Jason H. Wasfy is a cardiologist at Massachusetts General Hospital and an instructor in cardiology at Harvard Medical School.
Afew months ago, my 65-year-old mother had “screening” blood tests, which showed inflammation of the liver. She was healthy and had no symptoms of liver disease. The cause of the inflammation was unclear. To investigate, doctors ordered more tests.
As a physician, I have seen how excessive testing can lead to worry and more tests. That seemed to be transpiring — but this time, the patient was my mother.
An ultrasound showed that her liver was healthy. But the same ultrasound also discovered a small, fluid-filled cavity in one of her kidneys. The radiologist recommended a CT scan — a detailed series of X-rays that create three-dimensional images of the entire abdomen — to evaluate the remote possibility that the cavity might be cancerous.
The CT scan, unfortunately, did not settle anything. Like the ultrasound, it did not rule out the possibility of cancer in the kidney. So the radiologist recommended an MRIof the kidney. But that wasn’t all. The CT scan detected other small abnormalities, each of which required more testing. A small spot in the lower part of her lung required a PET scan, which involved injecting a radioactive substance that can highlight cancer cells in certain organs. A spot in the spleen was also possibly cancerous and required a separate MRI. The CT scan of her abdomen simply prompted another series of tests, each of which seemed to resolve nothing.
I thought this was an all-too-common misadventure. Many physicians consider tests like the initial screening blood test unhelpful because they often waste money and prompt more tests. When those follow-up tests involve radiation or invasive procedures, they can harm patients. My mother went through many tests, which unnerved her, exposed her to radiation and potentially wasted resources.
After several more scans, radiologists were able to work out all but one issue. The PET scan had not clearly determined whether the spot on her lung was cancerous. She needed chest surgery to remove the mass and examine it under a microscope. This, I thought, was the ultimate feared consequence of unnecessary testing: risky surgery.
The surgeon, one of my colleagues, paged me when the operation was over. My frustration with all the testing evaporated in an instant. The spot was cancerous. By surgically removing the cancer at such an early stage — before any symptoms — the surgeon probably saved my mother’s life.
Typically, patients do not know they have lung cancer until they notice symptoms such as a cough or weight loss. At that point, lung cancer is usually incurable. My mother was lucky. An unwarranted liver test led to a discovery in the lung, which spotlighted cancer caught early enough to be cured.
For our family, this experience was an emotional journey. It challenged many of the assumptions I had made about medicine and health-care reform. I still think that excessive testing wastes money and can hurt patients. Routine liver-function testing in patients without symptoms hurts people more often than it helps them. Targeting testing and treatments to the patients who will benefit from them is key to improving health care in the United States.
But my mom’s story reminds me just how difficult that task will be for all of us, physicians and patients. Just because a test is not recommended for most patients does not mean that a particular patient would not benefit. This paradox has driven public debates about testing for BRCA genetic mutations for breast and ovarian cancer and the prostate-specific antigen (PSA) for prostate cancer. Ultimately, patients’ needs, risk profiles, backgrounds and preferences are extraordinarily diverse — and defining appropriateness in testing is challenging.
As a doctor, I know that liver-function blood tests in healthy patients are not often indicated. I still wouldn’t recommend such screening to patients or colleagues. But I also realize that an unnecessary test launched a sequence that saved my mother’s life. For that test, however unnecessary, I am grateful beyond words.