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http://www.nytimes.com/2002/05/27/health/27SCAN.html?tntemail0

Cheaper Body Scans Spread, Despite Doubts

By GINA KOLATA

OLUMBUS, Ohio — The middle-aged men and women begin arriving before 7 a.m., coming to a trailer in a church parking lot here for screenings that they say could save their lives.

The tests are CT scans of the body — high-speed, highly sensitive X-rays that can find tiny tumors, weak spots on blood vessels that make them bulge out like balloons, and calcified areas that may be indicative of heart disease.

Body scans for healthy people were once the exclusive province of the rich, part of the gold-plated annual physical for executives. But with the endorsement of celebrities like Oprah Winfrey and a rush by radiologists, medical centers and entrepreneurs to offer them, the scans are available to the masses.

As a result of competition, prices are dropping, from $1,000 or more to a few hundred dollars. New centers are springing up in cities and strip malls across the country. They advertise in newspapers, including The New York Times, on the radio, on billboards and in fliers sent by mail.

CAT Scan 2000, a Florida company with mobile units that travel the nation's two-lane highways, stopping at places like the North Park Church of Christ here, charges $199 to scan any of three regions of the body, or $567 for all three.

It proudly calls itself the Wal-Mart of scanning.

But the growing popularity of these scans raises a conundrum of modern medicine: does a test that can spot such abnormalities actually guard against disease?

A rising chorus of experts and official groups advise people to save their money. They say that under close enough scrutiny, almost everyone will have some abnormality. But do these imperfections constitute a threat to health, and will treatment make a difference?

"We've sold ourselves the myth that getting everything early is always good," said Dr. Larry Kessler, the director of the office of surveillance and biometrics at the Food and Drug Administration.

But now, he said, with scanners that can find lumps smaller than a millimeter, or four-hundredths of an inch, what does early detection mean?

"No one knows the significance of a one-millimeter nodule," Dr. Kessler said. "No one."

He added that the tests are safe and effective in a literal sense: they are not harmful in themselves, and they are effective in finding abnormalities. But, he said, that does not necessarily mean that patients benefit from them. While the tests themselves are generally not covered by insurance, the health care system may well bear the cost of follow-up tests and operations for the abnormalities they detect.

"That's where science, the marketplace, and patients are caught in a bind," Dr. Kessler said. "This is a pretty heavy-duty exam that seems to have sort of escaped into the marketplace. We have a technology that's gotten caught in the gaps between the scientific agencies, the regulatory agencies, and the payers who pay for health care of all sorts. The fair evaluation of these procedures is no one's province. That's the gap here."

Those who provide the scans say they are a real service.

Dr. Kenneth H. Cooper, chairman and chief executive of the Cooper Clinic in Dallas, says he was one of the first to offer whole body scans, in the mid-1990's. The research arm of his center, the Cooper Institute, is in the midst of a federally financed study of heart scans to determine whether they have medical benefit. Meanwhile, the clinic is offering them with whole body scans, more than 35,000 to date. Dr. Cooper says he believes the scans are saving lives, adding that he and his wife have had several.

Cooper Clinic doctors have found, for example, small, solid kidney tumors in 70 people who had no symptoms, and all but three turned out to be cancerous.

"We know that if it breaks through the kidney capsule, only 6 percent survive the next five years," Dr. Cooper said. "Do you want to take that chance? I don't."

Some radiologists say full-body scans can be so profitable that it is almost irresistible to offer them. With patients paying out of pocket, there are no insurance companies to haggle with. "They make money, big time," said Dr. E. Stephen Amis Jr., vice chairman of the board of chancellors of the American College of Radiology. "People see an opportunity here and they grab it."

The six mobile units from CAT Scan 2000 are each staffed by a technologist who runs the scanner and a receptionist who takes the cash payments in advance. The units stop for a day at each place, arriving at small towns and cities in the South, Southwest, and Midwest, usually setting up in church parking lots. (The pastor gets a coupon for two free scans.) Radiologists at the company headquarters in Clearwater, Fla., read the scans and mail reports to clients in a few weeks.

Gina Johnson, the company's chief executive, says arguments against early detection for its own sake "do not make common sense to a layperson."

"Does it make sense to tell people they should not be allowed to have a scan because they will be overanxious?" she asked. "Does the chance of saving your own life outweigh the chance that the tumor is benign?"

The customers who flock to CAT Scan 2000's units say, in so many words, that an ounce of prevention is worth a pound of cure. Gary Cooper, a nurse in Columbus, compared his body to his car.

"I've got vehicles with 320,000 miles on them," Mr. Cooper, 56, said. "They don't get there by my not taking good care of them."

Tanya Ingle, 47, also a nurse, said she wanted a chest X-ray because she used to smoke and her uncle had lung cancer. Her doctor refused, telling her there was no medical indication. So, she said, when she saw fliers for the CAT Scan 2000 unit at her hospital she called for an appointment and came for a lung scan.

Ronald Remy, 52, a retired purchasing agent for the state government, worried about heart disease. His brother had had quadruple bypass surgery, and he himself was feeling fatigued. A stress test showed nothing wrong, he said, but his brother had also had a stress test that showed nothing wrong. "The worry wears on you," he said. After my brother's bypass, I had nightmares."

Mr. Remy brushed off medical authorities' concerns about the scans. "I'd rather be safe than sorry," he said.

Dr. William Casarella, chairman of the department of radiology at Emory University, says that argument is a bit too seductive.

Dr. Casarella should know, because he inadvertently ventured into the world of unforeseen consequences from a scan.

It began when he had a virtual colonoscopy, a new test in which a CT scanner examines the colon for polyps. His colon was normal but other parts of his body, that show up in the scan, were not. "A renal mass was detected, as was a liver mass as were multiple nodules in the base of my lungs," Dr. Casarella said.

He had another scan, using a special dye, to examine his kidney and learned that the lumps were renal cysts, a common and innocuous occurrence. In fact, Dr. Casarella said, half of all people over 50 have them.

But the inch and a half lump on his liver was still a mystery even after another scan with a dye. So he had a biopsy. "The pathologist couldn't tell whether it was benign or malignant," Dr. Casarella said.

"Then we had the lung lesions," he continued, which looked as if they could be cancer. He had two options: he could wait to see what happened. Or he could have a major operation to find out what they were. If they were cancer, however, the operation would not cure him because there were too many lumps and they were too large.

"I didn't want to sit around thinking I had a malignant lesion," he said. "A lot of that was psychological — I was either normal or I was terminal. It's kind of tough going around for a couple of years thinking about that."

His surgeon told him that they would have to collapse his lung and take out a piece. "He said, `This is not trivial. You're going to be sick and have a lot of pain,' " Dr. Casarella said. "I said, `Not me. I'm tough. I'll pop right up.' Of course, he was right."

It took eight weeks, Dr. Casarella said, before he felt normal again, and the bill for the surgery and the hospital stay was $47,000. His insurance paid, but, Dr. Casarella said, "it doesn't matter who pays — it's a lot of money."

The lung nodules turned out to be scars from an old histoplasmosis infection, a common fungal disease that is of no consequence in healthy people. That also explained his liver nodules, Dr. Casarella said.

If he had had a total body scan, it would not have been able to rule out colon cancer because patients have to be prepped for that, with their colons voided of stool and filled with carbon dioxide. The colon exam also has to be done twice, once with the person face down and once face up.

But a total body scan would have found the masses in his kidney, liver, and lung, Dr. Casarella said.

Of course, Dr. Casarella said, the scanning centers point to grateful patients.

"They have poster children. Here's a patient we found who had a renal cancer. We took it out and he's cured. I'm sure that's a true story, but how many patients did they screen to find it, was it going to kill the patient, how big was it, was it invasive?"

The very idea of total body scans promoted to the general population makes him shudder. "It's a prescription for panic," he said.

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