It sounded like a pretty good deal to Ken Doerflinger: a government study offering to scope and probe him tip to toe for signs of cancer.
“I thought, well, if they offer these tests, I’ll take them, free and all,” said the 75-year-old retiree from suburban Detroit.
But those free tests wound up costing a lot. By the time it was over, he had had more blood tests, a biopsy of his prostate, and a colonoscopy — thousands of dollars of additional work — just to prove that he didn’t have cancer after all.
Screening tests that turn out to be false alarms can cost people a lot more than lost sleep. A new study found that people spent an extra $1,000 or so on health care in the year after a screening test raised suspicions that later proved unfounded. Much of that was for more definitive tests to rule out cancer.
Benefits vs. harms
“The key here is to make sure that people are considering all the possible benefits and harms” when they go for a screening test, especially one that is not recommended by health officials, said Jennifer Elston Lafata, director of the Center for Health Research at the Henry Ford Health System in Detroit.
She led the study, which was published in this month’s Cancer Epidemiology, Biomarkers & Prevention, a journal of the American Association for Cancer Research.
Surveys show that Americans generally have high opinions of screening tests. Some fear cancer so much that they will even pay hundreds of dollars for tests that medical experts do not recommend, such as whole body scans at private scanning centers.
But by their very nature, screening tests are problematic.
“They’re not intended to be definitive. They’re intended to distinguish those who don’t have cancer from those who might,” said Robert Smith, director of screening for the American Cancer Society.
Varying degrees of value
For some screening tests — mammograms for women over 50 and Pap smears — there is evidence that they do more good than harm. But for others, that evidence is lacking.
Lafata’s study involves some of the 154,000 participants in a National Cancer Institute study designed to determine the value of some of these tests.
Participants were given chest X-rays for lung cancer and a flexible sigmoidoscopy exam for colon cancer. Women also were given an ultrasound exam and a blood test for ovarian cancer, and men were given the PSA blood test and a digital rectal exam for prostate cancer.
To estimate the cost of false alarms, the study focused on 1,087 participants in the Detroit area for whom insurance records were available on follow-up care. Costs in the year after a “false positive” test were compared with costs for people whose tests were accurately negative.
The bottom line: Men with false positives spent an extra $1,171, and women, $1,024.
Some experts disagreed with how the study classified costs for “false positive” sigmoidoscopies, which examine only the lower part of the colon. If follow-up testing by colonoscopy, which examines the whole colon, did not find cancer, the initial test was considered falsely positive and the colonoscopy costs were regarded as excess.
But these tests “really return a dividend” because precancerous growths called polyps are removed during the colonoscopy, which prevents cancer and saves money on screening in future years, because it only needs to be done every three to seven years, Smith said.
Economic plus emotional costs
Despite this disagreement, cancer specialists agreed with the central point of the study — that the imprecision of screening tests takes an economic toll, not just an emotional one.
“There are a lot of hidden costs, too,” such as lost time, lost wages, and travel and child care expenses that people incur while having follow-up tests that prove unnecessary, said Dr. Barnett Kramer, associate director of preventive health at the National Institutes of Health.
Some women in the study had expensive laparoscopic surgeries to rule out ovarian cancer, Lafata noted.
Many men had prostate biopsies because of false PSA tests, which measure a substance made by the prostate. High levels can indicate cancer but also a host of benign conditions.
Doerflinger was one of those men. His PSA score was 6, above the level of 4 that usually triggers suspicion. His sigmoidoscopy also raised suspicion, leading to a colonoscopy, another follow-up procedure requiring anesthesia.
To his relief, it came back negative for cancer. His insurer footed virtually all of the bill — he does not even know how much it all cost. But those costs ultimately come back as higher insurance premiums.
Kramer had this advice for people considering a screening test: Make sure there is good evidence that the test works, that the person doing it is qualified, and that it prevents deaths, not just finds cancer. Federal guidelines are a good place to start, he said.