[vc_row css=”.vc_custom_1463724439418{margin-bottom: 10px !important;}”][vc_column][vc_custom_heading text=”The Role And Value Of Health Screening In The Prevention And Detection Of Diseases” font_container=”tag:h2|text_align:center|color:%23040060″ google_fonts=”font_family:Libre%20Baskerville%3Aregular%2Citalic%2C700|font_style:700%20bold%20regular%3A700%3Anormal” css=”.vc_custom_1464075076670{margin-bottom: 10px !important;}”][/vc_column][/vc_row][vc_row][vc_column][vc_empty_space height=”15px”][vc_custom_heading text=”Introduction” font_container=”tag:h3|text_align:left|color:%23040060″ google_fonts=”font_family:Libre%20Baskerville%3Aregular%2Citalic%2C700|font_style:400%20regular%3A400%3Anormal” css=”.vc_custom_1463730350285{margin-bottom: 10px !important;}”][vc_empty_space height=”8px”][vc_column_text]Health screening programs are targeted at the individual level for the following purposes :

  1. Early detection of risk factors that may predispose the individual to the development of chronic diseases (e.g. cardiovascular disease, stroke, cancer, diabetes and chronic lung disease).
  2. Early detection of pre-existing chronic disease (underlying) that may be unknown to the individual at the point of examination.
  3. Serve as a baseline index of individual health.
  4. Provide follow-up indicators as measurements of wellness, after lifestyle intervention or treatment of risk factors and chronic diseases.

Whilst the health economist grapples with the cost-benefit ratio of health screening programs in an attempt to answer the following questions:

  • Who will benefit from the health screening programs?
  • At what age should doctors start doing such programs?
  • How often should this be done?

The doctor on the other hand is always keen to know the health status of every individual who walks into his or her clinic.

As the famous Chinese saying from Huang Dee: Nai-Ching (2600 b.c., First Medical Text) goes :

Inferior doctors – treat the full-blown disease (and its accompanying complications)

Mediocre doctors – treat the disease before it is evident

but  Superior doctors – are the ones who prevent disease before it strikes”

It is therefore, useful to know the range of health screening programs available and when to do them.[/vc_column_text][/vc_column][/vc_row][vc_row][vc_column][vc_empty_space height=”8px”][vc_custom_heading text=”What types of health screening programs are available?” font_container=”tag:h4|text_align:left|color:%23040060″ google_fonts=”font_family:Libre%20Baskerville%3Aregular%2Citalic%2C700|font_style:400%20regular%3A400%3Anormal” css=”.vc_custom_1463730372754{margin-bottom: 10px !important;}”][vc_column_text]Health screening programs can range from very simple programs targeted to look at risk factors and markers of a specific disease state (e.g. coronary artery disease, diabetes, hypertension, stroke, cancer, etc) to broad screening programs that cast a net to look at detection of major common diseases and lastly, to very high-end screening programs that involve more sophisticated blood tests, x-rays, imaging techniques and even genetic testings.  It therefore follows that the price range can vary from a few tens of dollars to hundreds and even thousands of dollars.

As there are so many health screening programs available in various hospitals, medical centres and clinics in Singapore, it would not be possible to describe every one of them.

However, the following descriptions generalize what most health screening programs will involve.

Health screening programs can be divided into 4 groups:

  1. Health Screening Programs Targeting a Specific Disease State
  2. General and Executive Health Screening Programs
  3. High-End Executive Health Screening Programs
  4. Genetic Screening Programs

[/vc_column_text][/vc_column][/vc_row][vc_row][vc_column][vc_empty_space height=”8px”][vc_custom_heading text=”1. Packages Targeting at Specific Disease State” font_container=”tag:h2|font_size:20|text_align:left|color:%23040060″ google_fonts=”font_family:Libre%20Baskerville%3Aregular%2Citalic%2C700|font_style:700%20bold%20regular%3A700%3Anormal” css=”.vc_custom_1463795247210{margin-bottom: 10px !important;}”][vc_column_text]There are numerous specialised packages which include the following :

  • Coronary risk factors (heart) screening programs
  • Stroke screening programss
  • Cancer risk screening programs
  • Anti-ageing screening programs
  • Women’s health check
  • Men’s health check
  • Pre-participation screening programs for individuals with intention to undertake high intensity physical activities like marathon runs etc.
  • Pre-marital screening programs and many more

[/vc_column_text][vc_empty_space height=”8px”][vc_custom_heading text=”Coronary risk factors (heart) screening program” font_container=”tag:h2|font_size:20|text_align:left|color:%23040060″ google_fonts=”font_family:Libre%20Baskerville%3Aregular%2Citalic%2C700|font_style:400%20regular%3A400%3Anormal” css=”.vc_custom_1463043558605{margin-bottom: 10px !important;}”][vc_column_text css=”.vc_custom_1463729205415{margin-bottom: 20px !important;}”]This is by far the most common and most sought after health screening program for the simple reason that many people die suddenly from a cardiac arrest.  It usually comprises of a detailed questionnaire to look at risk factors of cardiovascular disease, in particular family history of premature coronary artery disease, sudden cardiac death, diabetes and smoking.

Cardiovascular examination will include height, weight, calculation of BMI, pulse rate, blood pressure and retinal examination.  Blood examination will include a lipid profile, blood sugar and urine albumin levels.  A 12-lead ECG completes the basic test package.

Based on the above, the doctor will be able to calculate and derive a cardiovascular risk score.  This score can either be an international risk score, e.g. Framingham risk score or in Singapore, there is a Singapore risk score.  The risk score can then estimate the risk of a person developing a cardiovascular event (heart attack, sudden death, stroke) in the next 10 years.  For example, a person may be found to have more  than a 20% prevalence of a cardiovascular event in 10 years which works out to be > 2% per year and this  would represent a high risk group as compared to a person with less than 10% risk in 10 years, i.e. less than 1% per year which would be in the low risk group.  The doctor can then make a decision to either proceed with further evaluation of the cardiovascular system or a patient can be left alone.

Some centres offer a more extended cardiovascular screening heart program which will include further blood tests with measurements of APOA1, APOB, LP(a), hsCRP, serum uric acid, NT-proBNP, troponin T, homocysteine, serum fibrinogen levels.  These are newer novel markers for detection of heart diseases.  They are tested non-traditional risk markers and inflammatory markers.  For example the extended lipid panel – APOA1, APOB, LDL-Particle and LP(a) are lipoproteins that are known to be more atherogenic i.e. responsible for cholesterol deposition in the coronary arteries then the usual cholesterol screening panel.  The hsCRP (high-sensitivity C-Reactive Protein) is a measurement of inflammation of the blood vessels in particular the coronary arteries and an elevation will be an added risk to the patient (provided he has no underlying infection).  The NT-proBNP and troponin T are biomarkers that may indicate underlying heart failure or damage and injury to the heart muscles.

The extended cardiovascular package also include a Treadmill Exercise Stress Test to detect coronary artery disease, a 2D Echo/Doppler Study to detect structural defects and diseases of the heart, Ankle-Brachial Index (ABI) to look for peripheral artery damage and Carotid Intima-media Thickness (CIMT) to look for diseases of the neck arteries that supply the brain.

The Role Of Coronary Calcium Score and Coronary CT Angiogram

This is by far the most accurate non-invasive test to look for coronary artery disease. However, not everybody requires to undergo this test for several reasons:

  • It is expensive, in the range of greater than $1000
  • There is some trade-off including exposure to radiation (but the current technology of CT has reduced this substantially)
  • Use of contrast which may cause allergy or renal impairment

It is therefore better to leave this test to the doctor after the basic cardiovascular health screening program has been completed rather than a blanket use of coronary CTA on a routine basis.  Certainly coronary CTA should not be done routinely especially in the pre-menopausal women as well as young adults unless there are significant factors that put the person in the intermediate or high-risk group.

However, coronary calcium score is safe and can be used as screening tool to further risk stratify a person. It is also less expensive (< $300).  There is a range of calcium scores which will allow the doctor to categorize a person into low, intermediate and high risk group.

When And Who Should Undergo A Heart Screening Program

As there is currently no clear-cut age or cut-off point for defining the onset of risk of cardiovascular disease but it is known that elevated risk factors and subclinical abnormalities can occur in adolescents as well as young adults.  The accepted recommendation for a cardiovascular screening program should include asymptomatic persons beginning at the age of 20 years old.  The goal is to maximize the benefits of prevention-orientated interventions especially those involving lifestyle changes in people who are found to be in the intermediate and high-risk groups.[/vc_column_text][/vc_column][/vc_row][vc_row][vc_column][vc_custom_heading text=”Cancer risk screening program” font_container=”tag:h2|font_size:20|text_align:left|color:%23040060″ google_fonts=”font_family:Libre%20Baskerville%3Aregular%2Citalic%2C700|font_style:400%20regular%3A400%3Anormal” css=”.vc_custom_1463043572719{margin-bottom: 10px !important;}”][vc_column_text css=”.vc_custom_1466486625211{margin-bottom: 25px !important;}”]Generally, most cancer specialists do not recommend a broad cancer screening program as it is not possible to look at early cancer in every organ in the body.  The advice is to usually see a physician or a cancer specialist and have a medical history taken on cancer risk especially a family history and then from there proceed to evaluate that particular organ at risk.  For example, if there is a strong family history of colonic cancer, then the advice is to do stool for occult blood and then to proceed with either a CT of the colon or colonoscopy.

However, there are screening blood tests to look for cancer markers and the most common include the following:

  1. CEA (lung/GIT/colon/kidney/breast/pancreas)
  2. AFT (liver)
  3. CEA19.9 (pancreas)
  4. CA125 (ovary)
  5. PSA (prostate)
  6. EBV EA + EBNA-1 IgA Antibody (nose)
  7. SCC Antigen (lung)

Extended cancer evaluation may include an abdominal ultrasound to look at the liver, gall bladder, kidneys, pancreas, and spleen and for a female, a pelvic ultrasound and a mammogram.  A chest x-ray would also be useful to look at cancer of the lungs.  There is no cut-off age for such screening programs.  However, it would probably be more useful in the middle and elderly age group, above 40 to 45 years old and also with family history of cancer.

The Ministry of Health’s Clinical Practice Guidelines (July 2003) specified the indications for cancer screening of various organ as well as the duration of each screening program. This can be found in the website https://www.moh.gov.sg/content/dam/moh_web/HPP/Doctors/cpg_medical/withdrawn/cpg_Health%20Screening%20Jul%202003.pdf

Below are some more common cancer screening recommendations :

Screening for Colorectal Cancer

It is recommended for asymptomatic individuals above the age of 50 years old and would include asymptomatic individuals with a family history limited to non-first degree relative.  The screening option would include stools for occult blood testing annually.  Colonoscopy is recommended once every 5 to 10 years.  In those with family history of colorectal cancer in first degree relative 45 years or younger or a family with history of 2 or more affected first-degree relative, colonoscopy is recommended every 3 years.  If an individual is found to have colorectal polyps, colonoscopy is recommended once every year after polypectomy in the presence of high-risk features and 3 years after polypectomy in the absence of high-risk features.

Screening for Prostate Cancer

It is recommended for high-risk men above the age of 50 years old with a history of first-degree relative prostate cancer at a young age (< 60 years old).

Screening for Breast Cancer

It is recommended for all normal risk, asymptomatic women 50 to 69 years of age should be screened with a mammogram only every 2 years.  Women at normal risk of age between 40 to 49 years old should be encouraged to have annual screening mammography.  Normal risk asymptomatic women under 40 years need not undergo breast screening with any imaging modality.[/vc_column_text][/vc_column][/vc_row][vc_row][vc_column][vc_empty_space height=”15px”][vc_custom_heading text=”2. General and Executive Health Screening Programs” font_container=”tag:h2|font_size:20|text_align:left|color:%23040060″ google_fonts=”font_family:Libre%20Baskerville%3Aregular%2Citalic%2C700|font_style:700%20bold%20regular%3A700%3Anormal” css=”.vc_custom_1463796607698{margin-bottom: 10px !important;}”][vc_column_text css=”.vc_custom_1462862779689{margin-bottom: 25px !important;}”]Most health screening programs will include all or some of the following :

A body composition analysis of height, weight, body mass index, muscle mass/percentage body fat and edema evaluation, a full clinical examination including a medical history.  A clinical examination will include complete evaluation of the heart, lung, abdomen, rectal examination, blood pressure measurement and neurological and muscular-skeletal examination, a visual evaluation for near and far vision and stereoscopic vision, eyeball pressure tonometry to look for glaucoma, lung function test which involve spirometry to look at lung diseases, chest x-ray to look at the heart and lungs and ECG to look for abnormalities in heart rhythm and a treadmill exercise stress test.

Blood test will include the haemoglobin level, the red blood cells, white blood cells and platelet counts and blood film, a lipid profile which include the good (HDL-C) and bad cholesterols (LDL-C), the serum triglycerides and the total cholesterol to HDL ratio, hsCRP, blood uric acid, full liver function test, diabetes check which may include the sugar levels and the haemoglobin A1c, kidney function, thyroid function test, calcium and phosphate to look for osteoporosis, cancer markers, hepatitis status especially the A and B, evaluation of rheumatoid arthritis, screening for sexually-transmitted disease, urine examination, stool examination and for the females – a cervical examination including PAP smear and bone densitometry.[/vc_column_text][/vc_column][/vc_row][vc_row][vc_column][vc_empty_space height=”20px”][vc_custom_heading text=”3. High-End Executive Health Screening Programs” font_container=”tag:h2|font_size:20|text_align:left|color:%23040060″ google_fonts=”font_family:Libre%20Baskerville%3Aregular%2Citalic%2C700|font_style:700%20bold%20regular%3A700%3Anormal” css=”.vc_custom_1463796622846{margin-bottom: 10px !important;}”][vc_column_text css=”.vc_custom_1463796839246{margin-bottom: 16px !important;}”]There are also the very high-end executive health screening programs, which apart from including all that has been described above, will also offer high-end imaging techniques such as ultrasound of the carotid arteries (to look for atherosclerosis and measure the carotid intima-media thickness), stress echocardiography, myocardial perfusion imaging, coronary CT angiogram and Magnetic Resonance Imaging (MRI) which includes both the Cardiac MRI and the MRI stroke screen.  These imaging techniques usually need not be done as they are expensive as well as mentioned – potential trade-offs.

As can be seen from the above clearly, the choices for health screening programs are plentiful and the choice of health screening programs will depend a lot on the affordability.  The more comprehensive and more detailed health screening program, the more expensive it is.  As a general guideline, most young people do not need to undergo a fully comprehensive health screening program.  However as cardiovascular risk, including diabetes mellitus, hypertension, hyperlipidemia begins at a very early age, i.e. adolescence, the current recommendation is to do cardiovascular screening programs as early as 20 years old.

Most employers in multinational and local companies may throw in an incentive health screening program for their employees and it will therefore be useful to have at least 1 of such programs done to screen for common lifestyle diseases.  High-end imaging techniques should be avoided unless specified by the doctors.[/vc_column_text][/vc_column][/vc_row][vc_row][vc_column][vc_empty_space height=”20px”][vc_custom_heading text=”4. Genetic Screening Programs” font_container=”tag:h2|font_size:20|text_align:left|color:%23040060″ google_fonts=”font_family:Libre%20Baskerville%3Aregular%2Citalic%2C700|font_style:700%20bold%20regular%3A700%3Anormal” css=”.vc_custom_1463796641240{margin-bottom: 10px !important;}”][vc_column_text css=”.vc_custom_1463024166863{margin-bottom: 16px !important;}”]The era of “personalised medicine”, sometimes also called “precision medicine” has arrived.  There are now many genetic tests available worldwide and online – the so-called “direct-to-consumer” genetic testings.

To name a few :

  1. Genetic tests for heart attack
  2. Genetic tests for sudden death
  3. Genetic tests for cancer (especially BRCA gene for breast cancer)
  4. DNA for paternity testing
  5. Inborn talent genetic testing
  6. Deafness genetic testing
  7. DNA Fit – for genetic factors impacting fitness and exercise
  8. DNA testing on athlete’s health and performance
  9. Diet DNA testing – to make educated diet decisions
  10. Mental health DNA testing
  11. Pharmacogenomics – gene testing for efficacy and safety of medical drugs on the individuals

A word of caution is that these testings are best prescribed by doctors and specialists in the various fields of medicine as not everybody requires genetic testings.  Furthermore, they are expensive and require experts at interpreting the results.  Genetic counselling may be required and there are medico-legal and social implications that accompany such tests.  (See article on personalised medicine).[/vc_column_text][/vc_column][/vc_row][vc_row][vc_column][vc_empty_space height=”20px”][vc_custom_heading text=”Conclusion” font_container=”tag:h2|font_size:20|text_align:left|color:%23040060″ google_fonts=”font_family:Libre%20Baskerville%3Aregular%2Citalic%2C700|font_style:400%20regular%3A400%3Anormal” css=”.vc_custom_1463043623427{margin-bottom: 10px !important;}”][vc_column_text css=”.vc_custom_1462863293946{margin-bottom: 16px !important;}”]Health screening programs are useful tools in the primary prevention of medical diseases in particular lifestyle diseases.  When used carefully  and appropriately it is of great benefits to the doctor who can then plan for his or her patients’ lifestyle modifications and intervention to prevent the development of such diseases especially coronary heart disease, hypertension, diabetes mellitus, hyperlipidemia, cancers and stroke.  As the importance of primary prevention cannot be overstressed, the individual together with the doctor can go a long way to achieve the prevention of these diseases.[/vc_column_text][vc_empty_space height=”15px”][vc_column_text font_size=”15″]

by Dr Peter Yan
Medical Director & Co-Founder
Consultant Cardiologist & Physician
Gleneagles & Mt Elizabeth Medical Centres and Hospitals

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