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When More Health Testing Makes You Less Healthy
There is an engineering principle that seems particularly relevant to medicine: "the best part is no part" and "the best process is no process." This idea was constantly hammered home to me in a clinical sense during my time in medical school and my years as a junior physician: sometimes the best test is no test and the best treatment is to avoid doing an unnecessary one.
That may seem counterintuitive, especially in today's world of rapidly expanding longevity clinics offering a wide range of tests. The sales pitch is compelling. The more information you collect, the sooner you will detect problems and correct them.
However, too much testing can result in negative outcomes. Too much testing can produce harm that would never have existed if you had performed fewer tests.
South Korea's Thyroid Cancer Story
To illustrate how this occurs, consider the story of South Korea since 1999.
The number of thyroid cancer diagnoses soared. In 1999, there were approximately 6.3 cases of thyroid cancer per 100,000 population. However, by 2009, that number had ballooned to nearly 48 per 100,000 population.
On the surface, it appears as though something in the environment of South Korea changed suddenly and drastically, resulting in a huge surge in thyroid cancer. That is not what researchers ultimately determined.
Researchers ultimately determined that the rapid increase in the number of thyroid cancer diagnoses was the direct result of screening, not an actual increase in the incidence of thyroid cancer. As a result of a government-funded cancer screening program, ultrasound screenings became widely available for the thyroid gland. Doctors began discovering large numbers of thyroid cancer cases that had likely existed for years prior to the screening.
Did earlier detection actually extend lives? No. The mortality rate from thyroid cancer remained relatively constant.
However, what did experience a dramatic increase was the number of thyroid surgeries. By 2012, approximately 11,000 people annually underwent thyroid surgery, whereas in 2001 that number was roughly 1,000, and there were no meaningful changes in the death rate from thyroid cancer. Most of those surgeries were unnecessary.
A possible explanation for this phenomenon is overdiagnosis. Some thyroid cancers are slow-growing enough that they would never produce symptoms in a patient's lifetime. Therefore, their discovery does not contribute to saving a life; however, the treatment can produce harm to the patient.
Thyroid surgery comes with various risks including damage to the laryngeal nerve (which could impair a patient's ability to speak and swallow), infections, and bleeding. Thus, the public health implications of unnecessary thyroid surgeries are obvious.
Full-Body MRI Scans - A Modern Version of the Same Problem
This same phenomenon exists with modern longevity clinic trends including full-body MRI scans. Again, the reasoning behind the full-body MRI makes logical sense. If you identify a potentially problematic condition early enough, you can intervene to prevent a catastrophic outcome. Sometimes a scan identifies a dangerous cancer. More commonly, however, the scan identifies something else. High-resolution imaging techniques such as CT scans and MRIs frequently produce incidental findings, which are unexpected abnormalities that have no relationship to the reason for the imaging. Incidental findings occur in approximately 20 to 40 percent of all scans. If you are performing a high-resolution scan on a symptom-free and healthy person, essentially every finding is incidental by definition. Once you identify incidental findings, you must determine what to do with them.
Incidental Findings and the Cascade of Care
The typical course of action involving incidental findings is to initiate a cascade of care. An incidental finding typically generates additional testing, which leads to additional follow-up, which can generate biopsies or other procedures. Each step in the cascade of care produces cost and risk.
An example of this is incidental lung nodules. A single study evaluated patients undergoing coronary artery plaque scans. Among 479 patients studied, 81 (approximately 17 percent) developed incidental lung nodules. However, none of the incidental nodules represented cancer. Nevertheless, some patients required additional imaging and/or biopsy to rule out cancer. Biopsy is not a risk-free procedure. It is associated with risks including bleeding, infection, and damage to surrounding structures. Many of the incidental findings in this study did not require any intervention whatsoever.
This is perhaps one of the most counter-intuitive lessons in contemporary medicine. Detecting more does not necessarily equate to improved outcomes. In fact, in some cases, it may actually lead to greater harm and not contribute to extending lives.
Therefore, when evaluating screening programs, it is essential to differentiate between overly aggressive screening in individuals without symptoms and when the harms of the screening far exceed its benefits versus under-screening in populations with proven benefit.
Expert bodies such as the American College of Radiology do not support total body screening for asymptomatic individuals without a history of a known risk factor. Their primary concern is that screening programs for asymptomatic individuals will result in a large number of non-specific incidental findings, followed by additional follow-up and related costs, with minimal to no benefit in terms of extended life expectancy.
Why "Just Ignore It" Doesn't Work
Many advocate that once you perform the screening and you discover an incidental finding, you simply ignore it. Unfortunately, ignoring the finding is virtually impossible. When a person is informed that "we have detected a mass on your pancreas," even with assurances that it is likely benign, most people will desire absolute certainty. To obtain certainty, they will seek additional imaging studies, possibly biopsies, etc. Once you begin the process of follow-up testing, it is difficult to cease.
It Is Not Only Imaging
Longevity clinics do not only provide scans. Many clinics provide a multitude of lab panels (sometimes exceeding 160 different blood tests). Some of these tests are demonstrably useful and actionable. For example, measuring a patient's LDL cholesterol level and Apolipoprotein B (ApoB) levels are both established measures of cardiovascular risk. However, many other tests are clinically meaningless in healthy individuals and serve primarily as a marketing tool to induce anxiety and justify additional follow-up testing and treatments.
The Prostate Cancer Screening Paradox
Prostate cancer represents another example of why excessive screening may not always be beneficial.
Firstly, prostate cancer is relatively common. Furthermore, many men with prostate cancer will either never develop symptoms from their cancer or will die from other causes. If they were never screened, they would never have known the cancer was present.
Secondly, when screening detects cancer, it may prompt a biopsy and treatment. Treatment can result in serious adverse consequences, including impotence and urinary incontinence. Additionally, biopsies themselves are not devoid of risk and have a slightly higher risk of developing serious complications.
Thirdly, while there are certainly times when treatment is necessary and saves lives, there are also many instances when treatment is provided for cancers that would never have caused harm to the patient.
Thus, the U.S. Preventive Services Task Force determined that there is only limited potential benefit for routine screening in men aged 55 to 69, with considerable risk. Ultimately, this necessitates individualized decision making and not universal testing.
Spending Money on Unproven Treatments for Unproven Diseases
Another example of this is the increasing popularity of removing microplastics from blood. A single clinic reportedly charges $12,500 for the treatment.
Unfortunately, the scientific community does not yet possess sufficient knowledge regarding what constitutes hazardous levels of microplastics, what levels of microplastics should be targeted, or whether the procedures employed to remove microplastics effectively decrease the amount of microplastics in the bloodstream long-term. Moreover, there is an interesting aspect to this: many of the equipment used in microplastic removal procedures include plastic tubing that releases microplastics.
Therefore, this represents a quintessential example of investing a great deal of money on treatments where the disease is poorly defined and the treatment is unproven.
Right Answer: Evidence-Based Screening
The bottom line is not that screening is inherently bad. Rather, screening has trade-offs.
You can fail in two ways:
- Too much healthcare: Aggressive screening in asymptomatic individuals where the harms outweigh the benefits
- Too little healthcare: Skipping proven screening where the benefits clearly outweigh the harms
The best way to navigate this dilemma is to rely on evidence-based guidelines developed by expert bodies, which examine outcomes rather than simply detection.
For instance, evidence-based screening recommendations for cancer screening for breast, colorectal, cervical, and lung cancer exist due to the demonstration that these recommendations improve outcomes. Similarly, evidence supports blood tests such as LDL cholesterol and ApoB as strongly supported because they have been extensively documented to be predictive of cardiovascular risk and are actionable.
In contrast, when a screening program lacks strong evidence to demonstrate its effectiveness, especially in asymptomatic populations, a healthy dose of skepticism is warranted.
Focus on the Levers That Actually Move the Needle
If your goal is to achieve improved health and longevity, the largest gains are not buried in exotic tests. The largest gains are achieved through evidence-based levers:
Testing can be helpful when it results in clear action leading to improved outcomes. Conversely, testing becomes problematic when it generates undue anxiety, additional unnecessary procedures, and harm without producing benefit.
Sometimes, the best test truly is no test.