All about check-ups
It is essential that we tailor the components of each check-up to the individual. Past medical history, family history, age and life-style all alter the pattern of tests that we perform.This is why I disapprove of the approach taken by the larger check-up organisations such as BUPA - you cannot do the same check-up on each person.

And a check-up test is only useful if we have a reasonable chance of detecting something wrong, and more importantly, it helps us to put something right before it causes more serious problems. This is the concept of "outcome data" and it's a difficult one to understand. A classic example of this is the recent bombshell that what we eat has little or no outcome on future coronary artery disease risk. We have been nagging patients about their diet in this respect for 20 years only to find that it makes not a blind bit of difference.

At a Mayo Clinic cardiology conference a few months back I memorized a startling sound byte: "cholesterol is no longer a nutrient of concern for over-consumption".

So much for egg-white omelets....

First things first
About 50% of deaths are due to modifiable external factors, such as alcohol, tobacco, drugs, weight and exercise patterns, and accidents - so it's a bit of a waste of time worrying about your cholesterol level if you continue to smoke and drink to excess, worry constantly about your work and take no form of regular physical exercise. 

What pathology tests?
Trying to decide which blood tests to do for each patient is difficult. There are hundreds of tests to choose from, and I have to try to select those which will benefit you, thinking about your lifestyle, your family history, and what you've told me about when we discussed your various concerns. Of course these routinely include tests for cholesterol, kidney and liver function, blood sugar, haematology and the like.

And not forgetting the thyroid - thyroid deficiency is an easy thing to miss - and as it often follows childbirth it's particularly important not to assume a tired new mum is just - well - tired! I think it would be great idea if all new mums were checked for this 3 months after delivery or so.

I like to perform a prostate specific antigen (PSA) first as a baseline in all men at 40. This conforms to the guidelines of the American Cancer Society, but a little earlier. It's an easy test to do, but the worry is that we often find that a raised level of PSA is associated with a perfectly normal prostate gland. This is called a false-positive test - but it's a good sort of false isn't it? If a screening test is frequently false-negative it means that sometimes we are going to miss something important.
Unbelievably, there are still many doctors who feel that we shouldn't measure PSA routinely at all. They base this belief on the lack of proof that screening for prostate cancer affects the mortality from this disease. But men with prostate cancer on average lose 40% of the rest of their lives. And 75% of these deaths are due to the presence of metastases - where the cancer has spread, commonly to the bones. So even if we don't have the gold standard of proof, it seems that screening for, and treating prostate cancer will save lives.

PCA3 gene test for Prostate cancer
Because of our special relationship with the lab we were the first practice in the UK to be offered this new gene test for prostate cancer. If the PSA is raised we now have an alternative to going straight to a biopsy. A urine sample is sent to the lab and a search performed for the Prostate Cancer Antigen 3, a substance over-expressed (over produced) by prostate cancer cells. If levels are low we can often just keep a close eye on the PSA levels and reassure the patient that a cancer is very unlikely.

New markers for vascular disease risk
First we had cholesterol, and if your cholesterol was less than 6 you were a happy man. Then we started to break cholesterol down into its components - the HDL or "good" cholesterol, and the LDL or "bad" cholesterol. Next we started to move the goalposts, reducing the levels considered normal - it's down to 5 now for the total cholesterol.

Now we realise that other substances we can measure in the blood may have a greater predictive value than cholesterol, and correlate more closely with a future risk of developing heart disease.

The first of these was plasma homocysteine. This is an amino acid (one of the building blocks for body protein) derived from food, and an essential nutrient. The body needs it in moderation. But too much seems to cause damage to the lining of arteries, converts "good" cholesterol to "bad", and perhaps even promotes the formation of clots. There is a strong link between raised levels of the amino acid and arterial disease. Unfortunately it now seems that lowering the Homocysteine level has absolutely zero effect on heart disease so we have given up measuring it. Another example of the concept of "outcome data".

Many other substances are now known to be linked to heart disease risk. So a full cardiovascular risk work-up might include such exotica as Lipoprotein(a), Apolipoprotein B, Troponin-T, NT-ProBNP, D-dimer and high-sensitivity C-reactive protein. But the most exciting thing is that a lot of these new markers for vascular risk are also markers of inflammation in the body. The theory is that generalised inflammation may make plaques of atheroma laid down in the walls of arteries unstable in some way, allowing them to break off more easily, and clog up the artery causing a heart attack or stroke. 

So just remember that it's not just your cholesterol any more. If we are going to check you out thoroughly for the risk of developing heart disease we have to know if you're inflamed.

What other scans and X-rays?
There seems to be a wide divergence of survival rates for different cancers between the UK and the US and I believe that part of this is due to our attitude to screening for cancer. So here is the latest information from the American Cancer Society, and our screening protocols follow this closely.

Breast cancer - Mammography should be performed every year from age 40
The new digital mammography and computer-assisted diagnosis help us to reduce the risk of missing small tumours, and also of unnecessary biopsies. How dare the NHS winge about the frequency of breast cancer in older women and still stop performing mammography at 70. This should be illegal under the ageism laws.....

Colon cancer - A screening test should be performed from age 45
This means either annual faecal occult blood testing, or colonoscopy every 10 years. Faecal occult blood tests have been shown to reduce mortality from bowel cancer by 15-30% - and the benefits of colonoscopy are probably greater. Sometimes this test detects a polyp. As these are considered pre-malignant, here is a rare opportunity for us to prevent a cancer forming. I love this test - it's the only time I can tell a patient we have a written guarantee that they won't get a common cancer for 10 years.

I can't see the point of virtual colonoscopy; imaging the bowel with a scanner. Although it has been shown to be equally good at finding small polyps if we do find one it means another night of laxatives and a normal colonoscopy to snip it off - waste of time and effort in my opinion.

Prostate cancer - Annual PSA test from age 50
Here's one where I differ somewhat from the ACS guidelines - firstly we start testing the PSA earlier, from age 40 - it's so simple to do it as part of a routine blood screen and I prefer to have a baseline measurement in the file. Also I don't personally believe that digital rectal examination adds anything to the rate of diagnosis. I feel that the PSA is far more sensitive to early cancer than my finger, and the idea that rectal examination is an adequate test for bowel cancer is nothing short of fraud unless the examining doctor has an index finger three feet long! “Rectal examination adds nothing to the early diagnosis of prostate cancer”.

Cervical cancer - A smear every three to five years
The American Cancer Society recommendations have changed. The latest recommendations are that a smear can safely be performed every three years on its own, or if combined with testing for human papilloma virus simultaneously the interval may be extended to five years.
This is common sense really. It appears that this virus is absolutely necessary for the formation of a cervical cancer, so if you are in a steady relationship you are probably not going to catch it unless you are having an affair with the gardener.
Urine testing for HPV is on the way - that should eradicate the need for smear tests completely. I think that’s a change that will be embraced by many women.

Lung cancer - Routine Chest CTs may be helpful in smokers but it's early days
Such a common cancer, but we still have no good screening strategy. Routine chest x-rays certainly don't help and I've more or less given up on these, even in smokers. Chest CT scanning is currently under investigation as a screening modality. When you do chest CTs routinely, you do find pulmonary nodules. But we have no idea which of these nodules will go on to be early lung cancers. This means multiple follow-up scans in healthy patients to detect the very occasional tumour - and there is no evidence yet that this is a strategy that we should follow.

We got very excited in 2008 when a study suggested that routine CT scans in smokers reduced the risk of dying from lung cancer - until someone blew the whistle on the tobacco company that had funded the research.

We now have evidence that regular chest CT has a benefit in early diagnosis in those with a significant smoking history. See the section on scans for more about this.

Ovarian cancer - No screening strategy proven beneficial
It may be helpful to start screening women for ovarian cancer after the menopause, when the risks of ovarian tumours begin to become appreciable. A trial is underway of the use of pelvic ultrasound plus a tumour marker in the blood called CA-125 in routine screening for ovarian cancer, but this is an area of debate, and it is not yet established whether performing these tests routinely reduces ovarian cancer mortality. I like to do the ovarian cancer marker regularly on the basis that it may well help diagnose what is otherwise a disease that tends to present itself late - sometimes too late.

Skin cancers - Report anything suspicious - and if in doubt we'll refer you to an expert
Melanoma is on the increase and now affects about 1 patient in 10,000. This risk doubles following about 10 sun-bed treatments. Doctors have not been good enough at diagnosing these lesions early, nor patients at reporting changes in moles. Please point out any moles that worry you, or you feel may have changed in any way. Because of the difficulty in being certain that a lesion is benign, I tend to refer early for a specialist opinion. We have new technology available to perform digital photography of moles - mole mapping. I can't really see the point of this at present when we have such expert dermatologists available. I suppose it might help if you don't have a friend or lover who can keep an eye on those parts of your skin you can't see for yourself.