14 tests you (probably) don’t need (part one)

Studies estimate that 40-60% of medical tests are unnecessary, contributing an extraordinary burden to our already over-strained healthcare system. Moreover, unnecessary testing can lead to additional superfluous further investigation (tests beget tests). 

This not only inconveniences patients but puts them at risk when testing is invasive or initiates unwarranted aggressive medical intervention. For example, a “routine” x-ray may reveal the presence of a shadow—an unanticipated incidental finding, sometimes referred to disparagingly by doctors as an “incidentaloma”—necessitating further scans with radiation exposure and even biopsies, with attendant potential for complications.  

There are many reasons over-testing is rampant: First of all, we all really want to know what potential dangers lurk within our bodies. But not every finding is relevant; nor can some conditions be better managed with aggressive treatment than watchful waiting. Early detection doesn’t always equate to better survival or quality-of-life. The arterial plaque or nascent cancer found in a 78-year-old might be their death knell at 105—an age few attain anyway before dying of other natural causes.

Then, too, the ubiquity of imaging and testing opportunities. It was once estimated that there are more MRI machines on the island of Manhattan than in the entire country of Canada, highlighting the difference between for-profit medicine and a system that rations care.

Finally, there’s the ever-present fear of malpractice. “CYA” (“cover your a**”) medicine leads doctors to relentlessly pursue every possibility—just “in case”.

To complicate matters, different medical organizations promulgate disparate guidelines about when and how to test. Specialty organizations like the American Heart Association tend to be more aggressive, while oversight bodies like the U.S. Preventive Services Task Force (USPSTF) may be more skeptical about the value of testing in an effort to curb runaway healthcare costs. Commercial entities, like promoters of new blood tests and imaging gadgets, lobby for insurance approval and court media coverage of their new “breakthroughs”, which sometimes overpromise and under-deliver. 

Fishing provides a good analogy to medical testing. Just as there are two types of fishermen—those trolling with a huge net in uncharted waters hoping to catch something while not inadvertently coming up with “junk species”, vs. those savvy rod ‘n reel folks who know their quarry and go after it selectively, so too is there a difference between screening indiscriminately and testing with a specific goal.

The main thing to keep in mind when contemplating testing is to simply pose the question “How will the results of this test shape decisions about my future care?” 

Do acceptable options for treatment even exist? Or will the disclosure of a problem simply prompt undue anxiety without yielding a path forward? Worse yet, could results propel a patient toward an arduous treatment course they’re likely to regret? 

Sometimes it’s hard to remember that there’s as much a right not to know as there is a right to know.

The following are some candidates for tests you might not need:

1. The Galleri®️ Test: We’ve come a long way in preventive cardiology; we can assess risk factors six-ways-to-Sunday with an array of blood tests and probe the inner workings of the heart and blood vessels. Not so in oncology. Wouldn’t it be nice to have a simple blood test to tell us whether cancer was brewing somewhere in our bodies?

In fact, that’s the Holy Grail of preventive oncology, so much so that a company literally called “Grail”—a multi-billion-dollar biotechnology/diagnostic start-up—has sought to popularize the Galleri®️ Multi-Cancer Test. It purports to screen for 50 different cancers, and is pitched directly to consumers, costing around $1000, with spotty insurance coverage.

Initial studies looked promising, leading to the test’s approval by the FDA. It performs well in identifying the presence of cancer and even localizing it by cancer type. There are few false positives. 

This has led to a collaboration between the UK’s National Health Service and Grail to test its potential in a clinical setting. The results were underwhelming. The New York Times headlined “Grail’s Cancer Detection Test Fails in Major Study”. On that news, Grail’s stock price fell by a half, but has since partially recovered. 

The trial was paused after it did not show a statistically significant reduction in combined Stage III and IV cancer diagnoses overall during its initial primary review.

While detecting more cancers, experts still question whether this will translate to better cancer survival. Since we’re not yet at the point where cancer is as treatable as, say, gonorrhea, it’s unclear whether early detection will translate to cures, or even better quality of life. There’s also the danger that early detection, for some patients, may prompt unduly aggressive and ultimately unsuccessful treatment, to no avail.

The question is not whether Galleri finds cancer; rather, ask if finding it matters. 

That doesn’t mean that Galleri is worthless. With further refinement, it may prove more discerning as a predictive tool, and innovations in cancer treatment are progressing by leaps and bounds. Tests like Galleri are likely the future of cancer detection and monitoring of the effectiveness of treatment, but for routine screening purposes at present, I’d forego it. 

2. Whole-body MRI. Wouldn’t it be great to peer into the recesses of your body, searching for all signs of disease, to spot trouble brewing? That’s the promise of whole-body MRI, promoted by companies like Prenuvo, that boasts “Scan for hundreds of conditions. Take control of your health with leading whole-body MRI.” The likes of Kim Kardashian, Cindy Crawford, Paris Hilton, and Gwyneth Paltrow have endorsed Prenuvo.

But top medical experts are virtually unanimous in their condemnation of screening with whole body MRI. It’s not so much the danger from unnecessary radiation—MRI, unlike CT scans, delivers none. They’re concerned about finding “incidentalomas”—signals of indeterminate significance that might initiate medical goose chases. Currently, no medical society recommends MRI imaging of healthy patients.

3. Colonoscopy after 75: This requires a more nuanced discussion. Because of the increased incidence of colon cancer in younger patients, we’re generally recommended to start earlier with colon screening, especially if we have a family history or suffer from colitis.

But when can you stop? Should you keep up with those unpleasant exams every 5 years until you’re in your 90s? 

A recent study shed light on the subject. Even in septuagenarians who had a previous colonoscopy that had revealed benign polyps—not necessarily a prelude to cancer but suggesting higher risk—repeat colonoscopies in their 70s conferred little protection against death from colon cancer. Instead, they were found to have a much higher likelihood of dying from myriad other causes. In other words, colon surveillance assumed less importance as they approached their natural expiration dates. 

But under certain circumstances where colonoscopy is not “routine”, but addresses higher risk, or the onset of troubling symptoms, colonoscopy is recommended for people 75 and beyond. With many people now attaining greater healthy longevity, there may be more time for a missed early cancer to become life-threatening. 

4. Mammograms after 75. A similar situation prevails for breast cancer surveillance. There’s evidence that early breast cancers progress more gradually in senior women, which may reduce the imperative for continued annual exams. Older women who are not deemed high-risk and have had consistently normal prior mammograms may want to reconsider the annual ritual, particularly if other health conditions make it less likely they are to exceed ten additional years of life. Additionally, 75+ women with breast cancer may be more likely to make a personal choice to forego drastic treatment as a quality-of-life decision, even if a cancer were to be discovered. 

5. PSAs after 70: According to the often-cited guideline that routine PSA screening can stop once a man reaches 70, withholding the test from Joe Biden when he turned 70 while vice president was justified. Now he has widely metastatic prostate cancer, a terminal diagnosis. What gives? 

It’s even been proposed that, given the imprecision of PSAs and the tendency for early prostate cancers to be slow-growing and amenable to watchful waiting in older men anyway, plus the downsides of aggressive treatment in men with accompanying medical conditions and with limited life expectancy, that we forego routine PSAs for older men altogether. 

We came close to having an incapacitated president likely to have died in this, his second term, had not Biden bowed out—or been forced out. 

In my opinion, Biden’s prostate cancer was foreseeable, long before he turned 70. He’s 83. Metastatic prostate cancer doesn’t spring up overnight. It’s likely that PSA testing in his 60s would have revealed a troubling trend. Plus, he has long suffered from urinary problems which were attributed to an enlarged prostate—why was no further investigation done?

PSAs are valuable in older men, unless they’re likely to die soon of other causes. Nevertheless, a PSA of less than one in a man age 60 is a fairly good indicator that there’s less need for frequent repeat testing. 

6. Repeat CAC: Finding out your coronary calcium score is a good idea, as it will better predict your cardiac risk than blood tests alone. Once you’ve gotten your baseline number, there’s a tendency to ask “How’m I doing?” with lifestyle, supplements, or cholesterol medication, and get a repeat test after a couple of years. Don’t.

Unless you start with a zero score, calcification inevitably gets worse. A higher score doesn’t mean your treatment is failing; converting sticky vulnerable soft plaque to stable calcium is actually a hallmark of successful preventive treatment.

7. Repeat lp(a): Lipoprotein(a) is a recently recognized risk factor for cardiovascular disease. It’s mostly inherited and, unlike cholesterol, lp(a) is minimally influenced by diet or lifestyle. Currently-available drugs won’t change it much. So testing is mostly a matter of “one and done”. Either you have a high lp(a) that places you at high risk for heart disease, or you draw a get-out-of-jail-free card.

But that will soon change with the imminent approval of new drugs to lower lp(a). Then it might be warranted to get repeat tests to see how effective the drugs work on you and determine whether dose adjustment is required. 

Next week, I’ll be bringing you seven more tests that you may want to eschew. But remember, you should always consult with a trusted physician and weigh your own specific health needs before deciding whether to undergo or avoid any medical tests.