When Does Wellness Testing Cause More Harm than Good?

Author: Ron Feise, DC/Wednesday, January 20, 2016/Categories: JanuaryFebruary 2015

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By Ron Feise, DC

THE GREAT KILLERS OF HUMANITY for most of our history have been infectious diseases. Now most premature deaths and illnesses are the result of poor lifestyle choices. It is estimated that people’s lifestyles account for 70 percent of hospitalizations and 80 percent of health care-related expenses.1-5 The four main lifestyle issues related to poor health are: 1) lack of exercise, 2) smoking, 3) poor diet choices and 4) stress. Numerous researchers have found that lifestyle behaviors are the root cause of many chronic diseases.6-10 Smoking, unhealthy diets and sedentary behavior make people vulnerable to diseases that rank among the leading causes of death, such as heart disease, cancer, stroke and diabetes. Fortunately, there is a dose-response association between the number of healthy lifestyle indicators and a lower risk of heart disease.11-12

In a large prospective population study, Khaw et al. examined the combined impact on mortality of not smoking, being physically active, having a moderate alcohol intake and having a high fruit and vegetable intake among men and women 45 to 79 years of age.13 The study concluded that the difference between the highest and lowest health behavior score was equivalent to approximately 14 years in chronological age. Another research team found that those with four poor health behaviors compared with those with no poor health behaviors had an all-cause mortality risk equivalent to being 12 years older.14 Ford et al. found that Americans who had a healthy lifestyle lived 11 years longer than those who did not.11 Moreover, increasing healthy lifestyle behaviors improves the length and also the quality of life.15-17 Research suggests that if you want to add 11 to 14 quality years to your life, simply select and apply these healthy behaviors.

Promoting Prevention

According to several research teams, an underutilization of effective prevention strategies contributes appreciably to excess morbidity and mortality, as well as to higher healthcare costs.18,19 Although chiropractic has its roots in preventive strategies, as a profession, we are not doing a good job of promoting prevention. A National Health Interview Survey found doctors of chiropractic (DCs) gave health promotion recommendations to only 21 percent of their patients.20 Obviously, that is unacceptable. DCs need to rededicate themselves to the prevention paradigm.

Preventive Screenings 

A core component supporting this paradigm is using the right preventive screenings at the right time based on each patient’s health-risk profile. It is not only which screenings are appropriate but which are appropriate to exclude. The bottom line is that these screenings should provide a net health benefit to the patient (i.e., the potential benefit needs to be greater than the potential harm). A preventive screening test should meet four criteria before it is included in a prevention program:21

1. The disease should be an important health problem that imposes a notable burden on the affected population;

2. The natural history of the disease should be understood and measurable for monitoring;

3. There should be a safe, cost-effective, acceptable and predictive test to detect the pre-disease state; and

4. There should be safe, effective and costeffective ways to prevent or at least delay the disease from occurring.

If chiropractic physicians want to be holistic in our approach, we need to be well-versed in a variety of preventive screening tests, not focused only on neuromusculoskeletal issues. An understanding of the appropriate and inappropriate tests will help us provide guidance to our patients on key health issues. By way of example, we should understand the benefits and risks associated with prostatespecific antigen (PSA) testing. Does this popular screening test meet the outlined criteria?

Prostate cancer does impose significant suffering, but PSA testing fails to provide reasonable predictive accuracy for diagnosis or monitoring. When PSA testing was introduced, prostate cancer incidence increased dramatically in the Western world.22 But PSA screening is unable to distinguish indolent from aggressive cancers, which leads to overdiagnosis, more biopsies and an increased risk of overtreatment of clinically irrelevant tumors.23,24

Multiple research teams have found that PSA testing is not beneficial on the most important metric: What is its ability to reduce mortality? In a large North American study, Andriole et al. found that PSA screening had no effect on prostate cancer mortality.25 A metaanalysis of two RCTs of populationbased screening for prostate cancer using PSA and digital rectal examination found no reduction in prostate cancer mortality in men invited versus men not invited for screening.26 In a systematic review, early detection has not been shown to have an impact on mortality, and it comes at the price of additional testing, the risk of overtreatment and downstream adverse effects and impaired quality of life.27 After 20 years of follow-up, the rate of death from prostate cancer did not differ significantly between men in the screening group and those in the control group.28

The U.S. Preventive Services Task Force concludes that for asymptomatic men younger than 75 years, the benefits of routine screening for prostate cancer are uncertain, and the balance of benefits and harms cannot be determined.29 For men 75 years or older, there is moderate certainty that the harms of routine screening for prostate cancer outweigh the benefits.29

At the individual level, it is conceivable that some patients would value early detection, while others might want to avoid the risk of overdiagnosis and the cascade of unnecessary interventions. Moreover, a diagnosis of prostate cancer may increase the immediate risks of suicide and cardiovascular death.30,31 So it is important to counsel patients in a balanced manner by providing the best information to reach a shared decision.

It is fundamental to carefully and systematically determine which tests should be included and which tests should be avoided, because the health of your patients hangs in the balance. Providing the right kinds of preventive screenings, counseling and preventive therapies at the right times is vital to the health of your patients. Indiscriminately selecting tests is highly likely to cause patient harm.


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