Information on the Ultrafast CT Scan

COOPER CLINIC PREVENTION SCANS

One of the newest diagnostic tools available anywhere is offered through the Cooper Clinic's electron beam CT Scan. CT means computed monography and is also referred to as a CAT scan.

The speed of this scan provides stop-action pictures of the heart at rest and of the entire torso. Three-dimensional images of the heart, lungs, chest, kidneys, gallbladder, spleen, liver, aorta, pancreas and most of the spine are provided by this quick, non-invasive procedure.

The test can detect the amount of calcified plaque in the coronary arteries to help determine risk for heart disease. The scan may also detect suspicious masses in the lungs, and other organs, emphysema, kidney stones, hiatal hernia, osteoporosis and other diseases.

Wall Street Journal
Screen Tests: For the Very Cautious, A Physical Exam Now Includes a CAT Scan

But the Test Is Expensive, Sometimes Misleading; Doctors, Insurers Rebel

The Army's Troop Coverage
By Devon Spurgeon and Thomas M. Burton

03/23/2000 - The Wall Street Journal (Page A1)
(Copyright (c) 2000, Dow Jones & Company, Inc.)

His 40th birthday prompted California attorney Joseph S. Schuchert to ponder the question that that milestone begs: How many years remain? Instead of just wondering, Mr. Schuchert took action. He underwent a full-body CAT scan at an out-of-pocket cost of $695.

The CAT scan, designed to diagnose illness, is gaining use among people who feel fine. Some physicians are promoting it as the most credible provider of a clean bill of health and the most sure-fire detector of incipient disease. Never mind that insurance doesn't cover it on a preventive basis. The number of CAT scans -- which reached 26 million in 1997, the most recent year for which figures are available -- has been rising by about a million a year, and a big chunk of that growth is coming from seemingly healthy Americans willing to fork over hundreds of dollars of their own money for it.

"Poor people should get to do this," says Trisha Fortner, a 53-year-old insurance-agency manager who talks of the relief she felt after getting a preventive CAT scan last month.

The poor could get to do it -- through insurance -- if CAT-scan proponents had their way. Leading the way is the government. The U.S. Army is spending $1 million this year to provide preventive screening for 4,000 soldiers as part of routine physicals. The Army hopes to gain sufficient funding to cover full-body scans for all its troops, according to Ronald R. Blanck, surgeon general of the Army. "It is the next generation of medicine," he says. Meanwhile, the union representing Los Angeles Police officers has arranged for a $190 discounted rate for its healthy members to get a scan.

But is this a good thing?

Only a small portion of the medical community believes so. For these proponents, that the vast majority of doctors disagrees with them only confirms their status as pioneers. "What we are doing here is the wave of the future," says Kenneth Cooper, head of the Cooper Clinic and Aerobics Center in Dallas. But "those of us who specialize in preventive medicine have been outcasts."

Critics see more at stake than the out-of-pocket expenses of preventive CAT-scan believers. Results riddled with false positives can turn healthy CAT-scan customers into patients, forcing insurance companies to provide coverage of unnecessary and potentially dangerous biopsies and other procedures.

These physicians envision an epidemic of marketing efforts and dramas worthy of the ancient Greeks in which the process of trying to divine -- and therefore avoid -- fate leads people smack dab into it. "If you screen the general population, you can wreak havoc on the general population," says radiology associate professor William C. Black of Dartmouth Medical School in Hanover, N.H.

The benefits of a preventive CAT scan can sound irresistible. For Mr. Schuchert, no other birthday present could have equaled the value of the all-clear outcome he got from his CAT scan. In his view, the difference between physical evaluations with and without CAT scans is akin to "the difference between flying first class and coach."

A bigger proponent yet is Los Angeles Police Department Commander Betty P. Kelepecz, 44. Thinking it would be fun to see her organs on screen, and with a $525 police discount that reduced the cost to $190, she underwent a CAT scan that found a golf-ball-size tumor on her right kidney. A biopsy found it to be cancerous.

By the time she would have experienced symptoms, the tumor could have grown and metastasized to other organs, according to her urologist, Gary Lieskovsky of the University of Southern California Medical Center in Los Angeles. Instead, she had her right kidney removed without ever having experienced a symptom. Dr. Lieskovsky believes the preventive CAT scan saved her life.

Does Dr. Lieskovsky approve of the preventive CAT scan? "I do not believe it is justifiable" -- either in terms of cost or medical science, he says.

Critics say the problem is that almost any medical treatment applied to the masses will produce startling results in a few. The question is whether the benefits for those few outweigh the total cost, and not just or even mainly in dollars. The same treatment that saves a few lives can ruin a few more.

Moreover, it's rarely clear that a life has been saved. A malignant tumor found in a CAT scan may have sat dormant for years, and might never have grown threatening. "What we may be finding in screening exams is indolent disease that would never bother people," says Dennis G. Fryback, professor of preventive medicine at the University of Wisconsin.

But the discovery of a tumor, indolent or not, almost certainly would set in motion a set of exploratory procedures that themselves could prove life-threatening. The biopsy on a lung tumor can result in fatal complications -- only to determine that the tumor is benign.

"The dilemma is that once you've got a positive result, it's impossible to ignore it," says Derek van Amerongen, medical director of Anthem Blue Cross of Ohio.

Without question, early detection is crucial in certain kinds of cancer. Studies show that survival rates among victims of breast cancer rise dramatically when the disease is detected early. But even then, mammograms are demonstrably life-saving only for women over 50. Doing widescale CAT scans, by contrast, "is like doing a mammogram on a 20-year-old," says Richard P. Cohen, an internist affiliated with New York Presbyterian Hospital.

Moreover, studies showing the benefit of early detection can be somewhat misleading because they measure survival from moment of detection. Survival five years after early discovery is counted as a greater success than survival one year after late discovery -- even though early discovery may not have lengthened the patient's life. Indeed, early discovery can result in more extensive treatment -- which is to say agony -- without benefit.

But proponents say this opposition to CAT-scan screening is reminiscent of early resistance to mammograms, which many physicians insisted were useless until overwhelming evidence emerged to the contrary. CAT-scan screening "is not fully accepted by mainstream medicine because we are a conservative bunch," Dr. Blanck, the army surgeon general, says of physicians.

And conservatism may not be the extent of it. As technology plays a larger and larger role in diagnosing illness, the role of physicians, especially internists, could shrink. Some observers say that that fear alone could fuel opposition to new technology. "I think it may be threatening to internists," says Dr. Cooper of Dallas, who says his message to them is: "Don't fear us. We're in partnership with you."

Some skepticism about widespread use of the CAT scan may date back to revelations of early misuse. The technology emerged in the 1970s as a superior version of traditional X-rays. A computed tomography scan -- alternatively referred to as a CT or a CAT -- is a computer-enhanced series of X-ray images that can show cross-sectional images of an entire body region, highlighting the precise location of certain abnormalities. Like X-rays, the CAT scan exposes its subject to small levels of radiation. Consequently, even proponents of preventive screening tend to limit the tests to one a year per patient.

CAT scans are similar to magnetic resonance imaging, or MRIs, a technique that uses a powerful magnetic field to create images. People would be unlikely to get full-body MRI screenings because it takes much longer and because the precision of images of the chest, in particular, would be less clear than those from CAT scans.

The CAT-scan machines cost about $1 million each, and physician consortiums bought many of the earliest models. Soon, evidence arose of physicians with stakes in CAT scans referring patients willy-nilly for the tests, and earning profits from each. As a result, some states passed laws prohibiting hospitals or medical centers from buying a CAT-scan machine without first demonstrating need.

It was during the 1990s rise of preventive medicine that people without symptoms but with cash to burn began undergoing uninsured CAT scans. A typical case is the Dallas clinic of Dr. Cooper, who is widely regarded as the father of aerobics and one of the most vocal proponents of the idea that exercise can prevent disease. People visiting his clinic can spend as much as $2,200 on a thorough checkup involving CAT scans, ultrasound and X-rays, as well as standard treadmill and heart tests.

A CAT scan showing a buildup of fat and cholesterol in the coronary arteries "is the best motivating tool I have ever seen," says Dr. Cooper. "We take a photograph of the scan and tell people to put it in their wallets or on the refrigerator door. Then they are more inclined to start exercising and lose weight."

Indeed, it was just such a case that prompted Dr. Blanck, the Army surgeon general, to seek funding for his troops. A trip through the Cooper Clinic's CAT scan machine revealed calcification of Dr. Blanck's coronary arteries, prompting him to change his lifestyle and to suggest that the Army consider using preventive scans.

But the insurance industry is hardly ready to start reimbursing people for CAT-scan screenings. Charles M. Cutler, chief medical officer of the American Association of Health Plans, which represents managed-care companies, says that he doesn't think any insurance company would pay for whole-body CAT scans for someone with no symptoms. If such a scan found problems, insurance companies "would treat the results like any other finding." In other words, he says, insurers would pay for biopsies or further imaging if required.

But what constitutes a "finding"? A comparison of two providers of preventive CAT scans shows how unscientific this diagnosis can be. A Southern California radiologist named Harvey Eisenberg, one of the nation's largest providers of preventive CAT scans, says that results prompt him to refer 80% of his customers to other physicians.

But another Southern California radiologist, Jerry Dalrymple, says his CAT-scan screenings result in referrals to other physicians only 4% of the time. He calls the Eisenberg percentage "laughable."

Dr. Eisenberg responds that nearly every scan reveals "a little something" worth monitoring, and that in his opinion, it is better to play it safe.

One large-scale measure of results derives from Army participation in CAT-scan screening. Of 7,000 screenings of soldiers' hearts and lungs so far, six revealed tumors. Of the six people, none had symptoms, says Col. Michael P. Brazaitis, who administered the screens at Walter Reed Medical Center in Washington, D.C.

The Army results can be used to support both sides of the debate. Early detection of cancer may have saved the lives of some or all of those six people. Then again, some of those tumors might never have grown or spread. And it isn't known how many of the other subjects endured psychologically and financially costly tests to explore mysteries dug up in the CAT scans.

Even clear findings of calcium buildup in arteries, as discovered in Dr. Blanck's CAT scan, don't point to a clear plan of action. The National Institutes of Health has funded studies to look into whether CAT scans may help diagnose heart disease. The tests find calcium buildup in arteries, but it isn't clear that that buildup predicts heart attacks.

Researchers at Cornell University, New York Presbyterian Hospital and New York University published findings suggesting that CT scanning of smokers for lung cancer is useful. But many in medicine are skeptical. Dr. Black at Dartmouth, for example, says, "The jury's still out. You could do anything from a little good for a small number of people to a great harm to many, at a huge cost."

He says it would be "disastrous" for American medicine to allow market forces to dictate who gets what screening exam because that would lead to "a tremendous amount of overtreatment that would cause more harm than good."

The preventive CAT scan appears to be most popular in Southern California. Dr. Dalrymple's medical center there advertises on radio, including the Dr. Laura call-in show. Since initiating the preventive program in the summer of 1998, his business has increased 48%, he says.

In Newport Beach, Dr. Eisenberg expects 11,000 patients this year at his HealthView Center for Preventative Medicine in Newport Beach. That would be a double-digit percentage increase over last year. Dr. Eisenberg says the center's annual revenue is $3 million, a figure he hopes to ratchet to $9 million by leasing to other facilities computer software he created to process CAT images. With this technology, patients can take a virtual tour through their own body.

On a recent visit to HealthView to consider investing in it, Justin Hall-Tipping, managing director of SG Capital Partners in New York, underwent a CAT scan and found it fascinating to peek inside his own body. There, in his colon, he spotted his morning vitamin poised to depart his body without ever having been digested -- a sign he needs to change vitamins, Dr. Eisenberg told him.

Otherwise, all was well. "He told me I look like a 30-year-old," says Mr. Hall-Tipping, 43, "which I was quite happy to point out to my wife."

(See related letter: "Letters to the Editor: Stop Begging" -- WSJ April 13, 2000)

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