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September 3, 2003
Health Focus MEDICAL TESTS Which ones do you need, and when?
Here's a practical guide

By CHRISTMAS McGAUGHEY, Staff Reporter

CANCER TESTS, stress tests, various -oscopies and the dreaded digital exams. As we get older, the list of medical screenings recommended by physicians gets longer and more confusing.

Doctors say some of the easiest tests are the most neglected, while other, more invasive tests are sometimes done too often.

The black armband with the pressure gauge isn't painful or invasive, but getting regular blood pressure checks is one of the most crucial yet forgotten tests available, according to Mobile area doctors.

"We catch a lot of untreated hypertension and blood pressure," said Dr. Ashton Blessey, internal medicine physician with the downtown-based Taylor Clinic of Springhill Medical Center.

Heart disease is the No. 1 cause of death in Alabama, followed closely by stroke, according to state health statistics.

"But how many people actually get their blood pressure checked every two years?" Blessey asked. "Especially men - because they're machismo. Men just don't go to the doctor as much as women."

He added that cholesterol tests, which measure the amount of fat in a person's blood, are also important and should be done at least every five years.

Sometimes people overestimate the value of some screenings while neglecting others that are equally important.

For example, mammograms are proven to help only when done with a clinical breast exam for women over 50, Blessey said, but they are commonly done on younger women.

Some health agencies differ slightly on their recommendations, which can add to the confusion. While the U.S. Preventive Services Task Force recommends clinical breast exams starting at age 50, the American College of Physicians recommends the exams for women age 40 and older.

"A lot of this medical cultural stuff that men and women perceive is just wrong," Blessey said. "Individuals are not getting the colonoscopy, though it is a better screening test than the PSA (prostate-specific antigen test), but most insurance companies don't cover it (the colonoscopy), unless there is rectal bleeding."

The prostate-specific antigen test - in which blood is drawn and proteins are measured - is recommended by some groups to be done every year after men turn 50 and after age 40 for black men.

"The studies have been inconclusive about using that as an effective screening test, but physicians check a yearly PSA," he said. Because it has helped detect prostate cancer when done with a digital rectal exam, he said, "consumer demand is making it a common want."

During the digital exam, a doctor inserts a gloved finger into the rectum and feels the prostate gland through the rectal wall to check for bumps or abnormal areas, according to the federal Food and Drug Administration.

"The digital rectal exam, a lot of people shy away from that, but they need to be encouraged to get that," Blessey said. "There is mild discomfort, but it's not any worse than a woman getting a Pap smear."

Citing recommendations from MedStudy: Internal Medicine Board Review, Blessey said digital rectal exams are only effective for detecting late prostate lesions and less than 5 percent effective for detecting colon cancer, though it is recommended yearly for people over 40.

Speaking of the PSA, he said, "We need a better, more specific test, but this is all we've got right now." New tests for prostate-specific antigens are being developed, he said.

The American College of Physicians does not recommend a PSA, Blessey said, so he does not recommend them to his low-risk, asymptomatic patients.

Dr. Jack DiPalma, director of the Division of Gastroenterology at the University of South Alabama, agreed that PSA data is weak but covered by many health plans and Medicare.

While some doctors may not think certain tests are necessary for their patients, some may recommend them.

"Screening is now the standard of care," DiPalma said, "and failure to screen is becoming a malpractice issue."

Both DiPalma and Blessey said they believe one of the most important tests that is being missed by the general population is the colonoscopy - in which doctors examine the inside of the colon for signs of cancer using a thin, lighted tube called a colonoscope inserted into the rectum.

A sigmoidoscopy is similar, though a shorter scope is used to examine only the lower colon, Blessey said, so it can "miss more" than a colonoscopy.

"People put the colonoscopy off because it's uncomfortable," Blessey said. "I think it's pretty important. In fact, the American Cancer Society and the American College of Physicians recommend a colonoscopy every three to five years, starting at age 50, for both men and women."

Besides discomfort, Blessey said, cost may keep some people from getting a colonoscopy. Sigmoidoscopy generally costs about $200, while colonoscopy, which takes place in a hospital or outpatient surgical site, can cost from $500 to $1,000.

DiPalma said some insurers do pay for screening colonoscopy - including Medicare, USA Blue Cross/Blue Shield and Tricare.

Alabama Blue Cross/Blue Shield and the Mobile County Blue Cross/Blue Shield are among the plans that do not, he said.

"Women and men are equally affected by colon cancer, and screening is equally important," DiPalma said.

By contrast, some tests may be done more often than needed.

"One of the biggest success stories for preventive screenings is the Pap (Papanicolaou) smear in women, because it has reduced rates of mortality from cervical cancer," Blessey said.

Though the Pap test has been highly successful, he said, it is often done more often than recommended.

The American Cancer Society recommends the Pap test be done annually for sexually active women or those over 18 until at least three consecutive tests have come back normal. After three normal tests, it may be done once every three years.

"Women are used to getting them every year, and because of consumer pressure, they get in the routine of it," Blessey said. "But really, once you have three negative results, it should just be every three years until age 60."

If all tests have been negative, women over 65 do not need further Pap smears, he said, according to the U.S. Preventive Services Task Force.

Another important test people neglect, Blessey said, is the fecal occult blood test or FOBT - a noninvasive test to detect hidden (occult) blood in the stool, an important indicator of colorectal diseases, including colon cancer for those age 50 and over.

In the fecal occult blood test, a person smears a stool sample on cards from three consecutive bowel movements, then returns the cards to the doctor for testing.

The people who are at the most risk, Blessey said, are those who do not go for regular checkups.

"People need to establish care with a doctor to follow them as individuals and have a growing doctor-patient relationship," he said. He recommends a yearly checkup, starting in the patient's 20s.

"And more often if they have any medical problems, like diabetes or hypertension," Blessey said. "The big thing we're seeing is more diabetes and blood pressure troubles in the younger ones."

Cynthia Rathle, area manager for the American Diabetes Association, said she believes everyone should have their blood sugar checked once a year, especially since Alabama leads the nation in diabetes prevalence.

DiPalma works with Mobile United Health Services Task Force and designed the "Health Checks" guidelines distributed by area agencies, including the Mobile County Health Department.

"Screening guidelines for diabetes are not as clear as other recommendations," DiPalma said, "but adults should have periodic testing of blood sugar."

Blessey said individuals with a family history of certain illnesses or who have high-risk factors for other medical conditions should be tested for those things.

"For screening to be considered effective, it has to reduce mortality," he said. For instance, he said, lung cancer screening does not appear to be useful, since detecting lung cancer early does not seem to help people live longer.

An example of an effective screening test for high-risk individuals is the cardiac stress test, in which blood flow to the heart is measured during a period of rest and a period of stress - usually with the person running on a treadmill.

The test helps diagnose blockages in the coronary arteries and heart disease. The test includes blood pressure measurement and an EKG or electrocardiogram.

In general, cardiac stress tests are only done for patients who may be at risk for heart disease, according to area cardiology groups.

While there are no guidelines for routine cardiac stress tests, DiPalma said, some physicians will order them as part of an "executive screening" for patients who want to know more about their circulatory or respiratory systems but have no prior symptoms of disease.

CUTLINES: JOHN DAVID MERCER/Staff Photographer BILL STARLING/Staff Photographer

Teresa Lowry walks on a treadmill in a stress room at the Heart Station at USA Medical Center as cardiologist Dr. Michael Cohen and EKG technologist Monica Nelson monitor her heart rate, blood pressure and other indicators.

Dr. Bert Eichold, chief health officer for the county, takes a woman's blood pressure.

Register graphic Health screenings for average adults Source: U.S. Preventive Services Task Force; Mobile United Health Services Task Force

"Screening is now the standard of care, and failure to screen is becoming a malpractice issue." Dr. Jack DiPalma, USA's Dept. of Gastroenterology

"People need to establish care with a doctor to follow them as individuals and have a growing doctor-patient relationship." Dr. Ashton Blessey, Taylor Clinic, Springhill Medical Center

"For screening to be considered effective, it has to reduce mortality." Dr. Ashton Blessey, Taylor Clinic, Springhill Medical Center

"Men just don't go to the doctor as much as women." Dr. Ashton Blessey, Taylor Clinic, Springhill Medical Center