Quotes of the Day

Two years ago, when dr. gabby Freilich became chief radiologist at a company offering whole-body scans direct to the public, he encouraged some of his friends to come and be zapped. One of those was a 47-year-old dentist, "Don," who felt well. He worked hard and played tennis, and really couldn't be bothered getting scanned. "But Gabby was a pest," recalls Don, who finally relented. Returning to his car after the procedure, he found it vandalized. Right then he wouldn't have given Freilich the time of day.

That night at home, Freilich studied his friend's X rays. Clients of Total Health Screening, in Sydney's east, are scanned from head to pelvis by a $A1.4 million computed tomography (CT) machine. A procedure that takes about 40 sec. produces 870 images of the internal organs. Freilich analyzes the images for signs of illness, specifically heart disease, spinal abnormalities and cancer. One X ray of Don's left kidney stunned Freilich. "What the hell is that?" he said aloud. Freilich had spotted a tumor that, at the press of a key, he measured at an enormous 8 cm in diameter. Freilich phoned his friend. "Would you like to come over and see your pictures?"
"No."
"You should. They're interesting."

Don soon afterward had his cancerous kidney removed. Checks since then suggest he's in the clear.

Don's scan quite possibly saved his life. Freilich is convinced he has helped save many others in the past two years. So what do health authorities think of precautionary whole-body CT scans? They'd be all for them, right? Wrong. In fact, numerous medical bodies oppose them, and the New South Wales government, which recently brought down stringent regulations for operators, shares their skepticism. Partly as a result, Total Health Screening is the only place in the state (indeed, in Australia or New Zealand) known still to be offering the service. Business is slow, raising the possibility that whole-body scans may soon be unavailable in this part of the world. The question is, should we care?

It would be hard to believe that there is, anywhere, a more passionate advocate for whole-body scanning than Freilich. A 44-year-old dynamo, he defends his work in the manner of a debater with a brilliant speech who's just heard the one-minute bell - a legacy, perhaps, of being booed and heckled at conferences. In a country where adults can have liposuction, facial cosmetic surgery and penis and breast enlargements, he says, health authorities portray whole-body scanning as "some nefarious activity undertaken by grubby business people . . . charlatans who advertise." The facts, Freilich says, are that since August '02 he's analyzed the scans of more than 5,000 people. One in 20 had abnormalities needing "immediate follow-up," including more than 100 cancers. He could make more money in a standard radiography practice, he adds, "but it so happens I've become addicted to this."

Opponents make three broad arguments, the simplest of which concerns radiation. In its just-published position paper on whole-body scanning, the Australasian College of Physical Scientists and Engineers in Medicine estimates that subjects receive between 10-20 millisieverts of radiation per scan - a "non-trivial" dose, especially if the person has regular scans. (Nuclear facility workers are limited to an annual radiation dose of 30-50 mSv.) N.S.W. licensing laws require operators to explain to patients that "persons under the age of 50 years are more at risk of developing cancers as a result of the procedure." Radiation risk is probably the weakest argument against whole-body scans. Freilich says the dose from one of his scans is only 6.8 mSv, about 20% higher than occurs in a mammogram. In any case, it's debatable whether exposure to low-level radiation is harmful. Certain groups exposed to higher-than-average radiation - such as flight crews - have cancer rates no higher than the general population. "If anybody can produce a case of cancer caused by CT scanning," says Freilich, "I'll become a plumber."

Anti-scanners are on firmer ground hammering the implications of "false positives." That spot on the man's lung is probably nothing, but it must be checked out. Now fretting about cancer, he undergoes any number of tests. "There are dangers involved in following these blind alleys," says Prof. Alan Coates, chief executive officer of The Cancer Council Australia: for example, scores of Australians die every year from complications of anesthesia. Though clients receive no rebate on whole-body scans, which cost about $A500, doctors estimate that the average cancer scare takes about $1,000 from the public purse. "The scanners can point to individuals who've had early detection of cancers and been cured," says Dr. Derek Glenn, of the Royal Australian and New Zealand College of Radiologists. "That's wonderful . . . but our responsibility is to look at the issue for the population as a whole." Doctors also question whether people cleared by body scans are justified in feeling peace of mind. The heart component of the scan, for instance, provides data on only one predictor of heart attack.

A chink in the false-positive argument is that for years authorities have urged prompt action on health concerns. Don't be shy, we're told, see your doctor - nearly every disease can be beaten if it's caught early. The legal principle that better 10 guilty people go free than one innocent be convicted might have a medical equivalent: "If ultrasounds are performed on 20 of my patients with an ovarian growth, and 19 turn out to be harmless and one is cancer, well, I'm a saint," says Freilich.

Opponents respond that many of Freilich's clients are just wealthy hypochondriacs who have pressured their G.P. (last year's N.S.W. government crackdown included a ban on operators giving scans to people without an independent referral). But Freilich says 95% of his clients are "smokers, drinkers, people who haven't looked after themselves." Nearly everyone who wants a scan has some "relevant medical history . . . but I can tell you that people who felt completely healthy have been found to have life-threatening disease." The third argument against scanning is the most interesting. According to acpsem's position paper, "There is no proven evidence to date that early detection of life-threatening disease by CT has a significant positive effect on patient outcome." In other words, while Total Health Screening and similar practices overseas have detected disease in people, there's no proof they have lived longer or better as a result. An absence of proof in this context means benefit hasn't been shown in a controlled trial. That distinction is important to policymakers, but what about to a frontline oncologist like Dr. Martin Stockler, a Sydney specialist in renal cancer? Early detection of the disease is crucial: by the time symptoms emerge, it's often too advanced to treat successfully. But Stockler opposes whole-body scanning for asymptomatic people. He doesn't doubt it's helped some people, but for a great many more it's caused needless anguish. A cancer scare isn't a trifle, he says: the fear patients feel while a lump is checked can haunt them for years.

Freilich fumes at any suggestion that early detection of cancer makes little difference to patients' prospects. "Are we talking about medicine in the 1700s or medicine in the 21st century? We have imaging equipment so we can detect disease that we can treat. Not every patient that comes through a radiological facility is coming for palliative care." He gives a quick cancer lesson . . . Tumors start small and grow. The bigger they get the greater the likelihood that breakaway cells will travel to other parts of the body. This process of metastasis is what kills patients 90% of the time.

Freilich says he's not asking for favors from government or the medical profession, just an end to the "misinformation" that's poisoned attitudes to whole-body scanning. Both sides predict that the future of scanning is magnetic resonance imaging, which delivers no radiation but for now has technical limitations. "Scanning will survive," says Freilich. "People are going to take their health into their own hands." Oncologist Stockler says there's no doubt people like Freilich "believe absolutely in what they're doing. But that doesn't mean they're right." No, it doesn't. But try telling people like dentist Don or his loved ones that precautionary scans are more trouble than they're worth.

• Daniel Williams
• Total-body scanning can pick up hidden disease, but is it worth the cost in money or peace of mind?