Check up
Preventive examinations
Yaroslav Ashikhmin, Post-science
Preventive examination (in another way - check up) consists of tests conducted by healthy people who have no complaints, depending on their age, gender and risk factors, that is, features or negative environmental influences. The tests that are included in the checklist are called screenings. It is extremely important to understand that a checkup and a survey on complaints that a person has, no matter how scanty they may be, are completely different things. It is necessary to separate screening and early diagnosis. These concepts are often confused even by doctors. If suddenly the doctor says: "Oh, your blood pressure is rising, you need to go through a checkup," this means that the doctor, unfortunately, does not understand what he wants to do. Because the presence of such a symptom as increased pressure or weakness, abdominal discomfort, determines the need to deploy a diagnostic algorithm that has nothing to do with the checkup.
Interestingly, diagnostic pathways have been studied much better today, these are guidelines - guiding lines. We know very well how to examine patients who have complaints, because there are a finite number of diseases, and we know what we will get to. As for the preventive examination, the situation is much more complicated. Initially, the set of these texts, screenings, was based on the identification of the most frequent diseases or diseases that have high social significance, by the cheapest means. This was necessary so that by investing in screenings, in the detection of diseases that do not have symptoms, it was possible to save a large amount of financial resources at the level of the healthcare system. It is logical: if you catch common diseases at an early stage, then you can save money, and people who will not die will increase the gross domestic product of the state.
How do we choose whether a particular test can be considered screening? Many people think that it is enough for the test to recognize with high accuracy the presence of a disease in a person who has no symptoms. But this is not the case. In order for the test to be considered an effective screening, you need to prove that if you do this test in a specific population of patients, then conducting this test leads to a decrease in mortality from the disease for which it is scheduled to be diagnosed. And it is even better that the overall mortality rate decreases.
In order to prove that screening can be implemented at the level of the healthcare system, a major study needs to be conducted. This was done with respect to low-dose computed tomography of the lungs in those patients who have smoked for the last 15-30 years during their lifetime. It turned out that in this population, if you do a low-dose CT scan of the lungs, you can reduce the mortality from lung cancer due to early treatment. Several studies have been conducted. In the American study, a positive result was obtained, and in studies that were conducted in Europe using the same method, there was not the same result. This is an illustration of the fact that even such an explicit method as computed tomography does not show in all studies that its use can actually reduce mortality in the end.
A large number of tests that seem promising to people at first glance have failed. Unfortunately, we see that cancer markers today are not an effective strategy in the search for various types of cancer. This is due to the fact that they do not have a good enough sensitivity. For example, there is a great test that works in a test tube, but if it is done to a large number of people, false positive results may be found that will scare a person.
Today, the standard checkup for an adult consists of a very limited number of tests: glucose tests, cholesterol tests, analysis for hidden blood in the stool in patients over 50 years of age to detect bowel cancer and a number of other tests. There are very few of them, and they are usually quite cheap. The customer in these studies was the state. It is important for the state that GDP increases, which means that mortality decreases. And it is important for people to know whether they have an early stage disease or not. They also want to detect and treat the disease not only in order to reduce mortality, but also in order to maintain a high quality of life for longer. This conflict of interest is very serious.
This contradiction can be illustrated by the example of a single sensitive and specific cancer marker PSA - prostate–specific antigen, which then falls into the American key recommendations, then leaves them. This cancer marker is very sensitive in terms of finding prostate cancer at an early stage. But why is this test not recommended by the US PSTF guidelines today? It turns out that a large number of elderly men who have died from a variety of causes are found to have prostate cancer that does not affect their life expectancy. If it is treated at an early stage, it will lead to unjustified operations and an increase in the cost of expensive surgery. Therefore, the healthcare system is not interested in catching this cancer with this method at an early stage. They say that if the earliest symptoms appear in the form of urinary retention, then you need to go to a urologist already.
Other tests, which could be as specific as PSA, do not go a long way to validation in clinical trials today, because when forming this huge clinical trial, the question of finances and the question of survival are already initially put in the first place. That's why the screening set is so small today. Our patients who come to the doctor with a request to conduct the most complete examination of the whole body, as a rule, are faced with two options. They are recommended this small, compressed set of screenings, and they are unhappy because not all organs are checked. The second extreme is when unscrupulous doctors recommend a huge amount of research that has not been studied in any way in clinical studies. It happens that a person immediately, without symptoms, is recommended to take the entire spectrum of cancer markers, do an MRI of the whole body, various ultrasounds, something that a person most likely does not need.
The way out of this situation is as follows. When we encounter a patient, it is important for us to find out if he has even the most fleeting complaints that bother him, and work on complaints. A huge number of our compatriots have signs of diseases that need to be worked out, diagnosed, and then deploy a diagnostic track to search for a specific disease. For example, a person has a blood pressure above 135 and 85 – I must say that in our population 35-40% have hypertension – and he needs to be examined for arterial hypertension. This examination in a young person may include almost the entire checkup, which is shown to him by gender and age. If a person has dyspepsia, discomfort along the midline in the epigastrium, he may need to have a gastroscopy. We need to see if there is a bacterium Helicobacter pylori that can cause stomach ulcers or cancer. But these studies need to be done in accordance with the complaints.
If a person has high blood pressure or high cholesterol and there is a risk of death from heart disease, it is not appropriate to switch to MRI of the whole body and complex methods of research. First, the doctor must correct all the risks that a person has, draw up a prevention program for him. When everything is done according to complaints, according to the disease and the diagnosis is clear, it is necessary to finish those screening tests that were not done to a person. If an elderly person has coronary heart disease, he had a heart attack, the doctor should choose therapy to prevent the next heart attack. But then he has to do a test for hidden blood in the stool, despite the absence of symptoms, in order to determine whether he has asymptomatic colon cancer. On the contrary, if we have an oncological patient who is undergoing treatment for colon cancer, then, having done everything correctly and correctly, we need to assess the cholesterol level and conduct a cardiac check, despite the fact that he has an oncological disease. In this case, it will be an element of a preventive examination, suitable for a person who has some kind of illness.
They may object to me: why don't they do an MRI of the whole body, because this method is accurate? We know that today it is not inferior in a number of parameters even to PET CT and is not associated with radiation. I'll tell you a story. I had a patient who was very afraid of dying from pancreatic cancer because her mother died at the age of 49 from this diagnosis. We decided that we would do an MRI of the abdominal cavity and pancreas every year in order to determine if there is cancer. But she still, unfortunately, died of pancreatic cancer. Because between the two studies, her cancer managed to grow to the stage when she was inoperable. That is, she came to a routine MRI examination, where pancreatic cancer was detected, which was already incurable. In the previous MRI, a year ago, there were no signs of cancer. This is a tumor that progresses so quickly that it is not a fact that it can be caught even by this method. How often should MRI be done for such patients? Every six months, once a month? Then you can get to the point of absurdity. Not all diseases can be grasped at the right moment at an early stage.
Now there is an active study of various radiation, biochemical biomarkers in relation to the prevention of certain diseases. We don't see breakthrough technologies yet, but we have to wait. Perhaps in two or three years we will still have new markers that can be implemented as screenings of standard checkups. Now ordinary people need first of all to undergo a standard preventive examination. Our preventive programs offered by the Ministry of Health are significantly broader than those recommended in Europe and the USA. The downside is that you can find some inconsequential things and get attached to them, which will stimulate hypochondria. But the plus is that they are good at detecting a large range of different diseases. You can pass a Russian checkup or a checkup according to the recommendations of the United States Preventive Service Task Force Service (USPSTF). In the presence of complaints, even seemingly insignificant ones – snoring, weakness, decreased exercise tolerance, incomprehensible mild discomfort in the heart area – you need to immediately go to the doctor and deploy a normal diagnostic examination to identify the cause of the disease.
About the author:
Yaroslav Ashikhmin is a Candidate of medical Sciences, cardiologist, Advisor to the Director General of the International Medical Cluster Foundation.
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