We are realising that preventative medicine is as important as treatment. I have recently posted blogs on over-the-counter drugs that we might give to people without disease as well as a blog on healthy living. To complete my thoughts on preventative medicine, I wanted to post on health screening
I am a great believer in general practice. Politicians should appreciate that general practice is up to 8 times more cost effective than hospital medicine. General practice deserves more of the NHS cake. As well as providing continuity and oversight of an individual’s health care, a general practitioner also plays a vital part in health screening. The NHS is actually very good at primary screening which includes monitoring for blood pressure, cardiovascular risk, diabetes and cancer. Let’s look at these in a little more detail:
The biggest silent risk of heart attacks and strokes is high blood pressure or hypertension. When I pick up a patient with hypertension I like to think that it is, ironically, good news because by treating people with high blood pressure and bringing it back to a normal level we can dramatically reduce the risk of heart attacks and strokes. It is undiagnosed high blood pressure that is dangerous. I recommend all patients in middle age buy an automatic blood pressure machine. I have no vested interest so I recommend those made by Omron. Go for the cheapest because the more expensive ones just have unnecessary bells and whistles. Take your blood pressure twice a week at different times and record the systolic (upper) and diastolic (lower) readings – these are clear on the display. Write down the readings together with the time of day as well as what you are doing. Everyone’s blood pressure goes up and down so we are only interested in the lowest readings. Most importantly the diastolic reading should not be above the low 80s. If your readings are above this simply discuss it with your GP who will also assess your cardiac risk taking into account your weight, lifestyle and family history. Tablets may be needed although whether to treat depends more on this risk rather than the absolute numbers.
So if you’ve taken your own blood pressure what is left for your GP? Routine screening will include checking your urine for sugar or protein which can be signs of diabetes or kidney problems. Nowadays we tend to do a specific blood test for diabetes called HbA1c which effectively gives us the average blood sugar over the previous 60 days. As with high blood pressure, the risk from diabetes is failure to identify it, and if diabetes is treated the risks dramatically fall. Again, this is usually tablets in adults, although lifestyle changes in terms of weight loss, exercise and diet can actually reverse non insulin dependant diabetes!
Your GP may also look in the back of your eyes where we can see signs of high blood pressure diabetes and other diseases.
Nowadays the NHS is offering annual blood tests. It is important not to have every single test as many such as cancer markers can be raised for many reasons. They should be used where there is a specific suspicion of a problem. However it is sensible to have the following:
- Full blood count to identify anaemia and infection. Some people do iron studies and ferritin in women as we know a normal blood count but low iron stores can in a few people cause symptoms.
- Urea and electrolytes with creatinine. This checks the kidneys
- Liver function tests
- Fasting lipids and cholesterol. Raised fats in the blood increases the risk of cardiovascular disease. Nowadays everyone over 40 should seriously consider statins because they significantly reduce deaths from heart attacks and strokes and MAY help dementia. The fears about side effects such as muscle pains have been shown to be false, and merely an example of nocebo effect.
- Thyroid function tests. We are now less likely to treat people with only slightly reduced thyroid function as there is concern it is not symptomatically helpful, but an underactive thyroid is common and treatment is straight forward
- Men should also have a PSA which rises in prostate cancer. It isn’t very specific but if repeated annually it is easier to detect a change
- Women should have oestrogen and LH if there is a risk of perimenopause. I think the menopause is massively under treated and many women suffer. Early detection and referral to a menopause expert can help mange the myriad of symptoms some women suffer
- Men too can go through the menopause so a testosterone and LH test is helpgul if they have reduced sex drive, impotence, loss of muscle mass, mood changes etc
Finally there is cancer screening.
- Cervical screening is very effective. The NHS should offer this to all women aged 25 to 64 at least every 3 years and as well as a ‘smear’ for cancer a swab is taken for HPV
- Breast screening in younger women is beneficial although there are concerns that we are over treating positive findings especially in older women and may be doing more harm than good in some cases. Currently the NHS offers it between ages 50 and 71 every 3 years.
- For men screening is centred around the prostate with a PSA blood test. This needs to be read with care as high readings do not always indicate cancer. Fortunately more specific tests are being introduced and high-definition MRI is now recognised as the first test for abnormally high readings.
All these tests are offered without charge on the NHS. If you are not eligible for NHS treatment Phoenix Hospital Group 020 7193 3466 can arrange them for you. Please note I am a director of PHG involved in the screening programme. Other providers are available.
Many patients go for health checks or comprehensive screenings often costing a considerable amount of money. I am not a great fan of these as many of the additional tests can produce false positives which means they suggest illness which does not exist, and can lead to further investigations which themselves carry a risk. These medicals often allow people to be told about healthy living including going to the gym, diet and weight loss, but this is information that is readily available for free. So lets look at what tests are worthwhile:
Under 40 everyone should have an ECG to identify the small number of people with inherited problems to the conducting systems in the heart that can lead to sudden death. Many schools now offer an ECH but it is inexpensive and risk free so to be recommended.
Otherwise men should examine their testicles regularly and if they feel a lump an ultrasound is recommended
Women who have heavy periods should see their GPs but if the issue does not resolve a gynaecology referral is very useful as most can be helped. Simply giving iron tablets for anaemia is not correct!
Genetic testing is now readily available for under £1000. It is important to measure the entire genome (all the DNA). There are no UK Guidelines yet and the results need to be interpreted by a geneticist who can also advise which tests to use. I am happy to recommend a geneticist.
Over 40 there is one test that general practitioners do not offer which is virtual colonography. This uses a CT scanner with additional software to image the colon and identify polyps which may be developed into cancer. VC is recommended for patients with a family history of bowel cancer and ulcerative colitis but we are using it as a screening tool because bowel cancer is one of the commonest causes of cancer death in the UK, and vitally it is totally treatable if detected at this stage. VC does involve a small amount of radiation but the benefit outweighs the risk. Some patients undergo colonoscopies where cameras are inserted into the colon but this has a risk of perforation, often requires sedation and needs full bowel preparation which is not particularly pleasant. The American president used to have a colonoscopy but now has a VC !!. VC also allows us to image the abdominal cavity looking at the ovaries, kidneys and pancreas so it is a comprehensive examination of many organs.
We also offer a calcium score at the same time as an initial VC. This looks for calcium in the coronary arteries using the same CT scan. If negative you do not have coronary artery disease. If you do we can use more modern CT scanners to produce a map of the problem so our cardiologists can advise if further treatment is needed to avoid a heart attack.
People often ask about other tests. Many tests are available but we must be careful to only recommend those tests that provide useful and reliable information that allows treatment or correction. At Phoenix Hospital Group we are currently assessing many tests so we can offer advice based on the individual. Please email me if you would like to learn more. So for example cancer markers may be helpful in some patients but they can be raised for many reasons leading to high false positives. Tests such as routine MRI of the brain may merely show abnormalities such as an aneurism where treatment is not advised; identifying the aneurism may prevent an individual obtaining insurance or employment and not in their best interest.
So, when people asked me what screening they should have, I will suggest they take their own blood pressure, attend their GP for the usual screening, asked for a PSA every few years and consider a virtual colonoscopy and calcium score. Men who are concerned about prostate cancer can add an MRI which is safe and detects early cancer but only at that moment in time. More useful MRis are expected soon.
I am a director of Phoenix Hospital Group. PHG owns 9 Harley Street, one of a small number of units offering screening virtual colonography. However, my recommendations are based on peer reviewed papers, the views of my consultant colleagues, and my own experience of being screened!