by S. Todd Stolp MD
©July 2012
At first glance, “preventive health care” appears to refer to things that prevent us from getting health care, like when the nearest participating provider for your insurance plan practices in Albuquerque. In fact, preventive health care refers to steps a person can take to increase wellness and prevent illness. Examples are vaccinations, mammograms and colonoscopies, which a group of experts who know nothing about our personal lives recommends be performed on a specific schedule.
If these experts did know about our personal lives, they would know that competition for our time between these preventive health activities and virtually anything else – including playing Wiffle Ball barefoot in a field of star thistle – is no contest.
The committee of experts is the United States Preventive Services Task Force (USPSTF). It has the unenviable job of scrutinizing scientific research and weighing the risks and benefits of a long list of tests and treatments, then drafting recommendations which will make our lives longer and, presumably, more pleasant.
While it may sometimes appear like a game of Simon Says, these recommendations are the product of tedious scientific analysis and debate about collective values, social equity and cost. That they are regularly modified and updated is tribute to the humility of science in the face of new discoveries and the dynamic nature of the effort to improve our lives within a practical budget.
Their key preventive health recommendations – including colon cancer screening, mammography and regular physicals – just might successfully compete with Wiffle Ball-on-thistle for your time.
Colon cancer screening
There are two suggested tests for colon cancer, the second leading cause of U.S. cancer deaths after lung cancer (for which there is no recommended screening for the general population). A stool test can detect any blood that might be oozing from a small growth, a “polyp,” that can grow inside the colon.
About 3 percent of polyps larger than one centimeter in diameter will become cancerous each year. The key here is to remove the polyp before it becomes cancerous.
If blood leaks slowly from a polyp, it is not typically visible to the naked eye, so a chemical test of multiple stools on a card is usually required. Side note: It is still always a good idea to “look before you flush,” since a bowel movement, even if not as sensational as a supermarket tabloid, can provide some pretty good clues about our health.
The second test, a colonoscopy, uses a fiber-optic scope to detect polyps within the entire five-foot length of the colon. Polyps can often also be removed and biopsied during the procedure.
Persons of average risk should get this test at age 50, earlier for those with higher risk. Risk factors include a close family history of colon cancer, inflammatory bowel conditions, African-American ethnicity, obesity and smoking.
Breast cancer screening
A mammogram – a low-dose X-ray of the breasts – can locate abnormal growths while treatment is still likely to be successful. Breast cancer is the most common invasive cancer in females and is the second most common cause of cancer-related death in women. The discomforts of mammography are legendary and are a genuine source of empathy from the male gender, particularly when wince-worthy anatomical parallels are envisioned. However, considerable work has gone into minimizing the distress of the exam and, reportedly, the discomforts are much less than in past years.
Women with an average risk of breast cancer should have a mammogram every other year starting at age 50. Tests can begin before 50 if warranted by special risks – family history, smoking, medication and other scientific factors – or the patient’s personal values.
Art of medicine
Herein dwells the art of medicine.
It should be noted that none of the adversarial health conditions that we face throughout our lives are strictly linked to the exact number of birthday candles on our cakes. Nothing magic happens after age 40, 50 or 60, despite the fact that many of us are convinced that corrective lenses became necessary as we slept overnight on our 40th birthday.
Still, we cling stubbornly to a quantum theory of aging, worrying instinctively about age thresholds in groups of 5 or 10 years. Thus, while the USPSTF recommendations are standardized by extensive research, they also leave room for adjustment according to individual risk. Therefore, some providers may recommend a mammogram at age 50 for one patient and at age 44 for another.
It is also worth noting that part of risk assessment includes the impact of screening tests upon the convictions of the patient. Some patients feel better and in fact their health may improve after undergoing tests that confirm there’s no underlying disease or illness. This may enter into a doctor’s decision to order a test early.
Prostate debate
Prostate cancer screening in males has many issues in common with breast cancer screening in females. The routine screening of average-risk older males with the Prostate Specific Antigen (PSA) test remains controversial. The USPSTF recently came out with a recommendation against routine testing of the blood for PSA to detect otherwise undetectable prostate cancer in average risk men, but the committee also highlights that the decision to undergo PSA testing should include a careful consideration of health and lifestyle risk factors, personal values and should definitely include advice from one’s health care professional. It is important to obtain this advice before testing for PSA, since making a decision after the test results are in your hand means that you are already partly down the road of the assessment. The decision whether to embark on testing in the first place is easier than turning around and going back.
Routine physicals
How often should we have a routine physical exam even though we feel just fine? The USPSTF no longer provides a specific schedule, but the following standards generally apply – with a nod here to grandparents who may be responsible for their grandchildren’s health care.
During the first year of life, pediatric visits are scheduled frequently, with five visits during the first two years, coinciding with childhood vaccinations. Between 2 and 6 years, well-child visits are scheduled at least two to four times to monitor development and prepare for school. Between ages 7 and 12, at least one pre-adolescent visit should be done. One or two visits are very important between 13 and 18 years to contend with teenage turmoil, hormones, and vaccinations.
From age 19 to 40 or so, visits can be made every one to three years, depending on risk factors and your doctor’s discretion. Regular physical examinations should start for average-risk women at age 19 (earlier if sexually active), and Pap tests (a test of the woman’s cervix to screen for risk of cancer) at 21, and then repeated every 3 years until about age 65.
Just as tune-ups are important for your car after the odometer clicks past 250,000 miles, between 40 and 45 it is a good idea to increase the frequency of clinic visits in order to plan a schedule for periodic tests that screen for specific conditions like colon and breast cancer. At these clinic visits, the clinician will look over risk factors like family history, smoking history, occupation, medications and demographics in order to decide when to begin the special tests that were mentioned earlier or whether tests like mammography and colonoscopy can wait until after age 50. Someday, there may well be a battery of genetic tests that will be done in the decade between age 40 and 50 that will help plan a patient-specific schedule for such tests, but this day remains over the horizon. For now, an increased frequency of physical examinations during this decade of life serves the purpose. And do not forget that a “physical examination” requires the clinician to employ the senses of sight, hearing, touch and even smell to fully perform such an examination, the sense of taste having been replaced by laboratory testing.
Most doctors recommend physical examinations every year after age 50. After age 90, your doctor may encourage regular visits if only to gain advice from you.
Daily decisions
Another preventive practice is perhaps even more important than tests and treatments. This kind of care happens when we choose a salad instead of a Value Meal, drink a glass of water rather than a sugar-saturated soda, or walk to an appointment instead of driving.
We spend only about .02 percent of our lives with our doctors and health care providers. The other 99.98 percent of the time we are with our families, in our homes, preparing meals, meeting friends, going to work, raising kids, hunter-gathering and shopping.
The only healthcare provider available at these times is you, and your decisions are limited only by the choices available in your community. Recent research suggests that where we live may have more influence on our health than heredity or access to a caregiver. There’s a new push for communities to make healthy choices easier: encouraging access to stores selling seasonal fruits and vegetables, teaching skepticism about advertising claims, and designing residential areas with walkable access to amenities, schools and commercial areas. Preventive health care really gains traction in the unfolding of the daily routine of our lives.
Rx: Inspiration
People who have followed the rules throughout their lives by not smoking, by maintaining a good weight and by feeling good about themselves and their partners will on average be much better off when they enter the silver years than those seniors who have travelled rough and stormy roads. Those who have problems like high blood pressure and excessive weight gain during their lives can take preventive steps such as using medication, changing their diet and exercising more to prevent these conditions from worsening.
Of course, every person will eventually experience some kind of serious illness, and when this occurs treatment will include measures such as coronary bypass surgery or chemotherapy to reduce the consequences of further illness.
While we all face these inevitable risks in exchange for the privilege of waking up each morning, reminding ourselves of the rewards as well as the risks is worthwhile. Enjoying each day to the extent that we can is as effective a preventive measure as any. After all, every good laugh surely adds to the inspiration required to see to it that our personal machinery is well-maintained.