“How are you doing? It’s nice to see you again.”

“OK,” she replies, unusually tersely.

“How was your daughter’s wedding? I thought of you when the sun came out.”

“Yeah, it was good.”

And then, she burst into tears.

“Is everything OK?”

“Look love, I don’t mean to be rude but can you just tell me what my test showed? I haven’t slept all week and am nauseous with worry. I can’t take this anymore.”

“You had a test? But I didn’t order one. Your breast cancer has been stable for some years.”

“My GP did, and said you’d have the results. You mean you don’t know?”

Conventional medical training teaches doctors to start with perfunctory questions and build rapport before delivering significant news. After all, patients, especially in the public health system, don’t always see the same doctor and it’s important to cover or recap important details.

I used to greet patients at the door, ensure they were comfortably seated with phone turned off, hearing aid tuned in and notebook ready. I’d exchange a few pleasantries to humanise the interaction. But frankly, I am surprised it has taken me so long to appreciate that no oncology consultation goes far without first relaying the news of “the test”. “The test” is an umbrella term encompassing all manner of bloods and x-rays – haemoglobin, biochemistry, liver function, tumour markers, CT scans, PET scans and the rest. From the moment of their cancer diagnosis, patients are wedded to “the test”.

It’s different for brand new patients who are resigned to repeating their story multiple times to multiple doctors but when long-term patients return for their regular check-up they have one thing on their mind. So I have learnt to get to the point fast.

If the news is good, I tell the patient as soon as we’re out of earshot: “Your tests were fine, come and sit down.” Grips loosen, shoulders relax and some days you can feel the hiss of dissipating tension. When the news is bad, I escort the patient to a chair, make eye contact, and say, “I’m afraid the scans found a problem – we’ll have plenty of time to discuss this.”

Everyone does it differently but over time, I have decided this is kinder than, “How are you? Let’s go over any symptoms before we get to your results.”

Every patient has a story about spending sleepless nights and nail-biting days, fearing the worst but praying for a reprieve. When someone cries with relief at a scan that I’d always expected to be normal, I can’t help reflecting on how automatically scribbled test slips have the power to govern people’s lives.

“Your bone scan was normal again. There was no sign of cancer in your spine, only arthritis,” I recently reassured an elderly man with prostate cancer. He suffered from chronic back pain but the moment he mentioned it to a new provider, he scored himself another test. This time, a chiropractor had encouraged him to ask his GP for a scan.

Tests crowded his life – he rued that there wasn’t an event in recent times that hadn’t been disrupted by an appointment or a test, from his nephew’s wedding to his sister’s funeral. Knowing that I’d played a part in his misery, I suggested, giving him a break from tests. “They don’t really help nearly as much as talking to you and seeing how you are doing,” I said. But his wife was quick to squash his glee, “Oh no, I’d go mad not knowing! You must do a blood test at least.”

As cancer patients are living longer, they are seeing their oncologists more and many visits are accompanied by some sort of test. In the case of breast cancer, but also others such as prostate and colon cancer, blood tumour markers are used to track tumour activity, with changing markers often triggering costly scans. Patients regard painful and inconvenient tests as the cross to bear if they are to stay alive. After all, without tests how will their oncologist know what’s going on inside their body? For oncologists, writing test slips is as routine as breathing.

But the evidence suggests that cancer patients who are not receiving chemotherapy and are not enrolled in clinical trials do not need frequent testing. Depending on the disease, professional guidelines have long recommended against so-called “routine” testing in cancer surveillance but patients continue to receive them. Not all tests are ordered by oncologists – in a fragmented environment, patients see multiple providers. They order a test hoping it will reveal something that a good history won’t but this is seldom the case.

Pathology and radiology tests have grown by around 10% each year. The Grattan Institute estimates the overall cost of wasteful healthcare spending to be as much as a billion dollars.

It might seem intuitive that early detection of disease progression through tests might be helpful in instituting or switching therapies, avoiding unnecessary toxicity and guiding therapeutic choices but there is no evidence that a particular test done at a particular interval alone determines a change in course.

On the other hand, there is evidence that more tests cause more anxiety. Up to 65% of patients with advanced cancer are said to suffer some form of psychological distress. Undergoing frequent tests, not clearly understanding why and waiting weeks, even months, for results traps them in an unenviable situation. Patients who are preoccupied by test results have been shown to have a worse quality of life.

A recent study of more than 2,000 American women with metastatic breast cancer published in the Journal of Clinical Oncology found that more than a third of their providers were “extreme users” of blood tests and scans. (Here, extreme use was defined as more than 12 tumour marker tests and more than four scans per year.) Patients who were cared for by these providers had a 60% higher cost of care, more hospital-based care and later use of palliative care. A previous study found that tumour marker measurements in a range of advanced cancers altered management in a mere 2% of patients.

The overuse of pathology and radiology tests is by no means a problem specific to oncology but cancer patients are among the most heavily investigated, with the direct cost of cancer care in Australia reaching over $4.5bn.

Entrenched physician practice is hard to change through guidelines alone. In one study, over 90% of oncologists reported that repeat tests were ordered by someone simply copying the previous order. Without being constrained by rigid rules, doctors must be accountable for the tests they order. Making doctors aware, individually where possible, of the cost of tests, has been shown to influence practice, at least in the short-term. Awareness of the myriad costs of over-investigation must begin early in a doctor’s career. Good clinical practice means asking with every test ordered, “How will the results change my management?”

Patient expectations play a role in the prescribing habits of doctors. Comparisons in cancer are rife. “My neighbour with the same cancer gets a test every time, why don’t I?” is a common question posed to oncologists. The answer is not to order the test, rather to educate the patient. Patient surveys show a willingness to understand and avoid the harmful effects of indiscriminate testing. A key motivation for enduring tests is a feeling of security but patients need to understand that a good doctor-patient relationship, where concerns are promptly heeded, is no match for a battery of tests.

When I tell patients I’d rather not order tests that don’t provide meaningful results in their clinical context, they often ask what else they can do to look after themselves, as if submitting to tests were a proxy for self-care. I tell them that there is growing evidence that they should maintain a healthy weight, eat everything but in moderation, get some form of regular exercise, stop smoking and nurture good relationships.

Frequent testing improves neither quality nor quantity of life but these other recommendations nod to the foremost tenet of medicine, first do no harm.