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Contents 1 Overview 2 Articles 2.1 19-Dec-2007 - ‘I wouldn’t be here today if I hadn’t had a scan’ 3 Disclaimer 4 E&OE - Errors & Omissions Excepted

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19-Dec-2007 - ‘I wouldn’t be here today if I hadn’t had a scan’

‘I wouldn’t be here today if I hadn’t had a scan’

REBECCA McQUILLAN December 19 2007

Delia Story with her husband, Brian. Delia paid £600 for a private CT body scan which detected a Tumour in her Kidney.

For Delia Story, the issue is cut and dried: if she hadn't had a CT Scan, she would almost certainly be dead. "I'd suffered from tummy aches all my life," says the 64-year-old. "I'd seen an advert about body scans in the paper and cut it out and kept it. We had been in America and it is medicals, medicals, medicals on the TV over there. So I said to my husband, Brian, I would have it done, just to see."

Delia opted for a "body" CT (computed tomography) scan, with "an extra look in the bowel". CT uses X-rays to produce computerised images. The "body" scan, as described in the Lifescan brochure, captures X-ray images from the collar bone to the pelvis and combines bone density, heart and lung scans, plus scans of the abdomen and pelvis. It cost Delia £600.

She had the scan, returned home and was hardly through the door when the phone rang. "It was the doctor saying I'm afraid you've got a large mass on your left Kidney'," Delia remembers.

Shaken, Delia went to her doctor, who sent her straight to hospital. She was initially told she'd be scheduled for surgery two weeks later, but the consultant opted to bring it forward a week. It wasn't a moment too soon. The Tumour was aggressive, 4.5" square and, in another week, would have started attacking the Kidney's blood vessels, which might have led to her death.

The symptoms - tummy aches and constipation - turned out to be unconnected to the cancer, which was symptomless. "I had no blood in my urine, no pain in my lower back," says Delia. But what she did have was a family history of the illness.

"My eldest sister died eight years ago of Kidney Cancer. If Lifescan had been available eight years ago, my eldest sister would have gone for a scan." As it was, Delia pushed her other two sisters to have the scan - and they, too, discovered abnormalities - her sister, Celia, being diagnosed with bowel cancer and her sister, Patricia, in America with a kidney tumour. It's scarcely any wonder that Delia has become an evangelist for CT body scans. "I just wouldn't be here if I hadn't had it," she says.

The popularity of such scans is on the increase and they are presented as a way to achieve "peace of mind". The brochure for Lifescan, for instance, says: "We can give you reassurance at a very affordable price". The scans are either body (torso) or specific to certain areas, such as the lungs, heart or colon.

But not everyone is unequivocal about the benefits of CT Scans for people with no symptoms. Today, Comare (the Committee on Medical Aspects of Radiation in the Environment) releases a report, commissioned by the government, on the impact of CT scanning on such individuals (who are also known as asymptomatic).

Comare concludes that the government should consider regulating commercial CT services. Its views on particular scans vary. For instance, it agrees that cardiac CTs, to detect calcium in the coronary arteries, "has been shown to have value for predicting cardiovascular risk" and CT colonoscopy "has the potential to detect small lesions", though it recommends these procedures only for certain people.

But it is less positive about body and lung scans. Body scans are hard to "optimise", says the report - in other words, the best results are achieved at low doses using specific scanner settings for specific organs; if you are doing several organs at once, the setting may be ideal for one organ, but not as effective for others. This tends to increase the prevalence of false positives (where the result is positive, but the person doesn't have the condition). While scans can throw up "wholly unexpected findings", Comare argues that there are significant downsides, so much so that it "strongly recommends" services offering whole body CT scanning of asymptomatic people should be stopped, as there is little evidence to show "the benefit outweighs the detriments". It continues that CT Scanning of the lungs should also be stopped because, on current evidence, there is "no benefit" from it. Finally, it says CT Scanning primarily for spinal conditions, osteoporosis and body-fat assessment should also cease, since there are more appropriate methods of assessing those things.

Comare's concerns focus on the radiation dose delivered by CT Scans (the exposure has to be justified by the potential for substantial benefits); the number of false results or inconclusive findings, which have psychological and physical implications; and the cost to the NHS of doing follow-up investigations that turn out to be unnecessary.

Excess cancer risk, Comare agrees, has not been found at doses below 100millsieverts (mSv), which is much higher than delivered by a CT Scan. According to Comare, "a typical CT Scan" with an effective dose of 10mSv (some are much lower than that) is associated with a fatal cancer risk of one in 2000 over a lifetime. But, it says, the public health impact is "not negligible" in terms of excess cancer cases. The report claims that if 100,000 people underwent a CT Scan every five years from ages 40 to 70, then there would be around 240 extra deaths among them. If the scans were every two years, the figure would be 600; and if they were annual, 1200.

Patients, the committee says, assume the scans will be accurate and conclusive. But the problem is that sometimes they are not: as well as false results, they can show up abnormalities "of unknown clinical significance" which require further investigation, such as more CT Scans or surgery. This is particularly true of body scans, where "in excess of a third will undergo investigations for findings which will turn out to be of no health consequence but which themselves carry risk".

The committee believes that clients going forward for scans are given "inconsistent and incomplete" information. It recommends that the radiation risk, the rate of false positives and negatives, and particularly the likelihood of further procedures with their associated risks, should be outlined on websites and advertising.

Dr John Giles, the medical director of Lifescan, welcomes Comare's findings on the value of colonoscopies and heart scans, saying that 5-8% of Lifescan's clients are found to have "significant colon polyps" and that false positives are around 2-3%. He says that Lifescan seeks to identify only those people who are in the top 25% in terms of risk for the procedure. While Lifescan's brochure does offer a "body" scan, he says that this is actually three separate scans of the heart, lung and colon.

But he has concerns about the report, too. "I disagree with the concept of not offering lung scans," he says, adding that there are studies suggesting that lung scans, to detect early stage lung cancer, for instance, can be beneficial. "I admit there is no proven data one way or the other - that is, no double-blind randomised controlled trials - but I believe it should be a matter of personal choice." He believes that the rationale for recommending that lung scans should not be offered is "financial rather than clinical".

Comare is confident that the bulk of opinion about radiation risks is in its favour. But Dr Giles argues that the benefits of scanning are very significant: in the sample of 100,000 where 240 could be expected to die as a result of the scan radiation, he claims some 5000 lives could in fact be saved as a result of certain scans. Some 30,000-40,000 people have had scans with Lifescan in five years: "approximately 10% have had a significant impact on their lives and half of that 10% are alive today because of the scan".

He believes some criticisms are politically motivated. "There are people out there who don't like the idea of something that's beyond their control, a service that is better than what's provided by the state system," he says. He stresses that no excess cancer risk has been found at doses below 100mSv, far beyond what a scan would deliver, and believes that the risk posed by scanning radiation is "overstated, and, if you like, scaremongering, by people who have an objection to the concept of private medicine".

As for the prospect of regulation, Dr Giles responds that radiology is "already more regulated than any other branch of clinical medicine".

Dr Peter Mace, medical director at BUPA Wellness, says that BUPA does not offer lung scans anyway. "There isn't enough evidence," he says. Nor does BUPA offer body CT Scans or MRI Scans. "Our whole ethos is that we need to offer proven benefits or that there are likely to be benefits, and we just couldn't find that for CT Scans. The problem is the false positive results."

BUPA does offer heart scans and CT colonoscopies to those over a certain age, or where the client has certain risk factors because "the evidence seems to stack up".

Dr Mace would prefer a voluntary code of practice to regulation, as "there should be some element of personal choice". Any moves effectively to ban a procedure, he feels, would be wrong. But he thinks there is probably room for improvement among private scan providers in the way that decisions are taken about doing scans.

Comare says that as more research is published and the scanning technology evolves so that radiation doses decrease and false positives and negatives are reduced, its advice could change. But for now, it has made its views clear. The government must decide where to draw the regulatory line.

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