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Routine tests for various conditions can often result in false-positives, raising questions about when screening is really necessary.
Early detection can be the first line of defense against a potentially serious disease, but even common tests such as mammograms and electrocardiograms sometimes give false-positive results. These “false alarms,” in which a disease or condition is mistakenly diagnosed, can lead to more tests, unnecessary treatments and long-lasting psychological consequences. That raises important questions for patients and doctors about when the risk of a false-positive may actually outweigh a test’s benefits.
According to the Susan G. Komen for the Cure foundation, the risk of false-positive mammogram results is as high as 61 percent. Researchers at the University of Copenhagen in Denmark reported that women who receive false-positive mammograms can suffer the same psychological effects as patients who are diagnosed with cancer — and the effects are still felt years after those women are found cancer-free.
“It is well known that a person’s values and perceptions of life can change as a result of trauma and existential crisis,” the researchers wrote. “Women with false-positives reported changes just as great in existential values and inner calmness as women with breast cancer.”
Still, that doesn’t mean women should avoid having mammograms. The National Cancer Institute recommends that all women age 40 and over have a mammogram every one to two years. As Elisa Port, MD, co-director of the Dubin Breast Center of the Tisch Cancer Institute at Mount Sinai, points out, “the risk of dying from breast cancer when you do annual mammograms decreases by 15 percent.”
On the other hand, experts argue against widespread use of EKGs to reduce sudden cardiac deaths. The reason: It would result in too many false-positives to have a significant impact.
According to the American College of Sports Medicine, some 100 young athletes die suddenly on the field every year and the cause is often hypertrophic cardiomyopathy, a sometimes asymptomatic condition involving a thickening of the heart and obstructed blood flow.
Hypertrophic cardiomyopathy is easily detected with an EKG, yet the test is not part of routine screenings for young athletes in this country.
Why not?
Part of the problem, according to Scott Rodeo MD, co-chief of the sports medicine and shoulder service at the Hospital for Special Surgery and associate team physician of the New York Giants, is that physicians don’t know enough about the differences between the hearts of athletes and non-athletes to justify widespread EKG use.
Rodeo points to athletic heart syndrome — a condition where significant aerobic exercise enlarges the heart. While an enlarged heart is typically the sign of a serious medical condition, athletic heart syndrome is generally considered benign. As a result, Rodeo said, “we may see more false positives than actual positives.”
The American Heart Association is reluctant to recommend routine use of EKG screenings, stating in its guidelines that false-positives would result in “unnecessary anxiety among substantial numbers of athletes and their families, as well as the potential for unjustified exclusion from competition.”
Then there is the matter of cost. The AHA estimates that a national program designed to screen all athletes would cost $2 billion annually. Of course, any parent of a young athlete will tell you that no cost is too great if such a program can help save lives.
Rather than institute a blanket screening policy for tests like EKGs, Daphne T. Hsu, MD, division chief or pediatric cardiology and co-director of the pediatric heart center at the Children’s Hospital at Montefiore Medical Center, thinks doctors should be more precise in who they screen.
“Many of these diseases are inherited,” Hsu said. “If you have something pop up on a physical or in the family history, then the EKG should be done.”
Another test with a high risk for false-positives is the PSA test for prostate cancer. According to the National Cancer Institute, 75 percent of all PSA positives turn out to be false-positives and "the benefits, if any, are small and the harms can be substantial.”
The reason is that the test looks at PSA protein levels in the blood; and while a high PSA level makes it more likely that a man has prostate cancer, that’s not the only reason why the levels may be up.
“A man can have inflammation of the prostate, which would cause a high PSA, but that doesn’t mean they have prostate cancer,” said Pascal James Imperato, MD, dean and distinguished service professor at SUNY Downstate Medical Center’s School of Public Health. “The test is not highly sensitive for just prostate cancer, despite what many people think.”
False-positives are an unfortunate part of screening, and any test that doctors administer can sound a false alarm. “Anxiety regarding inconclusive test results is real and is only natural,” said Shawn Farley, director of public affairs from the American College of Radiology. But fear of false-positives should not dictate the best course of action.
Family history, age and other risk factors need to be considered when deciding whether a test should be performed. Doctors should discuss the possibility of false-positive results up front, and patients dealing with the effects of a false-positive may need special counseling. Ultimately, the benefits of any testing need to be weighed on a case-by-case basis.
Early detection can be the first line of defense against a potentially serious disease, but even common tests such as mammograms and electrocardiograms sometimes give false-positive results. These “false alarms,” in which a disease or condition is mistakenly diagnosed, can lead to more tests, unnecessary treatments and long-lasting psychological consequences. That raises important questions for patients and doctors about when the risk of a false-positive may actually outweigh a test’s benefits.
According to the Susan G. Komen for the Cure foundation, the risk of false-positive mammogram results is as high as 61 percent. Researchers at the University of Copenhagen in Denmark reported that women who receive false-positive mammograms can suffer the same psychological effects as patients who are diagnosed with cancer — and the effects are still felt years after those women are found cancer-free.
“It is well known that a person’s values and perceptions of life can change as a result of trauma and existential crisis,” the researchers wrote. “Women with false-positives reported changes just as great in existential values and inner calmness as women with breast cancer.”
Still, that doesn’t mean women should avoid having mammograms. The National Cancer Institute recommends that all women age 40 and over have a mammogram every one to two years. As Elisa Port, MD, co-director of the Dubin Breast Center of the Tisch Cancer Institute at Mount Sinai, points out, “the risk of dying from breast cancer when you do annual mammograms decreases by 15 percent.”
On the other hand, experts argue against widespread use of EKGs to reduce sudden cardiac deaths. The reason: It would result in too many false-positives to have a significant impact.
According to the American College of Sports Medicine, some 100 young athletes die suddenly on the field every year and the cause is often hypertrophic cardiomyopathy, a sometimes asymptomatic condition involving a thickening of the heart and obstructed blood flow.
Hypertrophic cardiomyopathy is easily detected with an EKG, yet the test is not part of routine screenings for young athletes in this country.
Why not?
Part of the problem, according to Scott Rodeo MD, co-chief of the sports medicine and shoulder service at the Hospital for Special Surgery and associate team physician of the New York Giants, is that physicians don’t know enough about the differences between the hearts of athletes and non-athletes to justify widespread EKG use.
Rodeo points to athletic heart syndrome — a condition where significant aerobic exercise enlarges the heart. While an enlarged heart is typically the sign of a serious medical condition, athletic heart syndrome is generally considered benign. As a result, Rodeo said, “we may see more false positives than actual positives.”
The American Heart Association is reluctant to recommend routine use of EKG screenings, stating in its guidelines that false-positives would result in “unnecessary anxiety among substantial numbers of athletes and their families, as well as the potential for unjustified exclusion from competition.”
Then there is the matter of cost. The AHA estimates that a national program designed to screen all athletes would cost $2 billion annually. Of course, any parent of a young athlete will tell you that no cost is too great if such a program can help save lives.
Rather than institute a blanket screening policy for tests like EKGs, Daphne T. Hsu, MD, division chief or pediatric cardiology and co-director of the pediatric heart center at the Children’s Hospital at Montefiore Medical Center, thinks doctors should be more precise in who they screen.
“Many of these diseases are inherited,” Hsu said. “If you have something pop up on a physical or in the family history, then the EKG should be done.”
Another test with a high risk for false-positives is the PSA test for prostate cancer. According to the National Cancer Institute, 75 percent of all PSA positives turn out to be false-positives and "the benefits, if any, are small and the harms can be substantial.”
The reason is that the test looks at PSA protein levels in the blood; and while a high PSA level makes it more likely that a man has prostate cancer, that’s not the only reason why the levels may be up.
“A man can have inflammation of the prostate, which would cause a high PSA, but that doesn’t mean they have prostate cancer,” said Pascal James Imperato, MD, dean and distinguished service professor at SUNY Downstate Medical Center’s School of Public Health. “The test is not highly sensitive for just prostate cancer, despite what many people think.”
False-positives are an unfortunate part of screening, and any test that doctors administer can sound a false alarm. “Anxiety regarding inconclusive test results is real and is only natural,” said Shawn Farley, director of public affairs from the American College of Radiology. But fear of false-positives should not dictate the best course of action.
Family history, age and other risk factors need to be considered when deciding whether a test should be performed. Doctors should discuss the possibility of false-positive results up front, and patients dealing with the effects of a false-positive may need special counseling. Ultimately, the benefits of any testing need to be weighed on a case-by-case basis.