Just before her father died of colon cancer, Lynne Milliron, then age 40, made him a solemn promise: She would get herself screened for the disease. Two months later, Milliron had that colonoscopy—and is profoundly grateful she did. “The doctor removed a large, precancerous polyp,” she says. “That test probably saved my life.”
Milliron, of Lancaster, Pa., benefited from an idea that took hold as early as the mid-1940s. In the town of Oxford, Mass., U.S. Public Health Service workers decided to look for signs of diabetes in people. To do that, they tested the urine and blood glucose of almost three-quarters of the town’s 4,983 residents. One goal was to show that early detection of diabetes through mass screening could prevent such life-altering complications as heart disease and nerve damage. Within a few years, diabetes screening was being done across the U.S., and similar tests for other diseases quickly followed.
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Today, as we’ve learned more about how to detect disease early, there are scores of blood tests, ultrasounds, and CT scans to screen for conditions like cancer and low bone density. And an increasing number are now offered direct-to-consumer (DTC), leaving you to pick—and pay for—screenings.
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The surge of interest in testing is propelled by “a trend toward people being proactive about taking better care of themselves,” says Alex Krist, M.D., a professor of family medicine at Virginia Commonwealth University and vice chairperson of the U.S. Preventive Services Task Force (USPSTF), an independent expert panel that makes recommendations to the government and medical organizations about preventive care. Generally, he notes, that’s a good thing. “Screening tests that have been shown to help people live longer or better are an enormous boon to public health.”
As with Milliron’s colonoscopy, a screening test could spare you the physical, emotional, and financial pain of dealing with a serious illness—and maybe even save your life. As just one example, screenings done at the right age and frequency can cut the risk of colorectal cancer death by as much as half, according to the American Cancer Society (ACS). That blood pressure check you get during a routine physical? If it reveals hypertension and you get it treated, you might reduce your heart attack and stroke risk by more than 20 percent.
The trouble is, too few people are getting the right tests. Overall, Americans get only half the preventive care—including screenings—that they should, the Centers for Disease Control and Prevention (CDC) reports. Many other people are screened too frequently, at the wrong age, or with tests that aren’t very accurate.
“We have a problem in this country where we both underscreen and overscreen,” says Susie Dade, M.P.A., deputy director of the nonprofit Washington Health Alliance (WHA).
For example, evidence-based guidelines from the USPSTF call for a one-time osteoporosis screening for most women ages 65 and older, and no screening for younger women at low risk for the bone-thinning disease. A 2015 study, however, found that almost half of low-risk women in their 50s had the screening, while 4 of 10 women between ages 65 and 74 and 6 in 10 women 75 and older had not.
Medical screenings aren’t an exact science, and therein lies the rub. All screenings, though some more than others, may still miss problems. The ACS notes, for example, that mammograms fail to find 1 in 5 breast cancers.
Screenings can also pick up harmless abnormalities or produce false positive results, which incorrectly indicate the presence of a disease. That can lead to unnecessary and invasive tests and surgery, which have their own risks. “The challenge is making sure that people get the right care,” Krist says. “There are a lot of tests that seem like they would help you but aren’t backed by any data and can actually open up a whole set of harms.”
A Cautionary Tale
Ron Braithwaite of Portland, Ore., knows that all too well. Last spring, at age 66, he had a slightly elevated PSA blood test result. A higher than normal PSA can indicate prostate cancer, but most often it signifies a noncancerous condition such as a prostate infection or an enlarged prostate, which he had lived with for a while.
On his urologist’s advice, Braithwaite had an outpatient biopsy; a sample of prostate tissue was removed. He knew there were risks. In one study, 5.6 percent of men who had a similar biopsy experienced a complication, such as infection, bleeding, or urinary problems.
Braithwaite’s results were negative for cancer, as they are for 60 percent of men who have such a biopsy, according to a 2018 analysis by the USPSTF. Soon after, Braithwaite says, he developed a high fever. He was hospitalized for six days for a severe E. coli bloodstream infection, during which the life-threatening illness damaged his kidneys and heart.
Braithwaite says his kidneys are functioning again, but he faces a long recovery. His first PSA test was likely his last; the USPSTF doesn’t recommend it for men ages 70 and older because the risks of follow-up tests, such as infection, outweigh the potential benefits. “It’s a safe bet I won’t get tested again,” he says.
A Surfeit of Screenings—and Costs
Screening has become a big business—worth tens of billions of dollars—with most of the spending in the mainstream healthcare system. For example, in 2010 consumers and health insurance companies spent an estimated $7.8 billion on mammograms alone, according to a 2014 analysis published in the Annals of Internal Medicine.
Little information is available on how many dollars are spent nationwide for screening that’s not beneficial. But in a recent study of health insurance claims from 2.4 million people in Washington state, the Washington Health Alliance found that from July 2015 to June 2016, about 26 percent had at least one test or treatment identified by experts as unnecessary. That cost consumers and their insurers an estimated $282 million for the year.
Most of the overuse was due to 11 services, eight of them screening tests. About $40 million alone went for annual electrocardiograms (EKGs) and other heart screenings for people at low risk for cardiovascular disease and without symptoms.
But when screenings are done in accordance with recommendations from major medical organizations, they can reduce harm and healthcare costs, says Dade, by decreasing the need for expensive treatment for advanced disease. Early detection and treatment of cancer, heart disease, and diabetes—which account for 7 of 10 deaths and 75 percent of healthcare spending in the U.S.—could help more people survive and pare costs, according to the CDC.
Outside the mainstream healthcare system, however, the value and cost of screenings gets murkier. And consumers are increasingly opting to circumvent their doctors for DTC screenings from for-profit companies.
Consumers desire “a sense of autonomy; they want to take charge of their own health,” says Ana María López, M.D., M.P.H., M.A.C.P., president of the American College of Physicians (ACP). “But more importantly, it’s become hard to access healthcare in many places. People may not have a regular physician they can talk to about their concerns.”
Right now, direct-to-consumer screenings represent a small but rapidly expanding part of the market. Consumers in the U.S. spent $15 million on DTC lab and genetic tests in 2010, a figure projected to climb to $350 million by 2020, according to the market research firm Kalorama. And these are almost entirely out-of-pocket dollars: DTC tests usually aren’t covered by insurance. Here, a sampling:
Mobile screenings. Using portable equipment, companies such as AngioScreen, Life Line Screening, and Matrix Medical Network offer screenings like EKGs or carotid artery scans at community centers, churches, hospitals, and workplaces. Life Line, the dominant player, markets bundles of tests through ads, flyers, and email, and says it screens almost 1 million people per year at 16,000 events.
Online and walk-in labs. Companies such as Walk-In Lab, Private MD Labs, and Direct Labs perform blood, urine, and other lab tests of your choice without your doctor’s input. (In some states, a doctor’s authorization is required.) Walk-In Lab invites you to “take charge of your health and your wallet” by ordering anything from a $28 blood-type test to an $800 “Anti-Aging panel” online.
High-end screening clinics. Companies such as the Princeton Longevity Center—which bills itself as “the Future of Preventive Medicine”—market comprehensive screening options. The executive health exam from Elitra Health in New York City costs $4,900 and includes a CT coronary scan and cardiac stress test. Additional services: carotid and abdominal ultrasounds and full-body CT scans.
At-home or in-store health tests. For these genetic tests, such as the $199 ancestry and health screening from 23andMe, you submit a vial of saliva and receive a report outlining your risks of illnesses like late-onset Alzheimer’s and certain cancers.
Simpler tests, such as cholesterol and blood sugar checks at drugstore clinics and health fairs, may make it easier to track key health markers, but other DTC offerings may lead to overscreening.
For example, the American Academy of Family Physicians (AAFP) advises against the carotid artery scans on many mobile screening menus. For healthy people, they can yield misleading results that can lead to riskier follow-up tests. The American College of Preventive Medicine cautions against full-body CT scans because they’re costly, expose people to a lot of radiation, and often result in false positives.
“It’s often cheaper to buy packages of many tests, which incentivizes people to get more tests than they need,” says Erik Wallace, M.D., associate dean of the Colorado Springs branch of the University of Colorado School of Medicine.
Those who represent DTC testing companies say their services are valuable. Ari Cukier, the chief operating officer of Elitra Health, says the firm offers efficiency—multiple screenings in one day—and the chance for consumers to have more tests than they would through their own doctors. “People are not getting the comprehensive testing they want,” he says.
He says Elitra’s staff discusses overscreening and false positives with clients. “They are capable of weighing risks and possible benefits for them,” he notes. “We have had cases of false positives, absolutely. And cases of real positives. That winds up for us proving the benefit of a test.”
Life Line Screening did not respond to our requests for comment.
How to Test Wisely
When recommending screenings, your doctor should generally rely on scientific evidence and guidelines from the government and expert organizations.
But studies have found that many doctors aren’t up-to-date on guidelines, says López of the ACP. For instance, a recent review of 25 studies in the journal Preventive Medicine found that up to 45 percent of cervical cancer screenings failed to follow the USPSTF guidelines that were updated in 2012. And López notes that it can be simpler for a harried doctor to agree to a patient’s request for a test than to discuss the pros and cons.
But guidelines aren’t everything. “Maybe a patient is at higher risk and should be screened sooner,” says López. That’s why, after talking to her doctor about her family history, Lynne Milliron opted to be screened for colon cancer at a younger age than is typically recommended. In addition to her father, an aunt had died of the disease at age 52.
Choose a doctor who will discuss all of the factors with you: guidelines, your medical and family history, the pros and cons of various screenings, and where the results might lead. You’ll be able to make smart decisions if you go into those talks informed about the options.
Editor's Note: This article also appeared in the January 2019 issue of Consumer Reports magazine.