Deciding about screening can be complex. First, we must distinguish screening from case-finding. It is always important for primary care physicians to ask appropriate questions and listen carefully to detect early symptoms that patients may not immediately offer—case-finding. All agree that people with signs or symptoms need to be evaluated. Screening as used here involves people with no signs or symptoms of the problem being discussed.

Although it is difficult to be opposed to finding disease earlier—screening sometimes does extend life and/or improve the quality of life—screening also has its down side. The harder we look for disease in asymptomatic people, the more we find not only the diseases that we seek, but also “pseudo-disease”—conditions that have some appearance of disease but never cause problems for real people. There are many examples: early cervical dysplasia, small (less than 5 mm) colonic polyps, many cases of ductal carcinoma in situ of the breast, small (3 to 3.9 cm) abdominal aortic aneurysms, many cases of prostate cancer, and probably many of the “abnormalities” found on total body computerized tomography screening. It is difficult to think of a screening situation where there is not some degree of detection of “pseudo-disease.”

Ideally, we would recognize pseudo-disease for what it is—a “lesion” that needs no treatment. Unfortunately, this is often difficult to …