BehindTheMedspeak: How do you define a normal person?

A. Someone who needs further workup.

No joke.

If you keep testing you're guaranteed to find an abnormal value which you can then pursue to the doctor's heart's content and the limits of the patient's insurance coverage.

Gee, I hope I don't sound cynical or anything.

What prompts this line of thought is an amusing — to me, at least, though not, I suspect, to others who may read it and come to a diametrically opposite conclusion about how they should respond — article by Philip Yam in the latest (June, 2006) issue of Scientific American about the Biophysical250.

What's that?

Long story short: a battery of 250 blood tests performed by a company called — surprise! — the Biophysical Corporation, out of Austin, Texas.

It costs $3,400 and — again, surprise! — is not covered by insurance so you'll have to pony up and write them a check in advance.

Sweet — for the Biophysical Corporation, which expects that about 1,500 suckers — oops, I meant clients — will smash their piggy banks and come up with the moolah in the hopes of discovering something which, detected early on, will save their lives.

Don't count on it.

Here's the article.

The Ultimate Blood Test

A pricey way to determine health risks: 250 tests at once

As the dizziness began to fade and nausea to subside, I kept thinking how two tablespoons did not sound like a lot of blood.

During regular checkups, my physician draws only about half that amount.

I suppose I might have guessed, especially after a 12-hour fast, I would sicken when my glucose levels dipped--I'm a terrible blood donor in that regard.

The nurse who drew my blood helpfully looked around my office for a sweet drink.

"Do you have any soda or juice?" she asked. But the only thing I had was a can of Diet Coke.

Which in a way is ironic: I used to drink regular Coke but switched to the sugar-free form after blood tests revealed that my triglycerides were too high.

Momentary ill feelings, though, were an acceptable physical price for 250 blood tests done at once--I was told that running them separately with conventional means would require a liter of blood.

Imagine how dizzy and nauseated I'd feel then.

So how could I not roll up my sleeve for Biophysical Corporation?

The Austin, Tex.-based company promised to use the blood to screen for presymptomatic cancers, potential immune disorders, latent infections, undetected hormonal imbalances and unrecognized nutritional deficiencies.

It seemed to mark a step toward that Star Trek future in which Dr. McCoy waves around a saltshaker device to determine a person's medical secrets. ("Heartbeat is all wrong. Body temperature is ... Jim, this man is a Klingon!")

The Biophysical250 assessment, as the firm calls it, is more than just a battery of tests.

It includes a medical-history interview; a personal visit to the home or office for the blood draw (I should have picked my home, where I actually keep sugar); and a follow-up physician consultation.

All this attention does not come cheap.

It costs $3,400, and it is not covered by health insurance.

The company states that doing each test individually would cost 10 times more, so Biophysical250 is a bargain by comparison.

Still, you need some disposable income, or you must be so indispensable to your employers that they will pay for it.

I don't fall into either category.

But because I was reviewing its product, Biophysical agreed to conduct the test on me for free.

The analysis focuses on blood biomarkers, which are chemicals whose presence or amount may indicate abnormal processes or reactions in the body.

Among the most familiar are cardiovascular ones: high- and low-density lipoproteins (HDL and LDL, the good and bad cholesterols) and triglycerides.

Checking 250 biomarkers at once might seem like overkill.

A routine exam screens for two or three dozen.

Looking at one biomarker in isolation, however, is usually not especially informative--for instance, the ratio of LDL to HDL is more important than either alone.

The Biophysical250 takes it much further: to assess the risk for heart disease and stroke, the firm analyzes 33 biomarkers.

And examining several biomarkers together improves the odds of finding problems early, especially malignancies.

Blood tests for cancers have been problematic, because healthy people may produce the same kinds and amounts of the biomarkers that cancer patients do.

Moreover, the chemicals do not always show up in cancer patients, and they may result from unrelated conditions.

The Biophysical250 screens for about four dozen blood chemicals tied to cancerous activity in general to increase the odds of detecting presymptomatic disease.

As an example, Biophysical points to ovarian cancer, which is usually diagnosed too late.

Cancer antigen 125, the most commonly measured marker for the disease, shows up in only half of patients in stage 1, when treatment is most likely to succeed.

The Biophysical250 tries to boost the chance of early detection by measuring other, biologically independent compounds, such as vascular endothelial growth factor, interleukin-6, and monocyte chemoattractant protein.

"Just the fact that we stack so many biomarkers really minimizes false positives," comments Mark Chandler, CEO and founder of Biophysical.

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That may well be but it's my opinion that Philip Yam, though he must be a very bright guy to write for the Scientific American, does not have a whole lot of common sense.

If the Biophysical Corporation offered to pay me $3,400 — or even $34,000 — I would still refuse to let them perform their Biophysical250 on me.

Why?

For the precise reason I noted in the beginning of this post: you are guaranteed to find something wrong that requires further investigation with this broad an initial screening.

And at the end of the far-more-likely-than-not negative workup you'll be left with:

• months of needless anxiety and worrying — maybe even panic

• more medical bills to pay for the in-depth testing required to prove the negative

• possible complications associated with the investigation

• a distinct possibility of now being uninsurable because of the abnormal result that precipitated the workup

Trust me: you're far more likely to die with prostate cancer than from it.

Leave well enough alone.

Still not convinced?

How about the findings of a study published last week in the British Journal of Cancer?

Dr. Chris Parker, the lead researcher, summarized the results thus: "Most men with prostate cancer detected by PSA screening will live out their natural span without the disease causing them any ill effects."

Here's the abstract.

A model of the natural history of screen-detected prostate cancer, and the effect of radical treatment on overall survival

The lead time and overdetection associated with prostate-specific antigen (PSA) screening, and generational improvements in all-cause mortality, make prostate cancer outcome studies from the pre-PSA era difficult to interpret in a contemporary setting.

We developed a competing-risks hazard model to estimate the natural history of screen-detected prostate cancer, and the impact of radical treatment on overall survival.

The model of hazard of mortality was fitted to clinical outcome data from the pre-PSA era, and the effects of screening, generational mortality improvements and radical treatment were incorporated.

Sensitivities to the choice of baseline data and values of key parameters were assessed.

Lead-time estimates in men diagnosed aged 55-59 years were 14.1, 9.3 and 5.0 years for men with Gleason scores <7, 7 and >7, respectively, assuming biennial screening with 100% attendance.

Central estimates of 15-year prostate cancer mortality for conservative management of screen-detected prostate cancer ranged from 0 to 2% for Gleason scores <7, 9 to 31% for Gleason score 7 and 28-72% for Gleason scores >7.

For men aged 55-59 years at diagnosis, the predicted absolute 15-year survival benefit from curative treatment was 0, 12 and 26% for men with Gleason scores <7, 7 and >7, respectively.

Estimates of the survival benefit of radical treatment were relatively insensitive to values of key parameters.

The case for curative treatment, rather than conservative management, of screen-detected localised prostate cancer is strongest in men with high-grade disease.

This conclusion contrasts with current patterns of care.

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But you're still not a believer, are you?

That's one of things I like about you: no one's ever called you easy.

But I digress.

Read Gina Kolata's May 21 New York Times article, "If You've Got A Pulse, You're Sick," in which she compares the British and American attitudes to preventive health.

It follows.

If You've Got a Pulse, You're Sick

For a nation that spends more than any other on health, the United States certainly doesn't seem very healthy.

Many cancers are on the rise — prostate, breast, skin, thyroid. We're fatter than ever.

As for diabetes, the number of people who say they have it has doubled in the last 10 years.

Now a report says that the English — those smoking, candy-eating, fish-and-chips lovers — are actually healthier than Americans.

And they spend half as much on health care.

The American-English comparison, published this month in The Journal of the American Medical Association, analyzed data from people's own reports of their health and also used some objective measures: a blood test for diabetes, using hemoglobin A1c, and blood tests for proteins associated with heart disease risk, fibrinogen and C-reactive.

Their blunt conclusion?

"Americans are much sicker than the English," wrote the investigators, led by Dr. Michael Marmot of University College Medical School in London.

People tried to find reasons.

Maybe, many said, the problem is that Americans are under too much stress.

But, as often happens when it comes to statistics, what this all means may depend on who is doing the interpreting.

It's hard to make cross-cultural comparisons — the populations may not be representative.

But it can be even worse when the question involves health.

Sometimes, the data that are needed just can't be found because what one country measures, another guesses.

Take obesity, for example.

Dr. Jeffrey M. Friedman, an obesity researcher at Rockefeller University, once wondered how much thinner Europeans actually were.

So he looked for nationally representative data that included actual measures of weight, not just what some groups of people said they weighed.

The United States has such data, but not Europe, with the exception of England.

"You can't get those data," Dr. Friedman said.

"They don't exist."

There is, however, one statistic that scientists say is fairly solid: life expectancy at birth.

And in comparing the figures for the United States and Britain, it turns out they are almost identical: 77.6 years in Britain; 77.1 in the United States.

"What do you mean by saying we're not healthy?" asks Dr. Nortin M. Hadler, professor of medicine at the University of North Carolina.

"How do you define health?"

The question of which country is healthier, Dr. Hadler and others say, turns out to be a perfect illustration of an issue that has plagued American medicine: the more health problems you look for, the more you find.

And Americans, medical researchers say, are avid about looking.

The British, doctors say, are different.

"The U.K. has a tradition of independent and perhaps more skeptical primary-care practitioners who are probably slower to label and diagnose people and more reluctant to follow guidelines than their U.S. counterparts," says Dr. Iona Heath, a general practitioner in London.

"I have heard it argued that the U.S. believes more in the perfectibility of humanity and the role of science than the Europeans."

Some people call it disease-mongering, says Dr. Lisa Schwartz of Dartmouth Medical School.

She once calculated that if everyone had the recommended tests for blood cholesterol, blood sugar, body mass index and diabetes, 75 percent of adults in the United States would be labeled as diseased.

And new diseases arise by the minute, she says, her favorite example being "restless legs."

Even cancer rates can be hard to compare from one country to another, noted Dr. H. Gilbert Welch, also of Dartmouth, and, with Dr. Schwartz, a researcher with the V.A. Outcomes Group in White River Junction, Vt.

Here, men over 50 routinely get a blood test for prostate cancer, the P.S.A. test, when they have medical exams.

It is so accepted that some doctors do not even tell the men they are doing the test.

Here, free skin-screening clinics pop up every year and doctors advise people to have their skin examined regularly for cancer.

Here, women get mammograms starting at age 40, and they get them every year thereafter.

Here, even thyroid cancer screening is on the rise.

And while screening picks up cancers that would become deadly if left unnoticed, in many cases it also picks up tiny cancers that might have gone nowhere — people would have died with them, not of them.

Autopsies have repeatedly found that people often have such cancers, but had they been found through screening and treated, people would have thought they'd been "cured."

That phenomenon, overdiagnosis, is a recognized consequence of increased screening, medical researchers say.

A telltale sign is a cancer whose incidence rises but whose death rate does not budge.

The most recent example was with thyroid cancer.

This month, in a paper in JAMA, Dr. Welch reported that the incidence of thyroid cancer in the United States had increased by 250 percent over the last two decades.

But the death rate from it remained the same.

Screening is much less common in Britain, Dr. Heath says.

For example, she said, "we don't do P.S.A. screening for nonsymptomatic men, and we don't do skin screening."

So, she and others say, perhaps it should be no surprise that even though smoking is much more common in Britain, and it is the leading cause of cancer, nearly twice as many Americans as Britons — 9.5 percent — said they had had cancer.

And the more educated Americans reported the highest rates — 10.5 percent.

As for heart disease, 50 percent more Americans than Britons say they have it, and more say they have high blood pressure and high cholesterol.

But when Dr. Marmot and his colleagues looked at actual measurements of blood pressure in British and American populations ages 40 to 70, there was no difference.

And Americans had lower cholesterol than the British.

The paper did not include actual outcomes from heart disease, like heart attacks.

The one area where the Americans stand out is with a blood marker for diabetes.

The paper reports that 6.4 percent of Americans had elevated levels of hemoglobin A1c, compared with 3.8 percent of Britons.

But the lesson for Americans is clear.

These days, and especially in the United States, with its screening and testing, "we are labeled," said Dr. Hadler of North Carolina.

"I call that medicalized," he added.

"And one of my creeds is that you don't medicalize people unless it is to their advantage. When you medicalize people, they think they're sick, and in our culture it's, 'Do something, Doc. Don't just stand there.' "

Dr. Hadler has written a book about the problems of medicalization, calling it "The Last Well Person: How to Stay Well Despite the Health Care System" (McGill-Queen's University Press, 2004).

The title refers to a story told by Dr. Clifton K. Meador, director of the Meharry-Vanderbilt Alliance, a cooperative program between the medical schools in Nashville.

One day, as Dr. Meador tells it, a doctor-in-training was asked by his professor to define a well person.

The resident thought for a moment.

A well person, he said, is "someone who has not been completely worked up."

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Still thinking about writing that $3,400 check to the Biophysical Corporation?

Let me offer a suggestion: send it to me instead — in the long run it will do both of us more good.

Ha.