On the Full Body CT Scan: Don’t Do It.

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NaBloPoMo 2016, Letters to Patients, Day 27

To Patients Considering Full Body CT Scans:

Please reconsider.

Forgive me for putting on my preachy doctor hat for this post.  I will also break my NaBloPoMo 500 word limit for this one.

As we approach the end of the calendar year, many of you may have met your health insurance deductibles.  Maybe now would be a good time to get in some tests to ‘check under the hood,’ as some of you have said.  I share below some of my screening  recommendations, along with rationale.

Keep in mind that for this article, I define ‘screening’ as looking for a disease in a person with a) average risk for developing the disease and b) no symptoms.

Please also know that the opinions I express here are my own only and do not necessarily represent those of my colleagues, employer, or professional societies.

 

  1. Full body CT scan: This is not recommended by any clinical guideline or medical professional society as a screening test for anything.  As I will describe below, specific screening tests are recommended for specific diseases, and the best ones obtain actual cells or tissue, rather than imaging alone.  In addition, a full body CT exposes you to significant radiation, the long term consequences of which are still not fully understood.  Lastly, CT scans inevitably detect incidental abnormalities that have no clinical consequences, but that often lead to invasive tests that can cause real harm, such as bleeding, pain, infection, and anxiety.  This article from the FDA and this one by a radiologist at Harvard explain pretty clearly how the risks of this test far outweigh the benefits.
  2. Colonoscopy (colon cancer): This is the one test that nobody argues.  It is both diagnostic (can see signs of early disease) and therapeutic (can take it out).  Start at age 50, and repeat every 10 years if normal, barring new symptoms.  Read the full guideline from the US Preventive Services Task Force (USPSTF) here.  I know the prep is a pain, and I know you have to take a day off of work to have it.  But on the whole, the returns here are well worth the investment.
  3. PSA and digital rectal exam (prostate cancer): This is perhaps the most personal decision of all cancer screening. Population-wise, we have yet to show mortality benefit from screening of any kind, such that the USPSTF now recommends against screening until better tests become available.  But it’s not really that simple, because prostate cancer affects so many men, and is the second leading cause of cancer deaths in men in the US.  The most important thing here is to decide which risks you are more comfortable with: potential serious harm from screening and unnecessary treatment, or finding cancer at a later, potentially more high-risk stage.  This article from the New York Times may help, and this one from the National Cancer Institute.cancer-cases-and-death-2016
  4. Mammogram (breast cancer): It’s hard to walk back from more screening to less; people fear loss of security. When I started my training over 20 years ago, the recommendation was to screen every woman every year, starting at age 40.  Since then epidemiologists have kept track, and similar to prostate cancer screening, the mortality rate from breast cancer has not decreased proportionally to the amount of screening done.  Diagnosis has increased dramatically, due to early detection.  Again, screening increases the risk of certain harms:  anxiety (so much, for so many), pain, deformity, infection (from invasive biopsies), and then commitment to repeated testing (a vicious potential cycle of imaging, needling, more imaging, and more needling), while likely not saving your life.  Here is the USPSTF guideline, and a helpful infographic .  Like prostate cancer screening, this is one you have to decide for yourself, with the help of your doctor.mammo-infographic
  5. Pap smear (cervical cancer): Again, former guidelines called for annual screening. Today, if your test is repeatedly normal and your sex habits are low risk, the interval can be lengthened to 3 to 5 years, and can start later in life (over 21).  Cervical cancer is highly correlated to exposure to human papilloma virus, or HPV, which is sexually transmitted.  Positive pap results, which range from mild to severe, occur far more often in younger women, and of those, many will revert to normal without progression to cancer in a woman’s lifetime.  The main risk of over-screening, again, is unnecessary procedures when true disease not present.

In summary, these are the most common conversations I have with patients about screening.  You may rightly infer that my personal bias is minimalist:  Primum non nocere.  Unfortunately, we have no good screening tests for some diseases, such as pancreatic cancer, ovarian cancer, and liver cancer, and the screening guidelines in other countries (eg Taiwan screens adults regularly for liver cancer) do not apply here because prevalence rates differ so widely.

This is why I think it’s important to establish care with a primary care physician and get regular check-ups.  That fatigue you feel is likely just life and chronic sleep deprivation.  You’re probably constipated because you eat too few stems/stalks/leaves and don’t move enough.  You and your doctor can review your general health together, and if there is suspicion for some underlying health risk, it can be addressed personally and specifically.

To look up USPSTF guidelines yourself, I recommend searching Google for “USPSTF (disease) guidelines” and look for the hit that starts with “Final Recommendation Statement…”  I have no financial or professional interests in Google or the USPSTF.  Other respected sources for screening recommendations include the National Cancer Institute, the American Cancer Society, and the American Medical Association.  As an internist, I recommend the American College of Physicians.

I hope this piece has helped illuminate the complex decision-making behind screening and diagnostic testing.  I have only scratched the surface; the links contain the data and full rationale.  Please take the time to read through them and discuss them with your doctor.

On Happy Movies

 

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NaBloPoMo 2016, Letters to Patients, Day 26

To Patients Getting Into the Spirit:

What movies do you recommend?

26 days and… writer’s block.  So duh, the obvious solution was to take a shower!  According to Shelley Carson, PhD, the defocused mindstate of showering allows for creativity and innovation.  I noticed the sullenness that envelopes me so often lately.  I wished for a mental uplift, and the gods obliged—they reminded me of “The Internship.”  Vince Vaughn and Owen Wilson play a couple of recently unemployed Gen-X salesmen who land coveted internships at Google.  They lead a dejected team of Millennial misfits who, of course, overcome all odds to win in the end.  It’s admittedly full of cheese.  But the endearing characters and uber-nerdiness get me every time.

Post-shower, I came down to movie night in progress:  “Music and Lyrics,” starring Hugh Grant and Drew Barrymore.  Grant, an 80s pop ‘has-been,’ falls in love with his substitute plant waterer and incidental lyrcist, played by Barrymore.  Once again, current-event melancholy yielded to drippy-sweet romantic comedy.  You just can’t sustain a sour mood in the face of all that adorableness.

Other movies that come to mind, and that I plan to watch in the coming days:

Love, Actually

The Holiday

White Christmas

You’ve Got Mail

While You Were Sleeping

It would really be nice to get fully into the spirit again this year.  Why not aim for joy, after all?  Vacation days, family gatherings, gift exchanges and excuses to shop with abandon…  It could all be good, and I can exercise more control over my mood than I have until now.

So, the feel-good, holiday-mood-elevation movie marathon begins tomorrow, yay!  Please feel free to make your suggestions!

On the Golden Positivity Ratio

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Courtesy of Bryan Jorgensen, Las Vegas, NV, 2016

NaBloPoMo 2016, Letters to Patients, Day 25

To Patients Seeking Positivity:

Aim for the Golden Ratio!

As many of you know, I have recently undertaken to re-evaluate my Facebook usage.  Not long after I established my account c.2008, I decided to make my page a monument to positivity.  I realized that after I die, it would be the most visible and accessible legacy I leave, and I have total control over what I post.  I minimized complaining and ranting, and when frustrated I would try to write with an attitude of learning, of moving forward.  Lately I tend to leave off the latter.

Somewhere along the way, I think over the past year, but I’m not sure, pessimism and cynicism snuck in, no doubt related to politics.  The layers of consciousness infiltrated by the negative campaigning this time around extend deeper than any other election cycle in my memory—but maybe I just don’t remember.  I think humans have evolved to forget pain as a survival mechanism.  If women remembered all the pain and anxiety of pregnancy, delivery, and caring for a newborn, we would never do it more than once, are you kidding me?

I used to review my Facebook posts and feel elevated.  Today they often bring me down; it feels terrible.

Thankfully, I have some tools to resist the negativity.  I was reminded recently during my 3 Question Journal Shares with Donna over at A Year of Living Kindly.  I remembered something about healthy relationships maintaining a 3:1 ratio of positive to negative interactions.  Turns out it’s actually 5:1, widely attributed to observations by Dr. John Gottman, renowned marriage and relationship psychologist.  I think the same thing applies in other realms, too, such as self-talk—a reflection of our relationship with ourselves.  It’s not a far leap to see how this idea pertains to news, social media, and any other human interactions.

Business researchers have discovered a 5.6:1 ideal ratio in highly functioning organizations, whereas low-performing teams’ ratio landed close to 0.3:1.

For more information on the science behind the theory (and motivation for practice), I highly recommend Positive Psychology in a Nutshell, by Ilona Boniwell.  For a brief overview, check out this PDF.  The book summarizes the origins of positive psychology as a field, and the research and wisdom of its study and application.  For example, psychologist Barbara Frederickson has described how positive emotions contribute to our personal growth and development (taken from Boniwell’s text):

  1. Positive emotions broaden our thought-action repertoires
  2. Positive emotions undo negative emotions
  3. Positive emotions enhance resilience

So hereafter, I will pay more attention.  I will likely continue to share articles that illuminate my concerns for the future.  But I will aim for the 5:1 positivity ratio.  Holy cow, can you imagine if that’s actually what we saw on the news and social media?  And why not aspire to 5:1 in my personal interactions, too?  That’s taking charge of my own happiness, yes.