How Important Are Screenings and Self-Exams

Let's rephrase that question. What is the most important thing in your life? Your spouse? Your grandchildren? That little sports car you just bought? (Just because you are over 60 doesn't mean that you have to slow down.) Screenings and self-exams are just as important. They protect you from cancer, heart disease, and stroke—and make it possible for you to enjoy the good things in your life.

But you don't want to walk into your doctor's office and ask for every test in the book. Some tests just aren't worth taking. Here is a rundown of what you do and don't need.

Blood Pressure Screening

"Testing for high blood pressure is at the top of the list of needed tests," says Timothy A. McAfee, M.D., associate director of preventive care at the Group Health Cooperative of Puget Sound in Seattle, the
nation's oldest and largest consumer-governed health maintenance organization (HMO). High blood pressure damages artery walls and dramatically increases your risk of heart disease and stroke.

It is easy enough to get a reading on the machine at the drugstore or take your own reading at home, but this test also is part of just about any visit to your doctor's office. Your doctor will place an inflatable cuff on your upper arm. When the cuff tightens, the doctor will get a reading of how forcefully your blood is being pumped by your heart. According to the American Heart Association, acceptable blood pressure falls within a range rather than a set number. For most adults, a reading that is less than 140/90 millimeters of mercury (mmHg) is good news. Talk to your doctor about what is a good blood pressure for you to aim for.

Blood pressure goes up and down over the course of the day, so a random reading may not be accurate. Here is how to get the best reading, says Lawrence LaPalio, M.D., medical director of geriatrics at Columbia La Grange Memorial Hospital in La Grange, Illinois.

Control consumption. Avoid stimulants that speed your heart rate, such as coffee or alcohol. A drink the night before can interfere.

Get comfortable. Five minutes before the test, sit in a comfortable, relaxed position with your arm at heart-height. Rest quietly.

Take the average. Ask your doctor to take several readings and average them. Get a reading before you head for home—you may be more relaxed. Or average the readings taken over several office visits.

Beware of the white coat. For some people, just being in the doctor's office causes nerves to surge and blood pressure to rise. "Unfortunately," says Dr. LaPalio, "if your blood pressure rises due to stress in the doctor's office, it may also rise in response to everyday events. If it goes up every time you drive in traffic or go to a new place, it should be treated."

Get the full picture. For high blood pressure, go for treatment immediately, says Dr. LaPalio. If you have mild to moderate blood pressure readings, get the true picture by monitoring your own blood pressure for a month or so. Follow this routine recommended by Dr. LaPalio.

Check it morning, noon, and night. Measure your blood pressure at different times of the day.

Use your moods. Measure when you are stressed, relaxed, happy, depressed, and active.

Keep a diary. Write down the readings, the time, and other relevant factors—what you ate and drank, if you exercised, if you took medications, and what you were doing when you took the measurement.

Breast Examination and Mammography

"A yearly mammogram and professional breast examination plus a monthly self-examination can reduce your risk of breast cancer death by a third," says Joseph Aisner, M.D., director of clinical sciences at the Cancer Institute of New Jersey in New Brunswick. "Every woman age 50 and over should have an annual screening."

You need all the parts to get the whole picture: Tumors that distort the breast's structure or have calcium often show up on a mammogram. Physical examinations, by you and your doctor, can pick up what the mammogram misses. While this trio may not find all cancers, their use provides earlier diagnosis and saves lives.

For a mammogram the breast is compressed between two plates, which may be a little uncomfortable. A low-dose x-ray records two or three images of the tissues. Your doctor will also feel for any lumps in the breast as part of your annual physical examination.

Your risk of breast cancer increases as you get older. There is some controversy over whether screenings are needed, because few studies have been done of the over-60 population, but "from an individual's point of view, it makes sense to continue to get mammograms," Dr. McAfee explains.

Breast cancer is the most common cancer among American women. What can screening do? A 20-year study of breast cancer published by the American Cancer Society showed that screening results in a survival rate of 86 percent in women diagnosed with breast cancer.

Dr. Aisner suggests these methods for getting the best results from your examination.

Check for quality. Make sure that the facility you go to for a mammogram is accredited by the American College of Radiology. That tells you the machinery is adequate and the staff is trained.

Make one trip. Use a facility that develops the pictures on the spot. That way, if there is a problem with the film, the technician can reshoot. You don't have to return for a second test.

Tune your technique. Ask your doctor or nurse to show you exactly how to perform a self-exam. Or ask for a referral to a class, especially one where you can learn by using a "phantom," a silicone model in which several tumorlike BBs have been implanted. You can learn what to feel for in your own breasts.

Cervical Screening

"Pap smears have reduced death from cervical cancer by more than 95 percent in the past 35 to 40 years," notes Dr. Aisner. Yet, a lot of women stop getting this important test as they get older—not a good idea.

In this relatively painless test your doctor inserts a speculum into the vagina, opens it to reveal the cervix, and takes a small sample of cells from the vagina and the cervix. The cells are examined for cancer.

Here's what you need for protection.

Test further. Unless you have had a full or partial hysterectomy, your doctor should get samples both from the vagina and from the endocervix, which is the cervix at its opening, says Dr. Aisner. In premenopausal and menopausal women an endocervical sample is necessary. In postmenopausal women it may not be possible to obtain an endocervical sample, he says. A vaginal Pap smear isn't always enough because the most common site for cancer is at the opening to the cervix.

Do a background check. Ask your doctor what tests were done and what the results were in your previous three exams. If they were interpreted as adequate and normal, you may need exams only once every three years. Otherwise, continue with yearly screenings, suggests Dr. Aisner.

Cholesterol Testing

Think of cholesterol as fat that comes in two forms. LDL (low-density lipoprotein) cholesterol latches onto artery walls and over time narrows them, thus increasing risk of heart attack and stroke. HDL (high-density lipoprotein) cholesterol is the good stuff that keeps the LDL in check. Protect yourself with low levels of total cholesterol and LDL, plus high levels of HDL. You'll need to donate just a very small sample of blood for a lab test to determine your levels of each.

A long-term study completed in 1992 indicated that people with HDL levels below 35 milligrams per deciliter (mg/dl) had a risk of dying from heart disease that was three times as high as for those with levels greater than 60 milligrams per deciliter. Low levels of total cholesterol, with a ratio of total cholesterol to HDL below 4.5, also protects you. In women, total cholesterol levels above 240 milligrams per deciliter increase risk of dying from heart disease by 80 percent.

Inexpensive home test kits give you the total cholesterol but not the level of important HDL cholesterol. Still, these tests may provide a starting point for you and your doctor to determine your risk, says Dr. LaPalio. If your doctor thinks that you are at risk for heart disease, more expensive cholesterol testing for HDL and total cholesterol will probably be covered by Medicare or other insurance.

Your cholesterol level varies. Ask your doctor to give you a second test one week to two months after the first. Average the results. If the difference between the two is over 30, take a third test and pool the three. Here's how you can make your readings more accurate, suggests Dr. LaPalio.

Take a seat. Sit down for between 5 and 15 minutes before your test. Standing up or lying down can affect the readings.

Keep it low-key. Don't do strenuous exercise the day before your test—it will temporarily elevate HDL levels.

Stay alcohol-free. Stay away from alcohol for 48 hours before your test—it artificially raises HDL levels.

Colon and Rectal Screening

"Screening decreases colon cancer mortality. It can have the same life-extending benefits as breast cancer screening," says James E. Allison, M.D., clinical professor of medicine and assistant director of the internal medicine program at the University of California, San Francisco.

Colon cancer is the third leading cause of cancer death in the United States for men and women, despite the fact that this cancer often starts out as a benign polyp. Screening can make the difference. Here's advice for getting reliable results.

Take a sample. There are several ways to get a fecal occult-blood test. One involves the doctor taking a smear sample as part of your physical examination. Another test can be done at home using a kit from your doctor. You just wipe a stool sample on pieces of cardboard that are then analyzed by a laboratory.

Watch what you eat. Chemicals in the test kit react to some foods, says Dr. Allison. To get an accurate reading, change your diet a few days before the test. Stay away from red meat, turnips, horseradish, broccoli, radishes, cauliflower, cantaloupes, and other melons. But do eat lots of other fresh vegetables and fruits—it will help stimulate bleeding from lesions, which helps ensure that they will show up on the test.

Avoid conflicts. Test results may be skewed by vitamin C supplements (which will give false negatives), and aspirin and other nonsteroidal anti-inflammatory drugs (which will give false positives). Avoid medication that can cause gastrointestinal bleeding. If your hemorrhoids are flaring up, wait until they quiet down, suggests Dr. Allison.

There is a newer home test available at drugstores without a prescription that uses a specially treated pad that you drop into the toilet after a bowel movement. The manufacturer of one such test, EZ-Detect, says that there are no diet constraints and that the test results are not affected by vitamin C.

Many tests—both the off-the-shelf type and those available from your doctor—give a lot of false positives. They just look for blood in the feces, which could be caused by hemorrhoids, diverticulosis, or a host of other conditions. And no fecal occult-blood test picks up nonbleeding cancerous lesions.

Still, this is a test worth taking because it is very inexpensive—under $20 for the lab work. Even if you have to pay for the test, a positive reading means that the more expensive tests that give you maximum protection will probably be covered by Medicare and other insurance.

Take a look. Okay, now we are into the stuff that you don't want to read about: flexible sigmoidoscopy. And both men and women need to go through this about every three to five years, says Dr. Allison. In this procedure a thin, hollow lighted tube is inserted into the rectum and lower colon. There, it picks up precancerous polyps and removes them before they turn dangerous. (That development usually takes several years.) The device also spots cancerous lesions.

The downside is that it views only one-third of the length of the large intestine's left side, although that is where many cancers develop, notes Dr. McAfee. But this test is much less expensive and less uncomfortable than the more thorough colonoscopy.

Be thorough. "I think colonoscopy is probably the best screening examination," says Dr. McAfee. That is because the thin tube travels the length of your entire large intestine, allowing your doctor to snip off any polyps and identify any cancerous formations. So what if it is more uncomfortable than the other tests? Since colon cancer takes so long to develop, "you're home free for 5 to 10 years, maybe longer," he says.

Diabetes Screening

"Forty percent of people over age 65 have diabetes. It is a significant risk factor for heart disease," says Dr. LaPalio. When you have diabetes, the extra sugar in your blood tears up artery walls and leaves them more vulnerable to fatty deposits and blockages. How serious is one more risk factor? When you have three or four risk factors—like high blood pressure, high cholesterol levels, being overweight, lack of exercise, being a smoker, or having a family history of heart disease—you are 15 to 20 times more likely to develop heart disease than someone with just one risk factor.

Talk about easy—testing only requires one drop of blood. Ask your doctor to test levels of sugar in your blood if you show symptoms of diabetes: if you're overweight, get thirsty often, urinate more frequently than you used to, or just don't feel well, advises Dr. McAfee.

Electrocardiogram

An electrocardiogram gives a printout of your heart's activity. It lets you know whether your heart is working efficiently. But you need it only if you already have heart disease or risk factors for heart disease.

"It's reasonable to have this test if you have a family history of heart disease, if you smoke, if you have diabetes or are hypertensive," says Dr. McAfee. Medicare usually covers it.

Lung Cancer Screening

"We don't recommend chest x-rays or any screening for lung cancer anymore," says Dr. McAfee. Studies show that by the time you can see a lesion on an x-ray, it has already spread too far. Also, doctors worry that clean x-rays lull smokers into a false sense of security.

Oral Cancer Screening

You're at risk for oral cancer if you have been a tobacco user or if you have a history of alcohol consumption. "I've never seen oral cancer in a patient who didn't smoke or drink," says Dr. McAfee. All the same, he notes, there is no reason not to make this part of your visit. Your doctor will simply perform a visual check of the inner workings of your mouth to look for suspicious-looking growths or lesions.

Ovarian Cancer Screening

Your doctor may recommend an ultrasound examination if you have a close relative who was diagnosed with ovarian cancer at a young age, says Dr. McAfee. Since your family history puts you at extra risk, your insurance will probably foot the bill. In this test a probe is inserted into the vagina, transmitting images of the uterus and ovaries to a monitor. Your doctor will look for changes in the cells lining the ovaries.

Prostate Cancer Screening

Eighty percent of prostate cancer cases are diagnosed after age 65, and 40,000 men die from it every year. Testing is a simple two-part affair: Your doctor will perform a rectal exam to check the prostate. And a blood test, called the PSA (prostate-specific antigen) test, will measure levels of a protein produced by the prostate.

Many doctors do not actively recommend screening for prostate cancer, however. Screening is controversial because the disease develops slowly. Most men never experience any symptoms, and only 1 in 380 men diagnosed with prostate cancer die of it. "Right now, we don't know that prostate surgery increases your chances of staying alive," says Dr. McAfee. "I'd avoid this test like the plague."

Further complicating matters, biopsied tumors that look dangerous under the microscope sometimes turn out to be slow-growing. And tumors that look easy going can suddenly shift into high gear, says Gerald W. Chodak, M.D., director of the Prostate and Urology Center at the University of Chicago Hospitals.

Even health organizations end up on opposite sides of the fence: The American Cancer Society recommends testing. The National Cancer Institute doesn't but has the question under study.

Dr. Chodak suggests considering these factors when deciding whether to test for prostate cancer. Get tested if:

* You want to minimize your risk of cancer and increase your chances of living as long as possible, regardless of side effects from prostate surgery or radiation, which can include impotence and incontinence.

* You expect to live for another 10 to 15 years.

* You and loved ones can handle the psychological burden of watching and waiting—one option for some slow-growing tumors.

Just say no if:

* You're more interested in the quality than the length of your life.

* You want to minimize your risk of complications from treatment to eradicate the tumor.

* You only want to take tests that have been proven effective. Prostate screenings miss 20 to 30 percent of cancers.

Skin Cancer Screening

"The difference between life and death is one-eighth of an inch," says Perry Robins, M.D., president of the Skin Cancer Foundation in New York City. We're talking not about that time you almost walked in front of the fast-moving truck but about minute changes in the moles and freckles that dot your body. Freckling occurs when the skin gets suddenly baked by the sun. Moles are malformed skin tissue. Little changes in these spots can signal the onset of malignant melanoma, a skin cancer that can be cured easily in its early stages but that quickly spreads.

Examine your body—from the top of your scalp to the bottom of your feet—twice a year. If anything looks suspicious, consult your doctor.

You're at extra risk if you spend a lot of time indoors and then go out and get "burned and blasted" by the sun, says Dr. Robins. "It's the sudden shock or intense exposure to sun that increases your risk." Also at risk are those who had bad sunburns as children or who sunburn easily or who have a family history of the disease. If you are in the high-risk group, ask your doctor to do a yearly skin check for you, says Dr. Robins. He will be able to get a better look at hard-to-see places.

For starters, you'll want to know the ABCs—and Ds—for skin cancer detection. The Skin Cancer Foundation has developed a self-exam guide called "The ABCDs of Moles and Melanomas."

A is for asymmetry. An irregular shape is a sign of trouble.

B is for border. Beware of irregular, scalloped, or notched borders.

C is for color. Different shades of brown or black signal a problem.

D is for diameter. Anything larger than the size of a pencil eraser may indicate a melanoma.

Here are other ways to detect trouble brewing.

Keep count. Count your moles. You're at risk if your total exceeds 100.

Check for changes. Keep a record. Use two line drawings of the human body, one of the back view and one of the front to make a chart (or ask your doctor for illustrations you can use). On the drawings make marks that correspond to the location of moles on your body. Draw a line from the mark to the margin and write down the size, color, and shape of each mole, along with the date of the examination. Use the chart to keep track of changes when you do your next self-examination.

Stroke Screening

A stroke fells someone in the United States every minute. Thirty-one percent of stroke survivors need long-term help to care for themselves. Fortunately, many people experience symptoms before a stroke. Here is what you and your doctor should look for.

Heed the mini-stroke. Your body does the screening for you. About 10 percent of strokes are preceded by transient ischemic attacks, or mini-strokes. Symptoms, which may last just a few minutes, include blurred vision, numbness or weakness on one side of the body, slurred speech, inability to talk, or difficulty in thinking. All these symptoms shout out that your brain isn't getting the blood supply it needs, says Dr. McAfee.

Beware the bruit. Your doctor can also use a stethoscope to listen to the carotid arteries on either side of the neck that carry blood to the brain. A soft, whooshing sound (called a bruit and pronounced BRU-ee) may indicate blockage in the arteries, says Dr. LaPalio.

If your doctor hears the sound, he will probably do an ultrasound test, using sound waves to provide a picture of the inside of the arteries.

Okay so far. But here's the problem: The surgery that is used to clear the blockage can also cause a stroke. And the jury is out on just how effective such surgery is. "So far, one good study has shown that screening in certain select populations and then operating on the carotid artery does lower the stroke rate, but we need to know more," says Dr. McAfee.

If surgery isn't your cup of tea, now is the time to make changes in your lifestyle to lower your risk of the big one.

Prescription for Prevention

Having the right screening tests can dramatically cut your risk of heart disease, cancer, and stroke. They can let you know if you need to make protective changes in your lifestyle and identify small problems before they mushroom out of control.

Do:

* Get your blood pressure checked yearly.

* Have yearly breast examinations and mammography screenings.

* Check your HDL and LDL cholesterol levels every year.

* Get a Pap smear every year.

* Use an inexpensive fecal occult-blood test to check for colon cancer.

* Have a sigmoidoscopy done every 3 to 5 years or a colonoscopy done every 10 years.

* Get a simple blood test to check for diabetes.

* Check your skin for changes.

Don't:

* Automatically get every test in the book. Discuss the positive and negative aspects of some tests, such as those for prostate cancer.