Seeking healthy scepticism

By amy Reiswig, May 2012

The downside of medical screening tests is examined in Alan Cassels’ latest book.

You want to save your life, right? And if someone—particularly someone in our much-esteemed medical field—told you that you could do so simply by taking a test, well hallelujah for modern medicine! Or maybe not. While he’s not promising to save your life, as Alan Cassels notes in his latest book Seeking Sickness: Medical Screening and the Misguided Hunt for Disease (Greystone, April 2012), asking questions about screening tests, rather than blindly having them, can be a much healthier path. 

Part scientific reporting, part consumer advocacy, Seeking Sickness critically examines the trend of doctors and clinics to promote—and patients to increasingly demand—medical screening tests despite no sign of illness. From seemingly innocuous eyeball pressure or cholesterol tests to more controversial procedures such as body scans, PSA testing, mammography, mental health screening, and screening of the lungs, bones, genes and more, Cassels cautions that “our collective efforts at seeking sickness often do nothing but promote health consumerism to the worried well.”

It’s important to note that Cassels—a drug policy researcher at UVic’s School of Health Information Sciences—is not criticizing medically necessary diagnostic tests ordered to investigate symptoms and he is not saying “don’t get screened.” Rather, he’s concerned about “doing scans on well people and trying to find things wrong with them” and hopes to promote “health literacy” versus “the marketing of fear.”

“The consumer is naked in this medical screening marketplace,” Cassels says soberly over coffee downstairs from his office above Murchie’s. That statement reveals one of his main problems with non-medically warranted screening: it turns healthy people into consumers for the benefit of the medical industry. But do these tests actually benefit the individual or society in general? Or do they violate the prime directive of health providers and actually do harm through misdiagnosis, overdiagnosis, dangerous overtreatment and harmful side effects, both physical and psychological? 

“The screening of our blood is perhaps so benign, so under-the-radar that we never question it. We believe that it can only do good…But the inappropriate treatment of healthy people that often follows screening tests (including drugs to treat risk factors instead of real diseases) changes the equation,” Cassels writes. 

As illustration, he recounts the story of a man, George (not his real name), in Richmond who, after a routine annual blood test, was told by his doctor that he had high cholesterol and should take the statin Lipitor. But George ended up with severe side effects before quitting the drug. Cassels notes that UBC’s Therapeutics Initiative, after a review of trials of the drug, concluded: “in thousands of patients over a five-year period, statins didn’t reduce the overall chance of death or hospitalization.” He says, “The implications of these findings are huge because almost all the people having their cholesterol screened…are people like George who have no health issues other than a failed test for cholesterol.”

In his chapter on mammography screening, besides discussing the case of a woman being harmed by screening, Cassels also looks at the controversy surrounding new recommendations for non-diagnostic mammography (that it only begin at age 50 and be done every two to three years until age 74). “Behind the changing recommendations,” Cassels writes, “is an accumulation of evidence that there are considerable harms associated with widespread mammography screening and that the benefits are a lot more modest than previously thought.” Number crunching reveals that screening 2,100 women for 11 years would prevent only one death and result in about 690 women having false-positives, which then lead to further unpleasant and harmful “treatments.”

And when it comes to bone scans for osteoporosis and the controversial and, in Cassels opinion, somewhat arbitrary T-score, part of the problem is that people labelled as having or at risk for osteoporosis are then often prescribed drugs from an industry that has grown from $280 million in annual sales in 1996 to $6 billion in 2006 and is projected to grow to $14 billion by 2014. The pharmaceutical industry, Cassels says, “knew very early that if it wanted to sell drugs, it needed to be involved in shaping the disease and defining the diagnosis, right from the start,” and he talks about firms that did just that—and also about the osteoporosis drugs that have been recalled because of serious health problems associated with them. 

There’s been lots of research done on the various medical screening tests and technologies, but, Cassels laments, “good research is almost never well-communicated to the consumer.” That’s where Cassels finds his niche and his passion: communication—what he calls “knowledge translation.” 

Originally from Saskatchewan, Cassels graduated from Royal Military College with a degree in, unexpectedly enough, English literature. (Proud of two peacekeeping tours, his Army parachutist’s wings and his Navy diver dolphins, he also still boasts of once being able to recite the entire Rime of the Ancient Mariner.) And with a Masters degree in public administration from UVic, he says a chance meeting in the early ’90s and an invitation to participate in a drug policy research project got him hooked on an area he hasn’t left since. 

Cassels has been awarded numerous research grants and has lectured and published widely. He has done several CBC Ideas documentaries. Online, he founded Media Doctor Canada, is an expert advisor for ExpertNetwork.ca, and maintains his website, www.alancassels.com—“where media and medicine meet.” 

He has also published two previous books: the international bestseller Selling Sickness: How the World's Biggest Pharmaceutical Companies are Turning us all into Patients (Greystone, 2005) and the smaller-scale, more lighthearted The ABC’s of Disease Mongering: An Epidemic in 26 Letters (Emdash, 2007), and local readers can follow his investigations via the monthly Drug Bust column in Common Ground.

While he says jokingly that “The only rational reaction to a lot of this stuff is to laugh at it,” Cassels is incredibly serious about helping prevent people from being manipulated by medical industry profiteers. “This is injustice,” he says simply, admitting that his research “turned me into an activist. You can’t let this stuff go on. I think I’m trying to stop irrational, unnecessary and harmful things from being done to people.” 

Cassels arms readers with lists of questions to ask and information from independent research. Aiming to take the emotional rhetoric out of the discussion about screening, he challenges readers not to be susceptible to emotionally-driven marketing messages such as “Early detection will save your life. Get screened. Do it for the ones you love.” 

Everyone will know someone who perhaps could have had their life saved by early detection of disease, as I do, and parts of the book will touch emotional nerves. But Cassels’ message to step back and look at the screening industry as a whole—what is happening, what is driving it, what risks are involved and what we should be asking—is crucial to heed if we want to be informed health care consumers.

Writer and editor Amy Reiswig has been reminded of how little we actually understand the way many ravaging illnesses work and dedicates this month’s column to her friends fighting disease of all descriptions.