Preventive scans bring promises, pitfalls
By Alice Keesing
Advertiser Health Writer
Brad Hill got a clean bill of health after his annual physical last year. But something didn't feel right, so he paid $1,500 to have a "snapshot" of his insides taken at the Holistica Hawai'i Health Center. What they found was alarming.
Calcium had built up in two of the main arteries of the 64-year-old's heart, creating what looked like a serious blockage. When he got home to Maui, he paid a follow-up visit to a cardiologist.
That led to an echo-stress test, which led to an angiogram, which led to his being flown immediately to The Queen's Medical Center for double bypass surgery.
"I feel like it saved my life," Hill said of the scan that found what a routine doctor's checkup had not.
Aggressively marketed on the Mainland, preventive scanning is taking a foothold in Hawai'i, bringing with it the promises and pitfalls of high-tech machines that can create clear pictures of the insides of the body and signs of pending disease.
Supporters say the scans offer a chance for early detection of heart disease and cancer, allowing quick — and possibly life-saving — treatment.
Critics say the screens are still not backed up by solid scientific evidence and can result in false positives, putting people through needless worry and further — possibly risky — tests.
"The studies are ongoing to prove how effective this new technology will be, but it's not for prime time right now," said Dr. Edwin Cadman, dean of the University of Hawai'i medical school.
Holistica Hawai'i was the first to bring the preventive screening tests to the Islands when it opened in late 1990. At its luxurious $5 million spa facility at the Hilton Hawaiian Village, Holistica offers a large menu of body scans to locals and tourists. They range from a $550 heart scan to a $1,215 full body scan.
Since it opened, Holistica has seen nearly 2,500 clients and performed more than 8,000 scans using electron beam tomography. The non-invasive procedure takes less than 10 minutes, with results available the same day.
About 80 percent of those who have visited Holistica "have a little bit of something," needing anything from an extra dose of calcium each day to surgery, said Robyn Schaefer, director of sales and marketing for Holistica.
CTs at hospitals
Several Hawai'i hospitals are now beginning to dabble in preventive screening using their high-tech CT scanners. The Queen's Medical Center has a lung cancer screening program. Kaiser Permanente Moanalua Medical Center provides calcium scoring for heart disease and virtual colonographies to look for colon cancer. And Kuakini Medical Center unveiled its new CT scanner last week — the fastest in the world — and is now offering the same tests.
Kuakini's executive health program offers the screening to those who want to find out their risk of disease, said Dr. Nobuyuki Miki. Research in Japan shows the technology can detect cancer at earlier stages, Miki said, and the program wants to turn that to patients' advantage.
"If your calcium scoring is high, the primary-care physician or cardiologist could talk to the patient to lower the risk factors; we could go after the high blood pressure, or diabetes, or smoking to lower (the risk of) a heart attack," he said.
Yet while the preventive scans are there for the taking, there is vigorous debate in the medical community about how they should be used and on which patients.
The Food and Drug Administration has come out against full body CT scans for otherwise healthy people, saying they are inaccurate and risky. The American College of Radiology and American Cancer Society also have said there is no evidence that the procedure is cost-effective or effective in prolonging life.
"This is being driven by commercialism," said Dr. Brian Issell, a researcher at the University of Hawai'i Cancer Research Center and chairman of the Health Sciences Advisory Committee for the American Cancer Society. "Of course, every hospital is afraid because there is so much business rivalry among the hospitals right now; everything is being squeezed with the cost-containments and things like that, so they're looking for anything that they can to try to help their revenue stream. But the point is that, above all, you've got to focus on quality and make sure you're doing good for people."
Self-referrals not covered
Insurance companies also are not convinced. People who want to self-refer themselves for a scan have to pay out of their own pocket.
"Our current conclusion is ... that they're unproven and we consider them investigational, which means it's not covered under our benefit package," said Dr. William Osheroff, medical director for the Hawai'i Medical Service Association. The scans may be covered by insurance, however, if there are other symptoms or risk factors.
Another worry for insurers is that the scans will drive up medical costs as people seek further tests to confirm the initial results of a scan.
"I think it's always a good idea to talk to your doctor before people go in and get the test done," Osheroff said. "It's not just a matter of paying for it, but it's a matter of understanding what are the upsides and downsides of getting the test done."
If patients are left confused as to what they should do as technology outpaces the research, it also has created a dilemma for doctors.
Most doctors are "in the dark ... as to what we should do," said Dr. Chun Yoon, a radiologist at the Moanalua Medical Center.
One alternative is to restrict the scanning to only those with high risk factors like smoking or a family history of disease. Moanalua also uses the scan in emergency room situations to check those who come in with unusual chest pain but no indications of heart disease, a use Yoon said that is supported by the American Heart Association.
If a patient comes in without symptoms asking for a scan, the hospital likely would do it, Yoon said, but doctors would discuss the slight risk posed by the radiation exposure and the possibilities of false positives.
Prospect of anxiety
False positives are common, he said, because the scans cannot yet accurately differentiate between signs of disease or other benign lumps and bumps in the body.
He has seen firsthand the anxiety that patients have gone through when they receive a scan that suggests something is wrong.
"We had a patient come in from Holistica with a nodule, a benign looking (lung) nodule," Yoon said, "and we told him, 'Listen, we think we should just follow you up because this is probably going to be a nothing nodule.' He insisted on having a biopsy, so we biopsied him. Fortunately, he didn't have any complications; the biopsy came back negative.
"In most people, in nine out of 10 ... those things are going to be benign, they're not cancer. If we biopsy those things, if we do something invasive, then we increase morbidity and occasionally we get a mortality. If we're going to cause 10 complications for every one life we save, then it's very doubtful that that's a very useful thing."
Holistica manages the possibility of false positives by giving its clients specific recommendations for further tests, said Dr. Fredric Pashkow, director of The Queen's Medical Center's Heart Institute, who also works with Holistica.
"With regard to high coronary calcium scores, we tell the client that the next step should be a non-invasive study that should only lead to further tests or invasive therapy only if strongly positive. By the way, the FDA warning is unfair to consumers in that it doesn't tell them how reliable the test is when it's negative and how useful this information can be."
As the debate churns, the potential peace of mind offered by the scans is spreading by word of mouth.
"We have about 60 guys in our golf group over here — they're all my age or older and there's probably a steady stream of them going," said Brad Hill, who got his warning sign from Holistic last month.
Hill said he was aware of the debate, but chose the peace of mind offered by a scan.
"I could have been laying out on the golf course on the ninth hole with a major heart attack because my physical was just fine," Hill said.
This weekend he's resting up after his surgery — but he hopes to get back on the golf course tomorrow.
Reach Alice Keesing at akeesing@honoluluadvertiser.com or 525-8014.
