Ready for a Close-Up

The good life is what brought David Clark to the Beverly Hills office of radiologist Stephen Koch. Good food and drink, tobacco and any other pleasant poison the 42-year-old ran through his system before thinking much about health.

“Hey, I smoked a pack a day for six years, back when I was in my teens, and I still like to go out; I like my martinis,” says Clark, a business consultant living in Santa Monica. “And I’m thinking, ‘Have I screwed myself up? Am I going to have to write my obituary now?’ ”

It’s that kind of morbid curiosity, along with some shrewd marketing, that has put Southern California out front of yet another controversial health trend: full-body CT scans to search for hidden disease.

The appeal of the scans is easy to understand. The machines use computed tomography, or CT, to produce X-ray cross-sections of the body that are much clearer than traditional X-rays and allow doctors to zoom in on abnormal-looking spots. The test is quick and painless, and 20 minutes later you’re sitting by a computer screen, watching a virtual tour of your own body. “ ‘Star Wars’ stuff,” says Robert Antin, 50, a Marina del Rey executive who visited Koch the same day Clark did.

Despite doctors’ warnings that the scans are unjustified in healthy people, programs such as Koch’s InsideTrac, and similar ones at Parkview Imaging in Santa Monica and Healthview Center for Preventive Medicine in Newport Beach, are packing them in. Thousands of men and women have been screened, many of them middle-aged professionals, and some swear the technology saved their lives.

“There’s no question about it for me,” says Richard Stone, a 58-year-old real estate investor from Santa Monica, whose InsideTrac scan found a 3 1/2-centimeter node on his left kidney. Stone had the kidney removed, and doctors confirmed the lump was cancerous. “I’ve had no spreading, no lymph node involvement, no chemotherapy, nothing. And I’m fine. I think the full-body scan is one of those things you can’t afford not to do.”

Don’t forget your checkbook, though. Most insurers don’t cover the $800 to $1,500 price tag, for the same reason doctors are skeptical of widespread CT screening: There’s little evidence that full-body scans of healthy people are cost-effective, compared with standard, and far cheaper, means of detecting disease, such as blood pressure monitoring and mammograms.

For every Richard Stone, doctors say, there will be patients for whom the scans find suspicious-looking spots that turn out to be nothing, putting people on a treadmill of follow-up tests for no good reason. And even a clean CT scan may have unintended consequences, if it encourages people to ignore the usual advice about exercise, diet and regular physicals.

“The marketing is simply way ahead of the science on this--more so that any other testing in medicine that I know about,” says Dr. Howard Hodis, who’s doing a study of CT scans and heart disease at the USC School of Medicine. “I wonder whether people who are having the scans know what they’re getting.”

A full-body CT involves several scans, Koch says. One runs from the neck through the pelvis and can pick up all sorts of odds and ends, from kidney stones to small tumors to abdominal aneurysms. Herniated, or “slipped,” discs often show up, radiologists say; small cancers of the skin, prostate and breast usually do not. The pictures may also detect organ inflammation or deformities, but doctors say they tell you little or nothing about how most organs are functioning--whether you’re beginning to stress your liver, for example, or eroding your stomach lining.

If it’s truly comprehensive, radiologists say, a full-body CT should also include separate scans for three things in particular: spots on the lung, spots on the colon and arterial calcium, which is often associated with heart disease. These three findings account for the vast majority of referrals coming from whole-body clinics, doctors say. “CT scans of the lung, colon and heart are the three tests that are the most thought-out,” says Dr. Sanjay Saini, director of CT services at Massachusetts General Hospital, “and you must look at each one separately.”

Usefulness Differs According to Risks

The first thing to know about lung cancer is its predominant risk factor: smoking. Many radiologists consider CT scans a good idea for people who have smoked about a pack a day for 10 years. “I recently did one for my father, who has smoked for many, many years,” says Saini. “You get much better images from a CT scan than you do from a chest X-ray.”

In a recent study of 1,000 longtime smokers, for instance, doctors found that 233 had a nodule on their lung scan that looked like it could be cancerous. Further scanning picked up 27 that were malignant, only seven of which showed up on chest X-rays.

“The malignant tumors they found were mostly in an early stage, which we believe makes them easier to cure,” says Dr. Paul Selecky, director of pulmonology at Hoag Memorial Hospital in Newport Beach and spokesman for the American Lung Assn. “So that’s very good news.”

But the other 206 suspicious-looking nodes were benign, mostly scars from old infections, the researchers reported. That is to say, about eight out of nine positive lung scans led to needless follow-up tests. One of the 206 led to a lung biopsy, a procedure that doctors say can cause life-threatening complications.

And this was among heavy smokers, in a highly controlled research setting. In nonsmokers, or onetime light smokers, a walk-in lung scan is even more of a fishing expedition, radiologists say. “The ability to look at the lung is so good that you will see all sorts of things,” Saini says. “The challenge here is not in finding something, but knowing when to act.”

If the radiologist sees something and isn’t sure what it is, for example, he or she might schedule a follow-up scan three or six months later to see whether the spot changes shape or size. But even this conservative course carries some risk to the patient, doctors say.

“You’re telling the person to come back in a few months, and it may be nothing,” Selecky says, “and all that time the person knows that there’s something in there that may be growing. Now, if that’s me or you, we might say: ‘I don’t care what it is--get it out!’ And now you’re having your chest opened up and having that section of your lung taken out. This is something to think about before getting one of these scans.”

Colon cancer is a different story. Doctors begin screening for the disease when people turn 50, using tests such as sigmoidoscopy (a partial scope of the colon) and a barium enema. But the most sensitive test for the cancer--colonoscopy--involves threading a scope all the way along the colon.

“Uh, no thank you,” Antin deadpans. “I’d rather pass.”

This is the great promise of a colon CT. When properly done, the scan requires the same preparation as a colonoscopy: emptying the colon, then puffing it with air to get a clear view. But if the test proves as reliable as a colonoscopy, and it’s negative, the scan could spare you an intimate encounter with the cold, invasive scope.

If the test does find a suspiciously large spot, doctors say, then you’re simply back at square one: a colonoscopy, to see if the thing is cancerous.

“Either way, it’s a good outcome,” says Dr. Robert Smith, director of cancer screening at the American Cancer Society. “That’s why there’s a lot of excitement about colon scans for screening.”

Yet so far, most of what doctors know about colon scans comes from studies of patients who already have polyps--a high-risk group, says Dr. Joel Fletcher, a diagnostic radiologist at the Mayo Clinic. “The scans are about 85% as sensitive as a colonoscopy in this group, which is very good,” he says. “But the sensitivity of any test drops once you start doing it in normal, healthy people. For now, we would recommend that people just get over it and have a barium enema, a sigmoidoscopy or a colonoscopy. This disease kills something like 130,000 people a year.”

The case for heart scans is even less clear-cut. Although CTs are very sensitive in detecting calcium deposits on artery walls, the connection between these deposits and heart disease is still a matter of debate. Some doctors believe that measures of the calcium could help predict the likelihood of future heart attacks; but the relationship is far from clear.

“The fact is that you can have calcium there and no arteriosclerosis [hardening of the arteries],” says Hodis of USC. “And many people with arteriosclerosis don’t have the calcium deposits at all.”

Hodis says he can learn most of what he needs to know about heart disease by sitting down with the patient and going through a list of risk factors: age, gender, family history, blood pressure level, and so on. “I have to ask myself: Does the calcium score from a CT scan add to that list, does it change the way I treat the patient?” he says. “It doesn’t.”

Dr. Robert Detrano, director of the CT Reading Center at Harbor-UCLA Research and Education Institute, says that if you have a cholesterol level within a very specific range, and you find calcium, it might be helpful to lower that cholesterol.

“But the point is that it’s a very, very specific group whom this screening might help,” he says, “and that’s why the scans shouldn’t be done without a consulting physician who understands the individual person and their specific health history.”

‘This Is Just Looking for Big, Bad Stuff’

Back in Koch’s office, the results of Robert Antin’s scan are now ready. So is the client himself; the man is radiating good cheer. Antin takes care of himself, plays basketball regularly and has every reason to be confident.

Plus, Koch has tipped him off that the news is pretty good.

“I feel healthier already,” says Antin, taking a seat beside the doctor.

The two watch as images of Antin’s innards scroll by on a computer screen, moving from the neck on down, as if shot from above. “There’s your trachea . . .” Koch is saying, “. . . your kidneys. . . there’s the stomach. With lunch in it.”

Koch explains that he’s looking for any mark that seems out of place, or abnormal. “Really, this is just looking for big, bad stuff,” he says. “It’s for people who have some family history of disease, or who used to smoke. Or baby boomers who’ve been eating fast food four times a week and want to make sure they’re OK. It’s screening. I would never give a diagnosis.”

Then he stops, turns to Antin. “Oh, I see a fleck of calcium. On your left anterior descending artery.”

And there it is, a pearl glimmer in a thicket of blue-gray light.

Antin tightens. His smile is gone. What does that mean? he asks.

Koch explains that many healthy 50-year-olds have some calcification on their arteries and that the deposits are stable. That is, the plaque has hardened, the artery wall has grown over the deposit, and there’s little if any risk that pieces will dislodge and cause a heart attack or stroke. Koch also explains that Antin’s calcium “score is very low, and you shouldn’t worry about it.”

Antin relaxes. He takes a breath; and another. But he still doesn’t look completely satisfied with the answer.

Detrano puts such natural worry in perspective. The most important question is this, he says: If you do find calcium on the screen, is there anything you can do about it that you wouldn’t do otherwise?

“And 95% of the time the answer is no,” he says. “If you have hypertension, it makes no difference whether you have calcium there or not; you’re still going to have to control the hypertension. If you have diabetes, same thing: It makes no difference if you have the calcium; you still have to control the diabetes.”

For that matter, radiologists agree, a full body CT shouldn’t be considered a replacement for doctor visits and regular screening tests. “Do CT scans pick up breast cancers earlier?” says Dr. Fred Mettler, chairman of radiology at the University of New Mexico. “No, they don’t. You do that with a mammogram, which is a much more sensitive test. Cervical cancer? No. You do that with a Pap smear; it’s more sensitive. And in men, do CT scans detect prostate cancer early? Again, the answer is no. The PSA blood test is much better.”

In short, getting better pictures of yourself doesn’t always mean you’re going to get better health care, researchers say. “That may be the biggest danger of full-body scans,” says Mettler. “If people believe they’re really useful, they’ll think, ‘Oh, I had a clean CT test, I’m fine, I don’t need to bother with these other screening tests.’ They’re going to create false levels of confidence.”

Whether false or not, that’s certainly what David Clark got--confidence. And peace of mind. His scan was clear: no big, bad stuff. “Hey, I’ve got a comfort level now,” he says. “I’m going to go out and celebrate. I don’t feel so guilty about the way I’m living now. The beautiful thing about this is it gives me peace of mind, allows me not to stress about potential problems.”