Check it seven times

Why do I need medical checks

Ruslan Absalyamov, Post-science

Over the past 150 years, the average human life expectancy has increased almost 2.5 times, but we still want to live even longer. Today, many people are concerned about the topic of preserving their own health, and such a phenomenon as checkup is gaining popularity and becoming one of the possible tools for achieving healthy longevity.

The head of the oncology department of the clinic "Dawn", oncologist Ruslan Absalyamov told post-science about where the idea of preventive examinations came from and what pitfalls can be encountered when passing a checkup in private medical organizations.

4P-medicine: disease prevention and healthy longevity

Modern society, especially in developed countries, places increasingly high demands on life expectancy and its quality. Throughout almost the entire history of mankind, life expectancy was about 30 years, in the middle of the XIX century — no more than 40 years, and only since the beginning of the XX century this indicator began to grow rapidly. In just a century, it has more than doubled, exceeding by now the milestone of 70 years, and in European countries — even 80 years. Such unprecedented growth is a consequence of the development of human civilization, the growth of technology and benefits. As the education of society grows and the number of private clinics, startups, biomedical companies, independent scientists and organizations increases, this trend will only grow.

Drawings by Katya Zolotareva

Modern medicine is able to effectively treat the vast majority of existing diseases, provides optimal prevention of their development in the future, for example, cardiovascular diseases, and turns dying into an increasingly lengthy process. At the same time, the main vector of medical development today remains the treatment of severe conditions, and preventive medicine is only at the beginning of the path. 

Relatively recently, the concept of 4P-medicine has been formed (from the English. predictive, preventive, personalized, participatory): predictive, preventive, personalized and participatory, that is, implying the active participation of the patient in the medical decision-making process. Its goal is not just to treat effectively, but to learn how to identify and eliminate the risks of developing diseases, taking into account individual human characteristics, including genetic ones. The preservation of health in this case is not just a service of the healthcare system, but also the personal responsibility of each person. Anyway, older people still suffer from chronic diseases, hearing and vision loss and dementia, and oncological and cardiovascular diseases are still considered the main causes of death worldwide. However, the burden of these diseases can be reduced. Against the background of an increase in the number of elderly people in the world, this means that the concept of 4P medicine will be actively developed to meet the need for healthy longevity.

The relevance of 4P medicine does not decrease even against the background of the epidemic of coronavirus infection. Even at the height of the epidemic, significantly more people die from non-communicable diseases than from COVID-19.

Today, both public and private medical organizations offer patients a variety of comprehensive examinations: "male" and "female", for those over 40, and for those who just want to check their health. Alas, many of these surveys lack a clear evidence base. Let's figure out how we ended up in this situation

How the idea of screening was born

In a modern clinic, you can undergo two types of comprehensive examinations: screening and checkup. Screening (from the English. screen — "examine") — a service where people who do not always understand that they are at risk of developing a disease or are already ill are offered a certain test. While screenings are common mainly in the public health sector, private clinics are more likely to offer a checkup. Checkup (from the English. check up — "check") — this is a comprehensive examination of the body of a conditionally healthy person, aimed at assessing his condition in general, identifying preclinical and early stages of severe diseases or conditions predisposing to them. Screening is usually aimed at identifying a specific disease, and a checkup usually includes a number of studies for a general assessment of the state of health, as a result of which, possibly, any diseases or risks of their development will be detected.

Periodic comprehensive examinations are not a new phenomenon. Back in 1861, the British physician Horace Dobell proposed using anamnesis, physical examination and laboratory tests to search for "the earliest defects in the physiological state." Subsequently, more and more doctors and scientists began to adhere to a similar treatment regimen, primarily cancer. In those years, oncological diseases were considered as a series of consecutive interruptions in the work of the body (the linear model of carcinogenesis is irrelevant today), therefore, early detection of these disorders could "break the chain" of the development of the disease.

Periodic medical examinations used to detect early forms of diseases were fixed in general medical practice in the 1920s, when the American Medical Association (AMA) spoke in favor of the effectiveness of this method, and also actively popularized it. In the 1930s and 1950s, the promotion of early cancer diagnosis was put on stream. For example, the American Cancer Society (later the American Cancer Society) created the so—called Women's Field Army — a group of volunteers to fight cancer. The main attention was paid to informing about the importance of periodic Pap smear from the cervix (Pap test), breast self-examination and clinical examinations, as well as vigilance against early signs of cancer. However, all these local initiatives needed standardization and confirmation of their effectiveness.

The modern era of screening development began in 1968, when the World Health Organization published the document "Principles and practice of screening for the detection of diseases". Its authors formulated ten fundamental principles that had to be guided when deciding on the creation of a screening test. These principles initiated a scientific discussion about the benefits and harms of preventive examinations, as well as the ethical and financial aspects of their conduct.

The Ten Principles of Wilson and Jungner

1. The detected disease should be an important health problem.
2. There should be acceptable treatment measures for patients with a diagnosed disease.
3. The means of diagnosis and treatment of the disease must be available.
4. The detected disease must have a recognizable latent or early symptomatic stage.
5. There must be suitable tests or studies.
6. Tests should be acceptable to the public.
7. It is necessary to understand well the patterns of the natural development of the disease from latent to explicit form.
8. There should be a consistent policy regarding who is included in the category of persons requiring treatment.
9. The costs of detecting cases of the disease, including the diagnosis and treatment of identified patients, should be economically balanced with the possible costs of medical care in general.
10. Case detection should be a continuous process, not a one-time campaign.

The subsequent development of screening in the 1960s and 1970s led to the emergence of a number of universal definitions, rules and methodology by which it is possible to compare the potential benefits and potential harm to the patient when planning diagnostic tests. At the same time, the effectiveness of periodic medical examinations was thoroughly tested for the first time using randomized clinical trials. A new way of thinking appeared in medicine, in which only intuition, even based on scientific theory, was no longer considered sufficient reason to conduct an early diagnosis.

For a long time, scientists have been trying to prove that comprehensive examination programs can prevent the development of diseases if they are detected at an early stage. For the first time, this was done in three randomized clinical trials, which demonstrated that undergoing screening mammography actually reduces mortality from breast cancer.

These findings have focused the attention of healthcare systems in different countries on screening strategies. Some medical organizations have noted serious shortcomings in the evidence base of screening recommendations. The US Disease Prevention Working Group (USPSTF), along with other organizations, created methodologically verified tools for finding really working tests, and countries began to use this data to form local prevention and screening programs.

While public health systems tried to establish which tests, to whom, how often and on the basis of what data can be performed, private medical institutions freely offered a quick and convenient health check. Free from clear regulations, flexible, and most importantly, decentralized, clinics have begun to create their own checkup programs. And advertising and service contributed to the further division of preventive examinations into programs of preventive examinations, medical examinations and screenings in the public health system and checks that are carried out in private medical organizations. 

An individual in this system has always been and still is in a conflict of interest zone. In the state system, preventive examinations primarily take into account priority health problems and economic feasibility, without taking into account the interests and characteristics of a particular person. On the other hand, private clinics may be guided by different logic when drawing up checks, where some value their reputation, treat well, qualitatively and modernly, while others simply earn money.

What's wrong with the checkups?

The checkup is intended mainly for people who do not have specific complaints or serious illnesses. It should not be used to make a final diagnosis in a patient with specific complaints, to monitor the course of the disease, or as a control examination after cured or severe diseases with a stable course, primarily oncological. In these cases, an individual diagnostic plan should be formed by the attending physician.

Issues of preventive medicine in There are rare doctors in Russia today who invest time and money in their education, read Western literature, get acquainted with modern clinical research and participate in international conferences on their own initiative. The system does not train such specialists: medical universities still do not teach the principles of evidence-based medicine, modern prevention and screening. Therefore, often people who are not very educated, and sometimes not doctors at all, are engaged in the compilation of check-up programs. This leads to a number of problems associated with the passage of checks.

Problem 1. "Profile" checkup

Specialized medical centers form check-up programs according to their profile. For example, the examination offered by the network of laboratories will include mainly analyzes, and the checkup of the center for radiation diagnostics will include MRI of all parts of the body. There is a substitution of concepts: the patient is assigned not the studies that he needs, but those that can be performed by a medical institution. Because of this, a person can get a false confidence that everything is fine with him.

Problem 2. Checkups by directions

Clinics often try to determine the most popular directions and target audience for each product: "men's health", "women's health", cardiocap, oncocap, and so on. The problem with this approach is that by focusing on one direction, you can overlook other important tests, and a person can get false confidence that everything is fine with him.

Problem 3. "Boxed" checkout

Most of the checkups are presented in the form of a "boxed" offer — one for everyone. Even being segmented by gender and age ("under 40" or "after 40"), such programs do not take into account personal characteristics and may not be needed by a person. At the same time, potentially useful research will not be done.

Problem 4. Cost separation

The idea of a comprehensive check already contains an understanding that according to its results a person learns about health problems or their absence. The division of checks by cost is speculative and either indicates the limitations of the economy program, or indicates that the premium check contains a lot of excess.

Problem 5. Inappropriate surveys

The desire of any commercial organization to earn more is quite natural. But this is often the reason for expanding the list of services to unnecessary, unsubstantiated and therefore even potentially harmful. Among the most popular and at the same time the most senseless methods of primary diagnosis in conditionally healthy people are testing for cancer markers, MRI, CT and PET/CT of the whole body, endoscopic examinations (for no reason and up to a certain age), examination of the level of antibodies to viruses in healthy people, and others. Each of these studies has its own scope — they should not be used for people without specific complaints.

A few examples of inappropriate research in checkups

Cancer markers

The idea of finding an indicator that will indicate the presence of a serious disease that can be treated at an early stage is brilliant in itself. Unfortunately, the cancer markers known today are unable to do this. Firstly, cancer is a group of different diseases, and specific cancer markers are needed for each of them. For example, the indicators for the cancer marker CA-125 may be overestimated (or may not be) when an ovarian cancer occurs; an increased concentration of the cancer marker CA-15-3 may indicate breast cancer, prostate-specific antigen (PSA) — for a malignant prostate tumor. 

Secondly, the cancer markers known to us have different sensitivity and specificity. This means that the indicators may be elevated in the absence of the disease and normal in severe illness. As a result, there is a risk of making two types of mistakes: to detect an increased indicator in healthy people who will worry, perform unnecessary research, spend money; and normal indicators in patients with existing cancer who may miss the time for a really necessary diagnosis of the disease.

MRI, CT or PET/CT of the whole body

Doing an MRI of the whole body is expensive and pointless, and most importantly, it is impossible at a qualitative level. Looking for a serious pathology in this way is like hammering nails with a microscope: you need to conduct thousands of studies in healthy people to identify something really serious, but not manifesting itself in any way. At the same time, there may be many frivolous diseases. This is fraught with overdiagnosis: a person will receive unnecessary information that has no clinical significance. In addition, the clinic cannot reserve a whole tomograph for one or two patients a day - this is the throughput of a high—quality MRI examination of individual areas of the whole body. The examination of one small area lasts about 40 minutes, and the same amount of time is spent by the radiologist describing and evaluating the results. Therefore, it is obvious that the general diagnosis of the body on an MRI scanner is carried out in an accelerated, superficial mode, which determines its low diagnostic value.

For the same reason, it is not necessary to carry out CT and even more so PET / CT of the whole body without indications. Unlike MRI, these studies have a radiation load on the body and, if performed very often and without reason, can cause the development of secondary malignant tumors. All this, however, does not mean that radiation diagnostic methods cannot be used as screening. If we ask the question whether we can detect pathological conditions using these methods, the answer will be yes. For people over the age of 55 who have been smoking for a long time, an annual chest CT screening may be useful. 

One of the interesting and promising directions is the use of CT to assess the degree of coronary atherosclerosis and more careful selection of patients at risk of developing cardiovascular diseases. All this suggests the need for further study of such studies from the standpoint of their applicability in conditionally healthy people in specific cases, which is radically different from a general scan of the entire body.

Endoscopic examinations for young people without complaints

Colonoscopy for patients over 45-50 years old (once every ten years) — a really effective way to detect colon cancer in some cases in the early stages of development. However, gratuitous endoscopic examinations before the age of 40-45 are often not only meaningless, but also potentially dangerous. There is always a risk, however small, that complications will arise during the procedure, and it should correlate with the potential benefits.

Studies of the level of antibodies to certain viruses in healthy people

Such viruses include, for example, Epstein—Barr virus, human papillomavirus (in the blood), herpes simplex, cytomegalovirus. There is a high probability that some of them will be detected, since they are extremely common in the human population. At the same time, we have not learned how to treat diseases caused by these viruses, so the very fact of their detection has no clinical benefit, however, it may serve as a reason for prescribing additional tests and treatment that does not have evidence-based effectiveness. 

Methods that are frankly anti-scientific and not very

Some institutions offer people diagnostic methods that are sometimes extremely remote from clinical medicine. These include bioimpedance diagnostics, rheogram, study of the state of immunity in healthy people, and by a variety of methods, including absolutely unscientific methods, the study of various currents, magnetic fields, and so on.

So you don't need checkups?

Not every checkup gives a person an understanding of risk factors and opportunities to somehow change the situation. Primary prevention works no worse than any examination. Quitting smoking, maintaining a normal body weight, regular physical activity and proper nutrition significantly reduce the risk of developing cancer and cardiovascular diseases. This is evidenced by a large amount of scientific data.

However, all this does not exclude the fact that a good and well-written checklist in the right hands can become a good tool on the way to healthy longevity. Such a survey program consists of proven and working diagnostic methods. It will not be very large, and the main point in it is interaction with a doctor who has relevant knowledge and the necessary skills. It is important not only the fact of passing the checkup, but also what happens after the examination — it should end with a final consultation of a good doctor who correctly interprets the results, will be able to assess all the nuances, including, for example, vaccination and the psycho-emotional state of a person, and will also make a plan of diagnostic tests, warning in advance about the potential benefits and potential harm each of them. And, if a serious illness is detected during the examination, the doctor will refer the patient for surgical follow-up and treatment.

Such a checkup can reveal not only severe diseases and factors predisposing to them, but also early manifestations of chronic and long-term developing diseases: coronary heart disease, diabetes mellitus, atherosclerosis (primarily coronary and carotid), diseases of the respiratory system, undetected chronic infections (primarily viral hepatitis). Most of them can be dealt with — either completely eliminate or stop their development and negative impact.

Checkups are a controversial phenomenon that is often criticized by scientists and doctors. However, medicine has not proved everything yet, and the fact that a number of studies have not revealed a significant contribution of checks to reducing mortality does not mean that they should not be performed. Science cannot yet provide answers to many questions, and although their search is constantly ongoing, it requires time and resources. And at this time, the demand for such services will only increase, and the task of the scientific community is to offer people a reasonable consensus: otherwise they will engage in self—diagnosis and trust their health not only to doctors, but also to people who do not have medical education at all. The correct check-up may consist of useful research, do not contain anything superfluous, and most importantly, it will end with a consultation not only about health problems, but also measures for their prevention.

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