Preventive health care can save your life but is becoming increasingly complex. Personal preference and lifestyle issues, as well as cost, inconvenience, and imperfection in screening efforts make participation an individual decision for you to make.
During your exam, the most emphasis is appropriately directed toward detecting risk for heart attack and stroke as these are very common and intervention is very effective. Arterial disease screening will be thoroughly accomplished automatically while other issues are covered only as time permits, making details in this handout important for you to read.
The handout is designed to help you weigh the advantages and drawbacks of various issues so that you can form your own conclusions. The last page contains my recommendations to you in table form. These were developed over a number of years using guidelines from the American College of Physicians, National Institutes of Health, National Cancer Institute, various medical journals, my own clinical experience, and a variety of other sources. The body of this handout contains what I want you to know about preventive health and elaborates on the table as well as other subjects I think are important.
I urge you to read through this completely and feel free to ask questions. I will initiate implementation of some of these recommendations, others I will not. You must decide which measures I do not initiate that you want done and communicate this to me. For example, if you are 50 years old and I do not initiate scheduling a colonoscopy, it is still recommended as in the table. You must decide if you want it, and if so, call us to arrange.
Preventive care is a matter of balancing risk from disease with our ability to accurately detect disease early and with our ability to do something about it if we find it. Cost enters in, but that is a more individual consideration. For example, we do not screen for pancreatic cancer because it is quite rare and even if we test aggressively, we cannot accurately say it is there without invasive testing. Once we know it is there early, we often do not possess great ability to alter the outcome.
False positive tests are a major problem in screening. For example, if we do a urine screen for blood to detect urinary tract cancer in young people, the disease is rare yet microscopic traces of blood in the urine are somewhat common and often innocent. In this situation we can exact a very heavy physical and emotional toll and save few, if any, lives, most of the blood being a "falce positive."
As you read through the next few pages, these principles will serve as the basis for my rationale in recommending some procedures and not others. Of course, anyone at high risk for a given problem should be considered for screening in a different light. If you are interested in a test that is not recommended, let's discuss it.
History and Physical should be done every year from age 18. We cover many things from screening for skin, thyroid, or colon cancer, to detecting diabetes, heart disease, high cholesterol, or hypertension. This is when risk factors for heart attack are found and dealt with, resulting in a substantial decrease in heart attack and death rates over the last decade. This also serves as the time to bring the medical record up to date and answer questions.
Self Breast Exam should be practiced once per month by all women 18 and older. Many women remark that they don't think they would recognize a lump if it were present, but after many months or years they sometimes do discover lumps.
Mammogram. Your mammogram is best ordered and interpreted by the physician who does your breast exam. I recommend mammography every year starting at 40 because, though breast cancer is less common under age 50, it is often more aggressive and younger breasts are more dense and the test more difficult to accurately interpret. Understand before the exam the odds of a "suspicious" mammogram are fairly high even though cancer is unlikely. Be prepared for the possibility of a worrisome phone call and possibly even a biopsy, both of which are much more commonly not cancer. This is the price everyone pays to help those few who do have cancer.
Pap Smear. Suggested every year over 18. Saves many lives, turns an almost always fatal disease into an almost never fatal disease. Women who have not had complete removal of uterus and ovaries should see a gynecologist for breast and pelvic exam and rectal exam if 40 or older in addition to an annual exam with me. If any of these are not done by the gynecologist, let me know. Women who have had complete removal of uterus and ovaries, in my opinion, do not require pelvic exams. You can either see the gynecologist for the breast and rectal exams or let me know and I can complete the exams during your physical here.
Stool Guaiac is the test to detect blood in the stool for colon cancer for all people age 40 and over. Please complete the 3 cards given to you during the exam and return them to us. If the dietary and drug restrictions cannot be followed the test is still worthwhile, though a higher false positive rate will result. If blood is found on these cards, a referral for a colonoscopy will be made.
Colonoscopy. While you are sedated a flexible, lighted scope is passed into the colon to search for cancer or polyps. I do not do the test be can refer you to someone who does. Is is recommended at age 50 and every ten years thereafter. Though this test is underutilized, it has definite value and I suggest you pursue having it done. This advice replaces prior advice to have sigmoidoscopy done more frequently. Advantages of colonoscopy are cost effectiveness, it examines the entire colon, is done less frequently, and you are asleep during the test. Double check, but recent Texas law requires insurance companies to cover this test every 10 years in average risk people 50 years and older.
Urinalysis should be done yearly to screen for urinary tract cancer beginning at 60.
Self Testicle Exam should be done by all men every month starting at age 18 to try to discover a lump that could be early testicular cancer.
Immunizations. Pneumovax protects against the most common bacterial pneumonia. Get it at age 65. The flu shot every year at age 65, decreases the number of flu cases and saves lives. It can be taken by those under age 65 and will decrease likelihood of flu but this age group is less likely to die from flu. A diptheria-tetanus booster should be given every 10 years even if you don't have any cuts.
PSA blood testing
It is hoped PSA testing detects prostate cancer in time to save the life
of someone destined to die from it. Having said that, there is no proof
this test is able to do that. I am willing and happy for you to have the
test done, however ethically I feel it is important you have adequate,
informed consent regarding the test, including knowing I am unwilling
to have the test done on me.
I turn your attention to the accompanying page with three medical journal excerpts.
The point of the first abstract entitled "Controversies in Prostate Cancer Screening" is to observe PSA testing has a lot of characteristics similar to chest x-ray screening for lung cancer in smokers. Chest x-ray screening was ultimately proven to be of no benefit in saving lives, however many people with benign chest problems had serious invasive chest surgeries with its attendant morbidity and even mortality, not to mention time off from work and physical pain.
This was done with a good, common sense notion that surely a chest x-ray would detect cancer earlier and save lives. On a common sense basis it should have worked, it simply did not and as physicians we made the mistake of not requiring proof of benefit before we embarked on this ultimately painful chapter in our history.
Interestingly, the American Cancer Society endorsed the chest x-ray idea and withdrew the advice when studies showed no value, just harm.
The second medical journal excerpt entitled "Variations in Recommendations shows only the American Cancer Society giving unambiguous support to the notion that PSA testing should be done. Certainly most of the other groups mentioned have a track record of more rigorous science. In particular, the National Institutes of Health and National Cancer Institute have been reliable in the past.
My concern regarding the test can be visualized by looking at the enclosed bar graph. Looking at 1987 when the test was seldom done, you can see the number of people who died from the disease and the number that were diagnosed. In looking at the number who died once PSA testing came on the scene, you can see that it is too close to call and in fact excellent studies are ongoing to try to determine whether the death rate from prostate cancer is going up, down or staying the same with the use of PSA testing. It would not be appropriate to look at this bar graph and conclude PSA testing is ineffective, as it requires careful ongoing trials to form any conclusions.
The important part of this bar graph is the increased numbers of men diagnosed with prostate cancer with the us of the PSA test. Everyone above the handwritten line that I drew in could be reasonably assumed to represent cases found due to PSA screening. Most of all these thousands and thousands of men will have surgery that potentially leaves them leaking urine or unable to have intercourse, assuming they survive the surgery as most do.
Certainly if we are saving lives we would perhaps individually be willing to assume the risk of surgery or radiation, but with no proof of benefit for those who are ultimately destined to die from the disease, it seems reasonable you should be aware the test has no proven benefit.
If we could go back to the time in medical history when we were doing chest x-rays in people who smoked I can assure you we were fairly secure in our logic; surely we were doing good work. That we were ultimately demonstrated to be doing not neutral or good work, but rather bad work, should have a sobering effect on all of us as we contemplate PSA testing.
Again, I will be more than happy to provide the test for you. Should you elect to have it, you simply need to let either myself or my staff know and we will add it to your lab, or if necessary, redraw a lab specimen any time at your convenience. Should proper studies someday demonstrate appropriate benefit, I will then advise the test be done.
Screening chest x-ray, even in smokers is no longer recommended because it does not detect cancer early enough to change the outcome.
Don't Smoke. It hurts your heart, lungs, and blood vessels. Studies have shown that people whose doctor tells them they should quit smoking, quit more often than those who don't. Therefore, "quit smoking, please."
Don't drink too much alcohol. It is easier than some think to be harmed by alcohol. The Center for Disease Control suggests any more than 7 servings per week in women or 14 servings per week in men risks long term harm.
Nutrition may have been overplayed in recent years, but I think a few principles are important: Unless you have high blood pressure, I wouldn't be overly careful about salt intake. Unless you have had your cholesterol checked and found to be high, I wouldn't be overly careful about cholesterol intake though decreasing the fat in your diet some, and maintaining ideal body weight through mild exercise and, if necessary, a modest reduction in calories pays big dividends. Attention to some fiber in the diet is probably worthwhile.
Sex outside of marriage is an important problem. not just AIDS but infertility, herpes, babies born with herpes, etc. Consider giving it up, at least for this lifetime. "Safe sex" is not a term a consensus of the medical community can agree on.
Don't use illegal drugs. If you are, tell me and we can discuss stopping.
There are many lab tests and appropriate ones are chosen each year depending on your situation.
See a dentist once or twice per year if you have teeth, an ophthalmologist once a year if you have eye problems, are over65, have a family history of glaucoma, or every three years even without these problems, if you are black.
I recommend against TB skin testing as a screen as do virtually all consensus organizations.
I don't screen for osteoporosis as a routine. It is sometimes worthwhile on a case by case basis. Either your gynecologist or I can discuss.
Car wrecks? Don't drink and drive, wear your seat belt, and watch out for the other guy. Remember to keep your back straight and bend your knees while lifting. Install smoke alarms and appropriate hand rails, etc. for the elderly who are unstable at home.
If your hearing is bad, let an ear, nose, and throat doctor see if he can help.
Study the table and these suggestions and let me hear from you.