Population medicine optimises for the average patient. The trouble is that no patient is average. Two people with similar bloodwork can sit on quite different trajectories, and the standard fifteen-minute appointment is rarely where the difference becomes visible. Personalisation is not a panel of tests. It is the willingness to take the long view of one person, and to revisit it as life changes.
The public spine, used well
Australia's preventive infrastructure is quietly world-class. Four national cancer screening programmes, the new National Lung Cancer Screening Program (commenced 1 July 2025) for high-risk smokers, the Heart Health Check from forty-five, an immunisation schedule that compares favourably with any in the world, and a maturing My Health Record now mandated to capture pathology and imaging. Modelled cost-effectiveness ratios for the cancer programmes — around $3,380 per life-year saved for bowel screening, ~$16,632 for cervical, $40–65k for breast — are orders of magnitude better than any private offering. Most private programmes add value only after the public spine has been used properly.
The largest levers are unsexy
Cardiorespiratory fitness, measured as VO₂ max, remains the single strongest physiological predictor of all-cause mortality (Mandsager 2018, n=122,007; no upper limit observed). Grip strength tracks closely. Resistance training adds independent benefit, and the LIFTMOR work out of Griffith overturned a generation of "go gently" advice for postmenopausal bone health. Mediterranean-pattern eating remains the best-evidenced dietary intervention (PREDIMED 2018: ~30% reduction in major CVD events in high-risk primary prevention). Sleep risk is U-shaped around seven hours, with regularity an independent predictor. Protein needs rise with age, not fall. None of this is glamorous. All of it moves hard endpoints in ways no supplement reliably does. Adherence — not knowledge — is the binding constraint.
Investigation that earns its place
When investigation is worth doing, it is chosen for the individual. The new AusCVDRisk 2023 calculator — recalibrated to Australian data, with fields for ATSI status, diabetes, kidney function, social deprivation, atrial fibrillation and a CAC reclassification step — replaces the old Framingham-based tool as the anchor. ApoB and a once-in-a-lifetime Lp(a) refine the picture; coronary calcium scoring in selected adults at intermediate or risk-enhancer-positive lower risk can shift therapy in either direction. CCTA with FFR-CT is now first-line for stable chest pain in current guidelines, supported by DISCHARGE 2022. DEXA where indicated. Multiparametric prostate MRI before biopsy on an elevated PSA (PRECISION 2018). A short, behaviourally informative continuous-glucose-monitor trial in the right person. The point is to answer a question that matters for that patient — not to fill a panel because a panel exists.
Genomics, used carefully
The most consequential genomics in Australia happens in the public system: Mackenzie's Mission for reproductive carrier screening (MBS-funded for cystic fibrosis, SMA and fragile X since November 2023), ZERO Childhood Cancer's precision-guided trial work, and the slow-but-real expansion of pharmacogenomic rebates — DPYD added from 1 November 2025 (a test that flags patients at risk of severe reactions to a common chemotherapy drug), with HLA-B*15:02 next under review. Polygenic risk scores and broader pre-emptive pharmacogenomic panels remain mostly private-pay and useful in narrow indications; the PREPARE trial showed roughly a 30% reduction in clinically relevant adverse drug reactions when patients were tested in advance. APOE and FOXO3 remain the only longevity-associated genes to survive repeated study; the practical translation lies more in rare cardioprotective gene variants reframed as drug targets than in "longevity gene" marketing. Whole-genome sequencing of healthy adults is not currently cost-effective at population level.
Where the hype outruns the evidence
Full-body MRI in average-risk healthy adults remains poorly supported: incidental findings are common, the investigations they trigger are not benign, and there is no mortality signal. Unselected whole-genome sequencing in healthy adults is low-yield. Most "longevity supplements" lack randomised-trial evidence against hard endpoints. Hormone "optimisation" outside diagnosed deficiency, and the wider stem-cell, exosome, peptide and NAD⁺-infusion market, sit awkwardly with the TGA's Biologicals and Personalised Medicines frameworks and the advertising restrictions in s.133 of the National Law. The honest claim for premium executive health checks is that they may improve adherence and continuity — not that they add hard-endpoint benefit beyond what national programmes already deliver.
Personalisation as a relationship
Personalisation is not a one-off report. It is a relationship over time, in which the picture is revisited, refined as life changes, and anchored to evidence rather than fashion. Continuity itself is therapeutic — Pereira Gray's 2018 review of 22 studies found relationship continuity with a doctor independently associated with reduced mortality. The aim is to support performance now and capability later — treated as a single problem rather than two — and to do so without manufacturing patients out of healthy people.
§ For professionals — mechanisms & evidence+
Burden & economic frame
AIHW Australian Burden of Disease Study 2024: 5.8 million DALYs lost; chronic conditions account for 91% of non-fatal and 78% of fatal burden. Leading disease causes of DALY — coronary heart disease, dementia, back pain, anxiety disorders, COPD. Total health expenditure $270.5 billion in 2023–24 (10% of GDP); chronic conditions $98 billion. OECD prevention spending averaged ~3% of total health expenditure in 2023 (peaking at 6% during COVID-19). Masters 2017 — median ROI 14.3:1 across 52 studies, 27.2:1 for national-level interventions.
The Rose tension
Rose 1985 — population shifts deliver the largest aggregate benefit but small individual returns (the prevention paradox). Stratified, precision and personalised are not synonyms. Heterogeneity of treatment effect and NNT temper enthusiasm. Bonneux 1998 — preventing fatal disease shifts mortality into older, expensive illness; not an argument against prevention, but against simplistic "savings" claims.
Public spine — efficacy and economics
NBCSP (iFOBT, 50–74) — modelled CER ~AUD $3,380/LYS; 41.7% participation in 2025; non-invitees historically had ~28% higher bowel-cancer mortality risk. BreastScreen Australia — biennial mammography 50–74, CER $40,279–$65,065/LYS; mortality fell 74→37/100,000 women (1991→2022). National Cervical Screening Program — 5-yearly primary HPV from age 25; self-collection universal since 1 July 2022 and rose from 1.2% to 26.9% in under two years; CER ~$16,632/LYS (Lew 2017). National Lung Cancer Screening Program — commenced 1 July 2025; biennial LDCT for 50–70 with ≥30 pack-years; Behar Harpaz 2024 modelled ~62 lung-cancer deaths prevented per 100,000 screened.
Cardiovascular refinement
AusCVDRisk 2023 — first Australian recalibration (based on NZ PREDICT-1°), includes ATSI status (from age 30), T2DM (from age 35), eGFR, social deprivation, AF and a CAC reclassification field. Heart Health Check (MBS 699, since 1 April 2019) — 427,336 claims Jan 2023–Feb 2025. ApoB over LDL-C in discordance (Marston 2022; Sniderman 2019). Once-in-a-lifetime Lp(a) — risk-enhancer at ≥50 mg/dL; RNA-targeted lowering therapies in late-stage trials. CAC scoring — recent MESA reanalysis reclassified ~10–17% of borderline-risk individuals over 16.7 years. CCTA + FFR-CT — DISCHARGE 2022 non-inferior to invasive angiography for MACE in intermediate-pretest-probability stable chest pain; now first-line in ESC and AHA/ACC guidelines.
Cancer — beyond the public set
Prostate — PRECISION 2018: mpMRI before biopsy increased clinically significant cancer detection (38% vs 26%) and reduced insignificant diagnoses (9% vs 22%). Lung — NELSON 2020: 24% relative reduction in lung-cancer mortality in high-risk men at 10 years. Multi-cancer early detection — PATHFINDER (Schrag 2023) more than doubled cancers detected when added to standard screening; PATHFINDER 2 reported PPV 61.6% in 25,578 participants; NHS-Galleri mortality outcomes pending; no MBS listing. Skin — Australia has the world's highest melanoma incidence; total-body photography and AI-assisted dermatoscopy emerging; no MBS-funded population screening. AI in mammography and colonoscopy — non-inferior or improved performance with reduced reader workload.
Metabolism & body composition
HbA1c standard; fasting insulin and HOMA-IR stratify pre-diagnosis insulin resistance but lack lab standardisation. Hall 2018 and PREDICT/ZOE — predictable post-prandial heterogeneity, limited hard-endpoint data. CGM PBS-listed for T1DM only. Waist circumference cheapest; DEXA quantifies visceral fat but MBS rebate is restricted to defined indications (glucocorticoid use, prior fragility fracture, malabsorption), not general body-composition screening. hsCRP/IL-6 — residual inflammatory risk; hsCRP supported by CANTOS and JUPITER for statin allocation in low-LDL/high-CRP.
Genomics & pharmacogenomics — Australian state of play
Mackenzie's Mission — RGCS in >9,000 couples; from 1 Nov 2023 MBS items 73451/73452/73453 reimburse essential RGCS for cystic fibrosis, SMA and fragile X. DPYD pre-fluoropyrimidine — MBS Item 73322 effective 1 Nov 2025. HLA-B*15:02 pre-carbamazepine under review. CYP2D6/CYP2C19 — relevant to codeine, tamoxifen, clopidogrel, SSRIs; private only. U-PGx PREPARE (Swen 2023, Lancet) — pre-emptive panel testing reduced clinically relevant ADRs ~30%. Polygenic risk scoring developing for CHD, breast (BCAC PRS313), T2DM, AF. APOE and FOXO3 remain the only longevity-associated loci to survive replication; the practical translation lies more in loss-of-function variants reframed as drug targets (PCSK9, ANGPTL3, APOC3) than in 'longevity gene' marketing. Stark 2019 — WGS of asymptomatic adults not currently cost-effective at population level.
Ageing biomarkers — useful but immature
Epigenetic clocks — Horvath, Hannum (1st-gen, chronological); GrimAge, DunedinPACE (2nd-gen, mortality/disease-trained). CALERIE (Waziry 2023) — 25% caloric restriction slowed DunedinPACE by ~2–3%. GDF-15, IGF-1, p16INK4a emerging but not validated for clinical decisions. Frailty index, sarcopenia (SARC-F, grip strength) and VO₂ max remain the most practical composite surrogates.
Behavioural change — the binding constraint
Michie COM-B; MINDSPACE; EAST. Wolever 2013, Kivelä 2014 — modest, consistent coaching effects on adherence, BMI, glycaemia. Diabetes Prevention Program (Knowler 2002) — 58% reduction in incident T2DM with intensive lifestyle vs 31% with metformin. Pereira Gray 2018 — relationship continuity associated with reduced mortality across 22 studies. Adherence is the binding constraint, not knowledge.
Over-hyped / unsupported
Full-body MRI in asymptomatic average-risk adults (ACR and AHA caution; high incidentaloma rate, no mortality evidence). Unselected whole-genome sequencing in healthy adults. Most "longevity supplements". Premium executive health checks beyond what national programmes deliver. Hormone "optimisation" outside diagnosed deficiency. Stem cell, exosome, peptide and NAD⁺ infusion clinics — TGA Biologicals Framework and Personalised Medicines Framework apply; advertising restrictions under s.133 of the National Law.
Australian regulatory architecture
AHPRA/Medical Board — s.133 advertising restrictions: no testimonials, no misleading claims, no creating unreasonable expectations. TGA — therapeutic goods, devices, biologicals, Personalised Medicines Framework. MSAC — HTA for new MBS listings (DPYD application 1760, NLCSP). PBAC — pricing/reimbursement, informal ~AUD $50,000/QALY benchmark. RACGP Red Book (9th edition). Choosing Wisely Australia (RACP-led) — explicit "do not" recommendations across specialties.
Is private 'longevity medicine' a substitute for the national screening programmes?+
No. The four national cancer screening programmes, the National Immunisation Program and the new National Lung Cancer Screening Program (from 1 July 2025) do most of the population-level work, at incremental cost-effectiveness ratios no private offering matches. Private preventive medicine is additive — it refines individual risk and supports adherence — but only once the public spine has been used properly.
Why is ApoB preferred to standard LDL-C for cardiovascular refinement?+
ApoB counts atherogenic particles directly; LDL-C estimates cholesterol mass within one lipoprotein class. Marston 2022 in UK Biobank and large trial cohorts found MI risk was best captured by apoB-containing particle number, independent of lipid content or lipoprotein type. ApoB unifies VLDL, IDL, LDL and Lp(a) signals into a single, discordance-resolving measure.
Should I have a coronary artery calcium score?+
CAC is most useful in intermediate or risk-enhancer-positive lower-risk adults, where it can up- or down-shift statin and lifestyle intensity. A score of zero confers low near-term risk; ≥100 supports moderate-to-high-intensity statin therapy. There is no Medicare rebate for screening CAC in Australia; typical out-of-pocket cost is around AUD $180–200.
Is whole-body MRI a sensible screening test in healthy adults?+
Not at present. The American College of Radiology and AHA both caution against it for asymptomatic average-risk adults: incidentalomas are common, downstream investigation cascades are not benign, and there is no mortality evidence. Selective imaging that answers a specific question for a specific patient remains the more defensible approach.
What does meaningful personalisation actually look like?+
A longitudinal relationship anchored to validated tools (AusCVDRisk 2023, mpMRI before prostate biopsy, DPYD pharmacogenomics from 1 November 2025) and to hard endpoints — mortality, major cardiovascular events, fracture, incident type 2 diabetes, cancer-specific survival. Continuity itself is therapeutic: Pereira Gray 2018 found relationship continuity with a doctor independently associated with reduced mortality across 22 studies.
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