31 January 2014

General medical examination: the opinion of a skeptic

Do I need to do fluorography every year?

Irina Krasnopolskaya, Rossiyskaya Gazeta

David Zaridze, Professor, Deputy Director of the Blokhin Russian Cancer Research Center, Visiting Professor at Oxford University:

From the statements of officials at various levels, it seems that the success of the medical examination of the population carried out in Russia is inevitable. Is it so?

The reports of those responsible for medical examination are full of figures, percentages. They are painfully reminiscent of the reports of their predecessors in the immemorial Brezhnev times, when the then Minister of Health promised the Secretary General to "fluorograph" the whole country. Although it was already known at that time that fluorography does not improve the early diagnosis of lung cancer and, accordingly, does not lead to a decrease in mortality from this serious disease.

Fortunately, the minister could not fulfill his promise. There wasn't enough film for the whole country. Nevertheless, the Minister's efforts to conduct mass fluorography of the population have borne fruit. Alas, not the best: among those who have had fluorography every year for many years, the incidence and mortality from lung cancer has increased. And this was to be expected. After all, fluorography is a method of radiation diagnostics and, accordingly, the subject is exposed to ionizing radiation. And if 2-3 times during life and on the basis of indications... But workers and employees of many large enterprises have had fluorography performed every year throughout their lives, i.e. 40 or more times.

Even today, forty years after the first unsuccessful attempt, fluorography is the main "trick" of medical examination. Moreover, an attempt to explain why we are stepping on the same rake again boils down to an unfounded statement that fluorography improves the early diagnosis of not only lung cancer, but also tuberculosis. And this is despite new data on the ineffectiveness of fluorography for the early diagnosis of these diseases.

It is surprising that the people who formed the medical examination program were not very interested in international experience or ignored it, which is even worse. For example, PSA screening for early detection of prostate cancer is recognized not only ineffective, but harmful in most countries of the world. In the USA, in a country that has twenty years of experience of mass PSA testing, most professional medical associations recommended to abandon mass PSA testing. A thorough analysis of the results of the American experience has shown that PSA testing often causes overdiagnosis, i.e. the diagnosis of cancer where there is none, and, accordingly, unnecessary and sometimes excessive treatment.

In an interview with one of the online publications, the medical director of the American Cancer Society, Professor Brawley, said that in the United States over the past 20 years, more than a million unnecessary operations have been performed, including prostatectomy, i.e. removal of the prostate. It is significant that American urologists, who have been on the defensive for 20 years, had to admit that mass PSA testing is not only ineffective, but harmful. In May 2013, a statement from the American Urological Association appeared, which does not recommend mass PSA screening for prostate cancer. Now Russian urologists are resisting: mass PSA testing appears in the order of the Ministry of Health on medical examination.

In general, the program of medical examination of the population (I'm talking about its oncological component) cannot be successful by definition. From the methodological recommendations and the order of the Ministry of Health, it is obvious that the success of each method of early diagnosis will be assessed by the number of examined. Don't you care about quality? So, for example, taking a smear from the cervix for subsequent cytological examination according to the recommendations can also be carried out by a paramedic, which is completely unacceptable. The diagnosis depends on the quality of the smear first of all, its application to the slide and its subsequent processing.

In many areas there are no midwives, much less obstetricians and gynecologists? It would seem that the first thing to do is to provide this site with a qualified specialist or, at the very least, temporarily, until better times, to abandon the senseless medical examination at these sites.

The quality of mammographic studies is also questionable. The plan to purchase mammographs for the entire primary medical network of the country was successfully implemented. The situation is worse with the training of mammography specialists. It is obvious that it is unrealistic to train qualified radiologists – specialists in mammography in one or even two years for such a large country as Russia. In addition, an extensive fleet of mammographs is not provided by medical physicists, who must monitor the condition of the equipment on which the image quality depends.

There are still many questions for the developers of the medical examination program. Here are just a few of them. Why is it recommended in Russia to undergo cytological screening of cervical cancer annually, while everywhere it is customary to conduct this diagnostic test once every 3 years? Why is mammographic examination carried out in one projection, and not in two? After all, this contradicts the accepted standards. Why is it that in a country where life expectancy is significantly lower than in developed and developing countries, occupational examinations are not limited by age? Is this a pursuit of quantity? Pensioners are easier to lure to a polyclinic than a working person.

It is promised that medical examination will lead to a decrease in mortality, in particular, mortality from malignant tumors. Mortality from malignant tumors in Russia has been declining since the mid-90s of the last century. So to interpret the decrease in mortality, say, in 2013 compared to 2012 as a result of medical examination is at best self-deception, as a consequence of incompetence, and at worst – a lie.

Each method of early detection of cancer, cancer screening, which is included in the medical examination program, works only when it is performed in compliance with all the rules, all the recommendations by highly qualified specialists. Otherwise, it is useless, and sometimes leads to unnecessary additional diagnostic and therapeutic procedures, which in turn can cause complications. All this indicates that cancer screening should be carried out in specialized centers by qualified specialists, and not in polyclinics, as it is now.

And finally, I would like to emphasize that there can be no "mandatory" medical examination. Mandatory or compulsory medical measures are applicable only in case of dangerous epidemics in order to limit them. In fairness, I note that the phrase "mandatory medical examination" is used by its developers with the caveat that it is, in principle, voluntary. Then why call it "mandatory"? If the goal behind this is to ensure that more Russians participate in this voluntary-compulsory event, then I'm afraid that this is unrealistic.

Russians who are invited to take part in the medical examination should have detailed information about the methods of prevention and diagnosis that are included in the medical examination program. We must understand its benefits and possible problems. People should have scientifically based information, and not fables about the usefulness of medical examination in general.

Portal "Eternal youth" http://vechnayamolodost.ru31.01.2014

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