screening tests should be determined by weighing benefit versus harm in large groups of people. It can be misleading to judge based on one doctor’s or one patient’s experience, he said.
“You never hear from the people who are hurt. You only hear from the people who think they were helped,” Brawley said. “Doctors who are not trained in epidemiology frequently don’t understand the harms associated with screening. They only see the possible benefits.”
For example, Brawley recalled having a patient who had a positive carotid artery screening test and a subsequent cardiac catheterization which showed the earlier test result was wrong. Because of the dye used in the latter test, the patient ended up with kidney disease. “That’s someone who was definitely harmed,” he said.
Also, in the 1960s many doctors advocated widespread screening with chest X-rays to detect lung cancer early and prevent deaths. But a Mayo Clinic study published in the 1970s showed that “people who got screening had a slightly higher death rate than the people who were not screened,” Brawley said.
Even though Life Line markets its tests to patients through direct mail and advertising, Manganaro said the company encourages patients to talk with their doctors before and after they get screened.
But Brawley said he worries patients might seek these tests “as a substitute for going to the doctor.” Even negative test results, or a good report, can cause harm, he said, because it might keep people from talking with their doctors about preventing other problems, such as diabetes.
“People should not take the tests and then talk to their doctor,” Brawley said. “People should go to their doctor and ask, ‘Should I be getting these tests?’…The basic principle is that screening is something that should be done within the physician-patient relationship.”
The U.S. Preventive Services Task Force makes recommendations about the benefits and harms of screening tests for the general population. For more information: www.uspreventiveservicestaskforce.org.