A new paper has shown that randomised controlled trials (the gold standard method of evaluation) show that few currently available screening tests for major diseases where death is a common outcome have documented reductions in disease-specific mortality, reports Science Daily. Screening for disease has long been a key component of modern healthcare. However, several popular screening tests have met with controversy, with breast cancer screening for women aged 40-49 and prostate cancer screening in healthy men losing their endorsement in the US.

New research shows that few currently available screening tests for major diseases where death is a common outcome have documented reductions in disease-specific mortality. Evidence was evaluated on 16 screening tests for 9 major diseases where mortality is a common outcome. The researchers found 45 randomized controlled trials and 98 meta-analyses that evaluated disease-specific or all-cause mortality. Reductions in disease-specific mortality were uncommon and reductions in all-cause mortality were very uncommon.

Researchers from the Stanford School of Medicine evaluated evidence on 39 screening tests for 19 major diseases from 48 randomised controlled trials (RCTs) and 9 meta-analyses identified via the Cochrane Database of Systematic Reviews, and PubMed – to find out whether screening asymptomatic adults for major disease led to a decrease in disease-specific and all-cause mortality.

Randomised trials were available only for 19 tests on 11 diseases (abdominal aortic aneurysm, breast cancer, cervical cancer, colorectal cancer, hepatocellular cancer, lung cancer, oral cancer, ovarian cancer, prostate cancer, type 2 diabetes, and cardiovascular disease). The authors' show that there is evidence of a reduction in mortality in only 30% of the disease-specific mortality estimates and 11% of the all-cause mortality estimates from the randomised controlled trials they evaluated. In the case of disease-specific mortality, findings from the individual randomised controlled trials are backed up by evidence from 4 meta-analyses, but none of the 6 meta-analyses that included estimates of all-cause mortality produced evidence of a reduction in mortality.

Professor John Ioannidis, senior author on the paper, says: "Our comprehensive overview shows that documented reductions in disease-specific mortality in randomised trials of screening for major diseases are uncommon. Reductions in all-cause mortality are even more uncommon. This overview offers researchers, policy-makers, and health care providers a synthesis of RCT evidence on the potential benefits of screening and we hope that it is timely in the wake of recent controversies." The researchers argue that randomised evidence should be considered on a case-by-case basis, depending on the disease, adding that screening is likely to be effective and justifiable for a variety of other clinical outcomes besides mortality. "However," they conclude, "our overview suggests that expectations of major benefits in terms of reductions in mortality from screening need to be cautiously tempered."

Few medical societies still recommend healthy adults undergo annual physicals, and some groups actively recommend against them, yet many physicians continue to offer the visits to their patients. And, says a Medscape Medical News report, oncologist and health policy expert Dr Ezekiel Emanuel, has taken the debate to the opinion pages of the New York Times, where he explains again why the formerly prescribed practice should be proscribed. Once again, however, not everyone agrees the healthy patient exam should be a thing of the past.

According to Emanuel, who is vice provost, global initiatives, and chair, department of medical ethics and health policy, University of Pennsylvania, Philadelphia, recent estimates say about 45m Americans will have a routine general physical this year, which he likens to the human equivalent of the 15,000-mile check-up on their cars. "If you estimate the cost of the exam alone conservatively at $100, it's beginning to be a non-trivial amount of money," Emanuel said.

And that is before you add in the costs of laboratory panels, follow-up tests, patient anxiety, and the over-diagnosis or overtreatment of conditions that, if left undetected, would never have become clinically significant. "We see this with prostate cancer and thyroid cancer," Emanuel said.

As he writes, "If you screen thousands of people, maybe you'll find tens whose exams suggest they might have a disease. And then upon further tests, you'll find it is really only a few individuals who truly have something. And of those individuals, maybe one or two actually gain a health benefit from an early diagnosis."

From a health-promotion perspective, then, the annual physical exam is of little value, does not reduce morbidity and mortality from acute or serious chronic conditions, and may even lead to unwarranted complacency in "people who just want to make sure," he said.

Another impetus for Emanuel’s article was the mounting demand on physician time with the broader access to medical care promised by Obamacare. "Doctors are already saying they don't have enough time for all their patients, so with annual check-ups, you're devoting time to exams in healthy asymptomatic people who probably don't need them," Emanuel said. Avoiding annual exams would free up many physician-hours for patients with manifest acute or chronic medical problems. But even healthy, "never-sick-a-day-in-my life" people should check in with a physician once in a while, Emanuel conceded. At that time, appropriate evaluations can be made.

Many US physicians continue to offer this annual staple, motivated, he said, by a combination of financial considerations, habit, and patient expectations. "Many patients are confused and think they need an annual physical to get recommended procedures like flu shots, cholesterol tests, and blood pressure checks," he said.

Emanuel noted that the US Preventive Services Task Force does not recommend routine annual check-ups, and the Canadian Task Force on the Periodic Health Examination has recommended against the practice since 1979. "Those who preach the gospel of the routine physical have to produce the data to show why these physician visits are beneficial," he writes in his article.

So far, physicians' response to his op-ed piece "has been 90% supportive. They've looked at the data and are not convinced by the data (of the annual check-up's value)," he is quoted as saying.

Many physicians, however, stand by an annual visit to the consulting room, including Dr Peter C Galier, professor of medicine, University of California, Los Angeles, School of Medicine. "You can manipulate the data from these meta-analyses any way you want, but when you see patients regularly, you get important information that you may never get until there's an acute problem," he said. And that has major implications for cost-saving health promotion and disease prevention, added Galier

In addition, compared with the cost of treating the damage done by the big silent killers, the costs of regular check-ups are modest. "I don't want to find out about a patient's unmanaged hypertension when he comes in with an acute stroke or about his unmanaged cholesterol when he comes with an acute (myocardial infarction)," Galier said. "Unless patients get regularly checked, by the time they come in, it's a catastrophe."

Dr Danielle Ofri, associate professor of medicine, New York University, New York City, agrees there is still place for the routine check-up. "In medical training here, we don't consider it laid to rest," she said. "I still feel there is benefit to the annual history, if not the whole exam and a big panel of blood tests. There's a lot to be found out by checking in." Skipping the laboratory work but keeping the 20-minute consultation may make the exam economically viable.

Doctors’ and patients have reacted to the debate in The New York Times.

This information could be confusing for those who have been hearing about the benefits of "preventative care," says CBS News medical contributor Dr Tara Narula in a CBS News report. "We know that there are certain preventative screening tests that work: mammograms, colonoscopies, blood pressure checks and pap smears can catch serious problems early when they can be treated more successfully. The frequency they're needed may differ depending on an individual's particular risk level. Not getting a yearly physical doesn't mean that you should skip these tests." The report says in the end, Emanuel argues that passing on the routine physical "will free up countless hours of doctors' time for patients who really do have a medical problem, helping to ensure there is no doctor shortage as more Americans get health insurance." Narula explains that one of the problems with routine physicals is that they are too generic. She says the future of physicals will take a more tailored approach based on the individual needs and history.

[link url="http://www.sciencedaily.com/releases/2015/01/150114205631.htm?utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+sciencedaily%2Ftop_news%2Ftop_health+%28ScienceDaily%3A+Top+Health+News%29"]Full Science Daily report[/link]
[link url="http://ije.oxfordjournals.org/content/early/2015/01/14/ije.dyu140.abstract?sid=0ec9e47a-c37c-41c8-8573-c806ae5db551"]International Journal of Epidemiology abstract[/link]
[link url="http://ije.oxfordjournals.org/content/early/2015/01/14/ije.dyu269.extract?sid=0ec9e47a-c37c-41c8-8573-c806ae5db551"]International Journal of Epidemiology comment[/link]
[link url="http://ije.oxfordjournals.org/content/early/2015/01/14/ije.dyu268.extract?sid=0ec9e47a-c37c-41c8-8573-c806ae5db551"]International Journal of Epidemiology comment[/link]
[link url="http://ije.oxfordjournals.org/content/early/2015/01/14/ije.dyu267.extract?sid=0ec9e47a-c37c-41c8-8573-c806ae5db551"]International Journal of Epidemiology comment[/link]
[link url="http://www.medscape.com/viewarticle/838223#vp_2"]Full Medscape Medical News report[/link]
[link url="http://www.nytimes.com/2015/01/09/opinion/skip-your-annual-physical.html"]Full report in The New York Times[/link]
[link url="http://www.nytimes.com/2015/01/18/opinion/sunday/your-annual-checkup.html"]Full report in The New York Times[/link]
[link url="http://www.cbsnews.com/news/do-you-really-need-a-yearly-physical-exam/"]Full CBS News report[/link]