When your doctor checks your blood pressure, you are getting the most valuable screening test of all. Everyone is at risk. The resulting strokes, heart and kidney failure and other serious ailments can be prevented with this simple test.

The value of others, such as Pap smears, mammograms, diabetic testing of pregnant women, et al., are well-established.

Colon screening has been shown to dramatically lower the death rate from this common cancer. Unlike other screening, the procedure can find growths (polyps) before they grow and become cancerous. Cancerous polyps are almost always larger than 3/8 of an inch in diameter. Many people have smaller benign polyps. It is believed these harmless polyps become malignant when they reach a certain size. Colonoscopy can find these polyps and remove them, preventing cancer from forming. It also finds and removes larger cancerous growths and allows for treatment early in the disease.

Everyone past a certain age should get this life-saving test.

However, the test itself causes many to forgo it. The risk of bowel perforation, the need for anesthetic and the unpleasantness of the tube insertion are some reasons. The other reason is cost. The total charges may be about $3,000 for the procedure. Thus less than 20 percent of those who should get the test are getting it. For many experts in the field, "virtual colonoscopy" is a possible solution to non-compliance. This test, which is a form of CT of the abdomen, has no associated discomfort. And, importantly, it costs about $300 - a tenth the cost of the standard test. Yet, Medicare refuses to pay for it.

Medicare's reason is that if a growth is seen on the CT, the patient will need a full colonoscopy anyway. But this still doesn't counter the large increase in colon screening that would occur if that test is covered for a population group affected by this disease.

Looking at strokes

Now we come to a screening that has little basis but is heavily promoted: stroke screening. In 1996, a national panel concluded that routine screening of patients without symptoms or a history of mini-stroke should not be done. After 10 more years of evaluation, they reaffirmed that recommendation.

Yet we see ads for stroke screening everywhere. Testimonials from patients who thank the screening for "allowing me to see my grandkids grow up" are prominent. Testimonials have no place in medical decision-making, as these are unknown people and, more importantly, there is no basis to believe they would have had a stroke without the screening. As a good rule, testimonials almost always are used when hard, scientific evidence is lacking.

A 2007 review in a major journal included the statement: "the benefit of screening is limited by a low prevalence of treatable disease and that ultrasound can lead to false positives with resultant risk of complications from further confirmatory testing and unnecessary carotid endarterectomies."

Various other groups feel that screening people without high risk is valuable. But these are groups that have a vested interest in these tests.

When a patient is found to have a narrowing on screening, they often get a carotid angiogram, a risky, invasive procedure. If the angiogram shows a high degree of narrowing, the next step is usually to a surgeon. Studies have shown that carotid surgery is frequently done without full indications, and is associated with a high risk of severe complications or death.

Three months ago, a review in the American Heart Association journal Stroke concluded that medical therapy, rather than surgery is best prevention of stroke in most patients. The same drugs used to lower heart attack risk are found to be safe and more effective than surgery in preventing strokes. And since most patients with carotid disease also have coronary disease, they are already taking these drugs.

In summary, it is best to discuss this with your physician. He should be able to determine if you have enough risk of stroke to justify a test that may lead to risky testing and surgery.

Stroke screening has become a major income generator for those who do the tests as well as the vascular surgeons and facilities that receive the referrals.

In the next column, I will discuss other screening tests, such as the one for the breast cancer gene.

Charles Barta retired to Green Valley this summer after 10 years as a medical director for several health care insurers in Denver, including Colorado Access, the non-profit Medicaid HMO, Community HealthPlan of the Rockies, United Healthcare and Anthem Blue Cross. Before that, he was physician-in-charge of Kaiser Permanente of Colorado. He also was a private internist in Las Cruces, N.M. He had previously held a management position in the Medical Systems Division of Pfizer. He can be reached at Cbar52@aol.com.

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