Cancer and disease prevention are underutilized in the United States along with many other countries. Poor health literacy, patient personal denial, healthcare providers that are not up to date on information, poor communication, suboptimal electronic records designed to maximize billing and not health, and a system that rewards disease treatment over prevention with huge financial incentives are all partially to blame. This article is intended to improve your health literacy regarding preventative screenings so you and your loved ones can get the care you deserve.
This article is a two part series on recommended preventative screenings for cancer, disease, and infection. Part 1 will include an introduction to prevention, as well as recommended screenings for children, adolescents, and pregnant women. Part 2 will discuss recommended screening in adults. Screenings that are not recommended will also be discussed.
Please note that the screening recommendations in this article are those performed by healthcare providers on patients. It is also important to understand that there are too many screening tests to discuss in one, two part blog post. These posts are meant to highlight some of the most important screening tests. They are also intended to serve as a starting point for further investigation.
Introduction
Every time you visit the doctor, you get screened for health problems. Checking blood pressure is a common example. However, it is likely that there are many other tests you may not be aware of. Getting proper screening tests can, and does, save lives. It could save yours! There is a lot of controversy and confusion surrounding preventative testing. We hope this article helps you understand some of the most important concepts regarding the prevention of health problems.
Preventative screenings and treatments are not without risk. For instance, sometimes tests yield a false positive, meaning the test results are positive when they should have been negative. This can lead to additional tests, invasive procedures like surgeries, or potentially harmful treatments, that were never needed in the first place. Other times the tests themselves may cause direct harm. For instance, during a colonoscopy (camera up the bum to look for cancer) there is a real risk that a puncture hole can be made in the intestines causing severe infection. Tests can also yield a false negative meaning they should have been positive, causing inappropriate reassurance and a lack of appropriate follow-up. These types of mistakes have and will continue to cause considerable harm, even killing some people! Finally, tests cost money. On a population scale, even a test for 1 US dollar can end up costing millions every year.
Since risks are a real part of any disease prevention test, panels of experts are often utilized to decide what the net benefit of any given test is. Such panels look at the risks, benefits, and sometimes the cost of any given test to determine if it should be recommended to the general public. It is important to understand that these recommendations are based on the population as a whole. As everyone is different, individuals should always discuss the need for any given preventative test with a trusted healthcare provider.
The United States Preventative Service Task Force (USPSTF) is one such panel of experts that gives recommendations for preventative screening. Their recommendations consider benefits and risks, but not cost. The panel is made up of primary care physicians and epidemiologists (people who study diseases in populations). Many other panels with educated individuals give recommendations on disease prevention. These recommendations are often discordant. So why can’t experts agree? As our medical and scientific knowledge is so limited, even in 2020, do “experts” even exist?
The reasons for discordant recommendations are complex. Insufficient research is usually the most important reason though. This leads “expert” panels to draw conclusions without enough information. This is a fancy way of saying, panels give their opinions and label them as “guidelines” to be followed. Much, much more research is needed! Please support the funding of research, it is how we move forward as a species and as stewards of our planet. Money also seems to play a role. Unfortunately, if a group of specialist physicians make money on a test or indicated treatments as a result of the test, they are generally more likely to recommend that test. Money has a pervasive influence on testing recommendations and our ability to rationalize any research that suits our needs. This should never be underestimated in medicine or any scientific field.
For the above reasons, the US Preventative Service Task Force (USPSTF) is my favorite panel of “experts.” This is because they are not really “experts” but instead generalist providers. This allows them to look at preventative tests from a birds eye view, considering the whole patient as opposed to a specific organ system. These individual providers do not stand to lose nearly as much as a specialty provider does, should a test that brings them money becomes no longer in vogue. Bias is crazy! Expect to find it everywhere. Always follow the money, even and especially in medicine.
The USPSTF uses a grading scale to assess the quality of evidence supporting any given preventative test.
Grade A: Best evidence, widely recommended, high net benefit
Grade B: Good, but more uncertainty or chance for harm exists
Grade C: Indeterminate, unclear if the benefits outweigh the risks
Grade D: Recommends against a given screening test, risk of harm high.
Grade I: Insufficient evidence, essentially more study is needed
Recommendations that are given are meant to be used in the United States general population. They are likely to be useful in many other countries as well. However, these are not fixed recommendations. As rates of cancer and disease change, as new and better tests become available, and as better research studies are performed, these recommendations will certainly change. They have changed markedly, just in the last several years. Change is the hallmark of both life and medicine. Those who can adapt and change quickly, will be rewarded! The best doctors are always making changes!
Please note that any good general medical provider should understand these recommendations. They should think critically about how you, as an individual, fit into a given recommendation. If your healthcare providers are not bringing up the screenings mentioned in this article to discuss with you, that is a problem. Advocate for yourself and bring screening tests up to your doctors, nurse practitioners, and physician assistants. If your providers are not taking disease prevention seriously, I strongly encourage you to find a new provider. It could save your life.
Please note that these articles cover many of the most important tests and treatments for disease prevention. However, many more recommendations exist. We recommend asking your healthcare providers about disease prevention at every single visit. Doctors and nurses are not perfect, we sometimes forget. Please remind us!
Pediatrics
Children are the future of our society. Developing and nurturing intelligent, moral, and hard working children and adolescents should be the number one goal of any society. Do you believe this is currently our society's number 1 priority? A prerequisite to doing this is keeping children and adolescents healthy. Proper disease prevention is a great first step.
Childhood vaccines are the most important preventative measure and arguably the most important medical advancement to date. We have eradicated diseases like smallpox and polio that formerly killed and debilitated millions of children. For more information on childhood vaccines please visit the CDC website: https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html
Childhood vaccines are exceptionally safe. The United States keeps track of any and all adverse events related to vaccines. Adverse events are few and far between. Stop the dissemination of “fake news” regarding vaccines being unsafe. It is killing children.
Grade A Recommendations:
To prevent blindness in newborn babies from gonorrhea, apply an antibiotic ointment like erythromycin, immediately following vaginal delivery. Gonorrhea can cause blindness within 24-48 hours in newborns, and can be permanent. If a mom has gonorrhea, the baby has a 50% chance of contracting disease during delivery.
Grade B Recommendations:
Counsel school age kids to avoid tobacco and nicotine products. This message should come from parents, teachers, doctors, and piers. Preventing this chemical addiction before it starts will pay societal dividends. Nearly every tobacco smoker I talk to eventually comes to the same conclusion. They wish they had never started!
Vision screenings should be conducted on children 3 to 5 years old to screen for amblyopia (lazy eye).
Screen kids older than 6 years old for obesity. If obese, provide children with behavioral therapy regarding diet and exercise.
Depression screening for kids between 12 and 18 years old.
In areas where water fluoride levels are low, prescribe oral fluoride supplementation to children younger than 5 years old. This will help them develop strong teeth. Additionally, apply fluoride varnish to primary teeth at the time of eruption for this same reason.
Insufficient Evidence exists regarding primary care doctor testing for the following issues if no concerns are present. Essentially, more studies are needed.
scoliosis checks
screening for mistreatment, when no evidence of mistreatment exists
screening for alcohol use in kids 12-17 years old
checking a blood test for cholesterol in individuals < 20 years with no risk factors
screening for autism if no concerns exist
checking a blood test for iron deficiency anemia between 6-24 months
screening kids less than 5 years old for any speech impediments
checking lead levels in kids less than 5 years old without symptoms
checking for dental cavities before age 5
counseling by primary care doctors regarding illicit drug use
checking blood pressure in asymptomatic kids and adolescents
Many screening tests were deferred entirely by the USPSTF. Sometimes this is because other entities like the CDC provide such recommendations, as for childhood vaccines. In general, behavioral recommendations, such as wearing seat belts, are guided by other entities. These behavioral interventions are very important for the prevention of accidents and injuries. However, they are beyond the scope of this article.
Interestingly enough, many recommendations are not provided by the USPSTF regarding a number of the tests and treatments performed on newborns immediately following birth. Namely hearing tests and universal bilirubin screening. High bilirubin levels can cause severe brain injuries in newborn babies. However, such brain injuries are exceedingly rare. Elevated bilirubin in newborns can add extra stress to new parents. Treatment can include staying in the hospital longer, placing the baby under bright lights to lower bilirubin levels, and even procedures like “exchange transfusions” of blood, which can be dangerous. Interestingly, very limited evidence exists to support universal newborn bilirubin screening, and it is controversial. The “experts” cannot seem to agree! It is something that is ingrained in medical culture though, and such things are very difficult to change. I would like to see a large clinical trial regarding universal bilirubin screening, but, for many reasons, it is unlikely to occur.
The newborn screen is a panel of tests for multiple genetic disorders that are performed on most all children born in the United States. These tests are thought to be important and recommendations are provided by the Federal Advisory Committee at the following link: https://www.hrsa.gov/advisory-committees/heritable-disorders/rusp/index.html
The USPSTF does not make any recommendations regarding newborn screening for genetic disorders.
Obstetrics (Pregnant Women)
Proper care for pregnant mothers is twice as important as the care of any other population because we are caring for two patients, mom and baby. In general, improving care in the pregnant population progresses slowly. This is because doctors are afraid to make changes to their practice for fear of causing harm. Researchers are even afraid to study this population, for fear of causing harm. However, I would argue that this is perhaps the most important population to study. Furthermore, just because something has always been done a certain way does not make it right, or in some cases, even safe.
Doctors have a long history of killing patients, in spite of our best intentions. Bloodletting, or the withdrawal of blood to cure disease, was one of medicine's most common treatments for 2,000 years before we discovered it was killing our patients. This practice was unfortunately used in pregnant women as well, possibly as late as 1945. In spite of medicine’s long tradition of failing and harming people, there are a few things we are fairly confident about in 2020 with regard to the care of pregnant women.
Grade A Recommendations:
Women capable of becoming pregnant should take between 0.4 to 0.8 mg of folic acid (vitamin B9) daily to prevent neural tube defects, most commonly spina bifida (hole at the bottom of the baby's spine that does not close properly). This is one of very few instances where taking a vitamin has been definitively shown to prevent an adverse health outcome in the absence of vitamin deficiency.
Check blood labs for Hepatitis B, HIV, and syphilis at the first prenatal (pregnancy) visit.
Ask pregnant women about smoking tobacco as well as alcohol use and advise them to stop.
Check blood labs for blood type and RhD type at the first prenatal visit. This will help prevent mismatches between mom and baby’s blood that could cause problems.
Please note that some infections like syphilis can cross into the placenta of pregnant women and infect their unborn baby, often causing devastating consequences and even death. This is why screening for certain infectious diseases early in pregnancy is so important. Remember that many of these infections are spread by sex, and sex brings babies.
Grade B Recommendations:
Screen for urinary tract infections in pregnant women without symptoms. Please note that pregnant women are the only population that healthcare providers recommend treating if significant bacteria are present in the urine in the absence of symptoms.
Refer depressed pregnant and postpartum (after delivery) women to therapy. Depression is common in pregnancy and after. You are not alone!
Check blood pressure throughout pregnancy.
Support breastfeeding and provide interventions to facilitate breastfeeding. I cannot believe that this does not get an A recommendation!
Women at risk for preeclampsia, a serious disease caused by problems between the mother and the placenta, should take a baby aspirin (81 mg) daily starting at 12 weeks of pregnancy.
Screen for diabetes at 24 weeks of pregnancy or soon after. Pregnant moms gain weight during pregnancy, which increases the risk of developing type 2 diabetes. Diabetes can hurt the baby. It is best to maintain optimal physical health prior to and during pregnancy.
Test for RhD antibody in RhD negative moms later in pregnancy, unless dad is known to be RhD negative as well. I know this sounds complicated. Talk to your pregnancy provider.
Insufficient evidence exists to test asymptomatic pregnant women for lead, iron deficiency anemia, and diabetes before 24 weeks of pregnancy. Pregnant women should not be screened for a vaginal infection called bacterial vaginosis if they do not have symptoms.
There are many more tests, screenings, visits, and monitoring that goes on during pregnancy. Some of these things are supported by research. Others have not been adequately studied. Trust your healthcare providers, but I always recommend trying to verify their recommendations using other sources. My patients like to tell me they trust me. I always respond, don’t!
Conclusion
Part 1 of this blog post was somewhat hard on healthcare providers. In our defense, we have done a number of things right in the last 100 years. Deaths in children < 1 year old and pregnant women plummeted in the 20th century. This has largely been the result of public health measures, though improvements in care have also contributed. However several challenges remain. Maternal deaths have actually been increasing since the mid-1980s. In fact pregnant moms have never been more unhealthy as a group than they are now. Additionally there are numerous health disparities. For instance black infants are more than twice as likely to die as white infants in the United States.
Health literacy can help keep you and your family safe. In my experience, many people seem to be silent passengers with regard to their health and medical care. Most of my older patients cannot even tell me what medicine they take or why they take them. Better health literacy and personal accountability are necessary to improve our population’s health.
As such, we strongly recommend that people know a little information about what screening tests and treatments are recommended and talk about them with their healthcare provider at every wellness visit. Question your healthcare providers. As a doctor, I can tell you that when my patients question me, it makes me a better doctor! It is time for people to stop being silent passengers and start driving their health. Improving health literacy is the first step.
Wonder Medicine’s Longevity and Performance Program improves your lifespan and healthspan with a research-driven proactive program that focuses on the big picture of your health so you can perform at your highest potential.
Author
William Brandenburg, MD, owner of Wonder Medicine clinic and full time rural hospitalist.
Editor
Karlee Brandenburg, RN-BSN, owner of Wonder Medicine.
Conflict of Interest
This article promotes Wonder Medicine clinic, which the author and editor own.
Disclaimer
This article was written for educational purposes only. It is not intended to serve as formal medical advice. Please talk with your healthcare provider about the tests and treatments you should consider to prevent cancer, disease, and infection.
References
United States Preventative Service Task Force. (https://www.uspreventiveservicestaskforce.org/uspstf/).
United States Preventative Service Task Force. Wikipedia. (https://en.wikipedia.org/wiki/United_States_Preventive_Services_Task_Force)
CDC Childhood Vaccine Recommendations. (https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html)
Federal Advisory Committee. Recommended Uniform Screening Panels. (https://www.hrsa.gov/advisory-committees/heritable-disorders/rusp/index.html)
Achievement in Public Health, 1900-1999: Healthier Mothers and Babies. MMWR. CDC publication. 1999.