Here is more evidence of drug company influence on patient advocacy groups.
The need for disclosure is so clear - so that sick people are not misled into thinking that all of the information they get from some advocacy groups is unbiased and free from outside influence.
I am continuing my criticism of journalists and news organizations that crusade for screening tests – seemingly oblivious to the controversies and the debates that swirl around many of these screening tests. When a news organization takes an advocacy stance for a controversial cause, it should know the facts and the facts are that some people will be hurt by their advocacy efforts.
The latest example is the Chicago Sun-Times, which is sponsoring free prostate cancer screenings throughout the Greater Chicago area this week. A Sun-Times news release states: “Men ages 40 and older are urged by the health officials to take advantage of the screenings” which include a PSA blood test and a digital rectal exam.
But the U.S. Preventive Services Task Force (USPSTF) – perhaps the nation’s best, unbiased, balanced source on such questions concludes “that the evidence is insufficient to recommend for or against routine screening for prostate cancer using prostate specific antigen (PSA) testing or digital rectal examination (DRE).”
But the Sun-Times didn’t stop by sending out news releases. It ran a story about its own campaign.
The story stated, under the heading “GET TESTED,” “Men ages 40 and older can stop by one of the mobile clinics for the free, private prostate cancer testing and physical exam.”
The USPSTF tells men that “screening is associated with important harms, including frequent false-positive results and unnecessary anxiety, biopsies, and potential complications of treatment of some cancers that may never have affected a patient's health. The USPSTF concludes that evidence is insufficient to determine whether the benefits outweigh the harms for a screened population…. Screening may result in harm if it leads to treatments that have side effects without improving outcomes from prostate cancer, especially for cancers that have a lower chance of progressing. Erectile dysfunction, urinary incontinence, and bowel dysfunction are well-recognized and relatively common adverse effects of treatment with surgery, radiation or androgen ablation.”
John Cruickshank, Sun-Times News Group Chief Operating Officer, is quoted in his news release saying, “The program demonstrates how the Chicago Sun-Times provides our readers with important, and in this case, life-saving information for residents of the Chicago region.”
The story should be that the Chicago Sun-Times ignores the best evidence in promoting prostate screening to all men – and in promoting it to men in their 40s, they have not only taken an advocacy stance but a radically aggressive stance that may find a few cancers but will also certainly expose some men to unnecessary harms. One can only wonder what the informed consent form looks like during these quickie exams (20 minutes, says the news release) in these mobile clinics.
Two great stories on page one of the Wall Street Journal today.
One is a followup to yesterday's story about Thailand standing up to Abbott Laboratories about drug pricing, and about how "Abbott's troubles in Thailand suggest that cracking the new markets can be tough because governments are driving a hard bargain on price."
The other story is about "how an e-mail rant jolted a big HMO." Excerpt:
On a Friday morning last November, Justen Deal, a 22-year-old Kaiser Permanente employee here, blasted an email throughout the giant health maintenance organization. His message charged that HealthConnect -- the company's ambitious $4 billion project to convert paper files into electronic medical records -- was a mess.In a blistering 2,000-word treatise, Mr. Deal wrote: "We're spending recklessly, to the tune of over $1.5 billion in waste every year, primarily on HealthConnect, but also on other inefficient and ineffective information technology projects." He did not stop there. Mr. Deal cited what he called the "misleadership" of Kaiser Chief Executive George Halvorson and other top managers, who he said were jeopardizing the company's ability to provide quality care.
"For me, this isn't just an issue of saving money," he wrote. "It could very well become an issue of making sure our physicians and nurses have the tools they need to save lives."
Read the whole story. Especially with all the claims being made about the power of health information technology and what can be achieved by conversion to electronic medical records, it is enlightening to hear a bit about one insider's view.
Thailand - little Thailand - has stood up to drug companies in ways the U.S. has not or will not. Read today's Wall Street Journal story.
But the U.S. - even with changes in Congress - can't muster the courage to even negotiate drug prices for Medicare. As Paul Krugman wrote in the New York Times:
"... The political news over the last few days has been grim. ...The Senate failed to end debate on a bill — in effect, killing it — that would have allowed Medicare to negotiate over drug prices. ...[I]n spite of overwhelming public support..., 42 senators, all Republicans, voted no."
Guess the drug lobby isn't as strong in Thailand.
There’s a saying about the some of the problems with screening tests: How much disease you find may be a matter of how hard you look.
Recently, I have evidence that how many problematic news stories on screening tests you find is only a matter of how hard you look.
I won’t repeat episodes I’ve already written about on this blog. Just click on the screening category - http://blog.lib.umn.edu/schwitz/healthnews/cat_screening.html - to see the past evidence. But here are some new examples.
1. Tom Burton, in the Wall Street Journal this week, had an article under the headline, “Three Tests May Foil Artery-Disease Deaths.” He wrote: “Three simple tests that can potentially save thousands of lives from strokes, aneurysms or other arterial problems are getting a big endorsement today. …As of today, the Society for Vascular Surgery, representing the nation's 2,400 vascular surgeons, is for the first time recommending these three tests to screen for artery disease in many people 55 years old and over.”
But the only professional perspectives he included were from vascular surgeons. He could have easily included a perspective such as the one I elicited from Dartmouth’s Dr. Gil Welch, in response to the story: “Screen many, to find the few --while many others get labeled at risk in the process. And thus many will be treated "wrong", have an immediate operation for which the risks exceed the benefit. To see the full effects, you need to randomize. And there has been no randomized trial showing its net effect.”
This story was reported by a veteran, Pulitzer-winning journalist at one of the newspapers whose health coverage I respect the most. Yet he reported a one-sided story with a clear pro-screening emphasis.
2. CNN’s Elizabeth Cohen last week had a story in which she listed an entire litany of screening test recommendations for women – many of them unsupported by the best medical evidence. Perhaps the most glaring was this: “At 40 … women need to start having mammograms every year.” Are she and CNN totally unaware of the controversy over mammography in the 40s, fired anew most recently by the American College of Physicians just two weeks ago? Her statement – as if fact – is simply not supported by the ACP or the U.S. Preventive Services Task Force, perhaps the most balanced, unbiased source on such questions.
3. Georgia Public Radio last week aired a special report, “Breast Cancer in the African American Community.” On the air they stated, “Typically every woman should start having mammograms at age 40.”
On their website, they stated: “The American Cancer Society recommends that every woman over 40 have a regular screening mammogram.”
It is another example of journalists appearing to be oblivious to the contrary recommendations of other learned bodies of experts in this country.
What accounts for this apparent pro-screening bias seen in some stories? I’m going to continue to track these practices and try to investigate journalists’ rationale.
The U.S. Senate today will consider a bill that would correct one of the most short-sighted clauses of any legislation ever passed in this country - the part of the Medicare Part D legislation that kept the government from negotiating the best prices for the drugs now being sold to seniors.
A Star Tribune editorial summarizes some of the folly of the current law:
"When the Department of Veterans Affairs buys prescription drugs for veterans, it negotiates discounts from drug manufacturers. When Medicaid buys drugs on behalf of poor families, it demands the lowest available price. Yet when Congress added a prescription drug benefit to Medicare in 2003, it specifically banned the government agency from negotiating discounts on behalf of senior citizens and taxpayers.That was an egregious and bizarre decision, and Congress should reverse it as soon as possible. ....
It is the biggest new federal entitlement since the Great Society, and it is costing billions of dollars in borrowed money. The least Congress can do is let Medicare get the best bang for the taxpayer's buck."
The Health Affairs website today published a study that shows how physicians are often stretching or breaking the law when they refer patients to diagnostic imaging facilities with which they have a financial relationship. Excerpts:
"Laws enacted during the early 1990s to curb physician self-referral were a major step toward addressing the concerns about these arrangements; however, they contain exceptions that could enable self-referral to reappear but in a different form tailored to fit the exemption. This study is the first to document the prevalence and scope of self-referral arrangements in light of these exceptions. ...Using data from a large insurer in California, we identified the self-referral status of providers who billed for advanced imaging in 2004. Nearly 33 percent of providers who submitted bills for magnetic resonance imaging (MRI) scans, 22 percent of those who submitted bills for computed tomography (CT) scans, and 17 percent of those who submitted bills for positron-emission tomography (PET) scans were classified as "self-referral." Among them, 61 percent of those who billed for MRI and 64 percent of those who billed for CT did not own the imaging equipment. Rather, they were involved in lease or payment-per-scan referral arrangements that might violate federal and state laws. ...
These findings should be of considerable concern to policymakers, employers, insurers, and consumers who recognize the need to control rapidly escalating health care spending. Efforts that address the exemptions in existing federal and state prohibitions on physician self-referral are likely to have major impacts on the increased use that characterizes these arrangements."
The Wall Street Journal has a front-page story today under the headline, "Questions on Efficacy Cloud a Cancer Vaccine: Merck Predicts Big Fall In Cervical Lesions, But Data Are Complex." Excerpt:
"...behind the scenes, Gardasil has been dogged by uncertainty about how effective it really is. Merck won approval for the vaccine based on research that showed it protected against two strains of the human papillomavirus, known as HPV 16 and 18, that are thought to cause 70% of cervical-cancer cases. The Food and Drug Administration didn't ask its panel of experts advising on Gardasil to rule on whether the vaccine specifically prevented the cancer itself. In clinical trials, 361 of 8,817 women who received at least one shot of Gardasil went on to develop precancerous lesions on their cervixes within three years of vaccination, just 14% fewer than in a placebo control group.Scott Emerson, a professor of biostatistics at the University of Washington who sat on the FDA advisory committee, says he's not persuaded the vaccine is worth the billions of dollars likely to be spent on it in coming years. "I do believe that Gardasil protects against HPV 16 and 18, but the effect it will have on cervical-cancer rates in this country is another question entirely," says Dr. Emerson. "There is a leap of faith involved." "
An FDA advisory committee voted 20-1 to reject Merck's request for approval of their hoped-for successor to Vioxx, Arcoxia.
Dr. David Graham said "What you're talking about is a potential public health disaster."
The panel's patient rep, Martha Solonche, said, "The idea should not be we need new drugs. The idea should be we need better drugs."
Princeton economist Uwe Reinhardt, on the Health Affairs blog, counters claims made in an earlier Health Affairs article about what high-deductible "consumer driven health plans" (coupled with health savings accounts or HSAs) will be able to accomplish. Excerpt:
“…the very high degree of out-of-pocket spending visited on individuals and families by many of the HSA products now on the market guarantees that especially low-income Americans are very likely to tighten their belts und forego health care they would have wanted under the more comprehensive, conventional insurance products. This self-rationing by price is doubly guaranteed, because the tax-preference accorded to HSAs effectively makes health care more expensive for low-income persons than for high-income persons.On the other hand…the HSA/high-deductible construct is not likely to alter significantly the health-care behavior of high income people …. For one, high-income individuals and families will be able to absorb high deductibles with relative ease into their higher incomes. Furthermore, as noted, the tax code actually makes health care cheaper for high-income families, relative to Americans with lower incomes. With the government picking up close to half of the health care cost of high income people under HSAs, it can be doubted that self-rationing of health care by price will play any significant role among such families if they were forced to switch from the comprehensive baseline policy to an HSA product. It is fair to wonder whether the advocates of HSAs, who usually live in high income brackets, are aware of this asymmetric impact of HSAs on the rationing of health care by price and ability to pay.
These are ethical policy issues that economists can identify but on which they cannot offer normative dicta. Policy makers, on the other hand, might wish to explore these issues further, before shifting the nation wholesale toward the HSA/high-deductible health insurance, as this product is currently designed.
The Guardian of the UK reports:
"A campaign fronted by doctors and celebrities to persuade European governments, including the UK, to vaccinate all young girls against cervical cancer is being entirely funded by the drug company that markets the vaccine.Sanofi Pasteur MSD, which markets Gardasil in Europe on behalf of the drug giant Merck, spent millions on what was billed as the "first global summit against cervical cancer", held in Paris on Thursday with doctors and patient organisations from across Europe.
The revelation comes as public health experts express disquiet about the promotion of a vaccine that is only effective in young girls - possibly at the expense of screening programmes that are essential to protect adults. They also worry that the long-term effects of the vaccine are not known. The vaccine protects against the most common strains of the sexually-transmitted human papilloma virus (HPV) which causes cervical cancer.
Diane Harper, a professor at Dartmouth medical school in New Hampshire, who led two vaccine trials, said the vaccine would not protect against all strains of the virus, and that nobody knows whether vaccinated 10-year-old girls would still be protected in 10 years' time, when they are sexually active and at risk. Mass vaccination programmes, she said, would be "a great big public health experiment".
Celebrities, doctors and journalists were shipped in from across Europe and the United States by PR agencies working for Sanofi. The summit, which resembled a political rally, called for country-wide vaccination programmes.
Arcoxia, Merck's new painkiller, comes up for review by an FDA advisory committee tomorrow. The Wall Street Journal Health Blog reports that a memo released yesterday "sets up the likely standard for Arcoxia’s review." Memo excerpt:
“…a new product that appears to have an increased overall risk profile for CV disease, particularly beyond that seen with other drugs, would not be appropriate for marketing unless the product fills an unmet medical need for a particular patient population that has no relatively safer approved products available to them, and provides a reasonable risk to benefit balance for that population.”
And the Public Citizen Health Research Group - a watchdog agency - asked the FDA " to order Pfizer to immediately stop its misleading 2 ½ minute television advertisement for Celebrex that began airing on April 2nd."
Public Citizen faults the Celebrex ad for:
* asserting, contrary to scientific evidence, that the cardiovascular dangers of Celebrex are no greater than those of any of the other non-steroidal anti-inflammatory (NSAID) painkillers; and* claiming that there are overall gastrointestinal benefits with Celebrex over two popular, over-the-counter painkillers, while trying to downplay the risk of serious stomach and intestinal problems such as bleeding and ulcers that applies to Celebrex and all other NSAIDS.
The Wall Street Journal's "Media & Marketing" section today has a column on "New Medical Device Ads; Old Concerns."
The Journal mentions Medtronic's ad for an implantable defibrillator with the line:
"If you've had a heart attack or have heart failure, inside this little device, you just might find 10,000 more kisses, snow, 200 more football wins..."
And Zimmer Holdings' ad for a knee replacement for women. The ad tells viewers they will be "amazed at what a difference a knee replacement can make."
The column's subhead is "Can a knee implant be sold this way, and should it be?"
Can't wait for next year's Super Bowl ads for penile and hair implants, artificial knees specifically designed for couch potatoes, and defibrillators to shock you back to life in time for the second half.
I want to give a couple of plugs for interesting new health news blogs.
The Wall Street Journal health news blog is terrific.
One recent entry was on the trial that “showed that using stents in stable patients with mild to moderate chest pain doesn’t reduce the risk of heart attacks compared with drugs alone. … The Health Blog’s take-away: The idea of clearing out clogged arteries is so appealing, and the idea of leaving them clogged so terrifying, that patients and doctors are inclined to open them up, even if the data say that won’t do much good.”
And another entry analyzed the new questions about the benefits of mammography for women in their 40s. It included a quote from a mammography expert: “The evidence shows that it does help some women [in their 40s] — but the evidence shows that it’s only six out of 10,000 over a decade.” If only some mainstream news media could analyze the data as concisely as that.
Another noteworthy blog is Pharmalot.com - “a home for lively discussion about news and trends in the pharmaceutical industry. The guy behind the curtain is Ed Silverman, a veteran journalist for The Star-Ledger of New Jersey.” Interestingly, this is Ed’s fulltime baby. He doesn’t even file for the paper anymore.
It's good to see that some news organizations are catching on to this Web thing.
CNN’s House Call with Dr. Sanjay Gupta once again showed its one-sided, pro-screening bias this weekend. Excerpt:
We're starting with a change in what's been standard medical advice for a long time. For years, women over 40 have been told they need routine mammograms. Now the American College of Physicians says women with no risk factors for breast cancer should talk to their doctors first, that perhaps they could postpone their mammogram until they turn 50.The American Cancer Society says annual mammograms starting at age 40 are still the way to go. You know what? It's leaving a lot of women wondering who they should believe.
So here to clear things up is Dr. Larry Norton. He's director of Breast Cancer Programs at Memorial Sloan-Kettering Cancer Center.
Well, Dr. Norton doesn’t accept the College of Physicians’ reasoning, writing them off as “an organization of internists” – not cancer specialists or surgeons. He said:
"But the fact is that every woman that I speak with would much rather have a needle biopsy, which is not such a big deal, to make sure that the thing that the mammogram finds is not cancer, than actually miss a cancer that could cost her her life, or cost her her breasts."
OK, but that's personal anecdote, not evidence. There's an old saying: the plural of anecdote is not data. One big chunk of evidence he didn’t address is DCIS – or ductal carcinoma in situ – which shows up more often in earlier mammograms and leaves women confused about whether it’s a cancer, or, as it’s often called, pre-malignant or precancerous. And there is no consensus about what to do about DCIS once you find it. Why didn’t he talk about these cases? And why didn’t Gupta ask about them?
And why did Gupta and CNN only give airtime to one side of the argument? The perspective of the American College of Physicians (ACP)- the largest medical specialty organization and the second-largest physician group in the United States, representing 120,000 members - was simply not represented.
The ACP says its "clinical guidelines are developed in an explicit, rigorous process based on extensive review of available scientific evidence. They are considered 'evidence-based' rather than “expert-opinion” or consensus guidelines. In addition to publications from the original mammography trials, ACP reviewed 117 studies to evaluate the evidence about the risks and benefits of mammography screening for women between the ages of 40 and 49."
Yet CNN didn't give ACP a voice in this segment, and let its guest get away with saying "We still need to figure out why they made this recommendation." Why not ask them on the air?
Three times in the segment, Gupta said his guest “cleared up” the confusion. I guess it’s easy to view something as clear if you only open your mind to what you want to believe.
CNN has shown a pro-screening, evidence-be-damned mentality before. It is not balanced. It is not complete. And it is not journalism. It is advocacy.
If you didn’t see 60 Minutes last Sunday (April 1), go to their website and read the story and watch the video link for the segment called “Under the Influence.” It’s the story of the incredible manipulation of Congress by the drug industry that took place to get the Medicare Part D legislation passed.
Excerpt:
The unorthodox roll call on one of the most expensive bills ever placed before the House of Representatives began in the middle of the night, long after most people in Washington had switched off C-SPAN and gone to sleep.The only witnesses were congressional staffers, hundreds of lobbyists, and U.S. Representatives like Dan Burton, R-Ind., and Walter Jones, R-N.C.
"The pharmaceutical lobbyists wrote the bill," says Jones. "The bill was over 1,000 pages. And it got to the members of the House that morning, and we voted for it at about 3 a.m. in the morning."
Why did the vote finally take place at 3 a.m.?
"Well, I think a lot of the shenanigans that were going on that night, they didn't want on national television in primetime," according to Burton.
"I've been in politics for 22 years," says Jones, "and it was the ugliest night I have ever seen in 22 years."
Despite what a terrific piece this was, one wonders why it took 60 Minutes several years to catch up to this story. Some viewers wrote to CBS about how late this report came. Examples:
“Great story, AWESOME Story!!! Too bad CBS & 60 minutes waited over 3 YEARS after President Bush Jr. signed the bill into law to report on this. Perhaps if we the American people had heard this story back in early 2004, we would have made different choices when the 2004 presidential election came around.”“CBS, where the hell were you in reporting this when it happened. Everyone else who was paying attention knew we were being screwed by this legislation, that it was just a give away to the drug companies. but like all (mainstream media), you were totally going to let it pass. Shame on you for taking so long wake up.”
The AP reports on a new Harvard study that suggests that high-deductible, so-called "consumer-driven" health plans may drive women to have to pay more than men. Excerpt:
High-deductible, consumer-driven health insurance plans often wind up being an unfair burden to women, a study says, largely because women need many routine medical exams that quickly add up.The median expense for men under 45 in these plans was less than $500, but for women it was more than $1,200, according to the study by Harvard Medical School researchers.
They also found that only a third of insured men in that age group spent more than $1,050 in annual medical costs, while 55 percent of women did.
"High-deductible plans punish women for having breasts and uteruses and having babies," said Dr. Steffie Woolhandler, the study's lead author.
"When an employer switches all his employees into a consumer-driven health plan, it's the same as giving all the women a $1,000 pay cut, on average, because women on average have $1,000 more in health costs than men," she said.
The Center for Science in the Public Interest reports:
The Food and Drug Administration last week gave three scientists, including two with financial ties to Merck, permission to serve on an advisory committee and to vote on the fate of the company’s new Cox-2 inhibitor pain pill. The Arthritis Drugs Advisory Committee will consider Arcoxia (etoricoxib) when it meets later this month. Preliminary clinical trial data released by the company last year indicated Arcoxia raises blood pressure in some patients, but does not result in the same heart attack risk as Vioxx, the Cox-2 inhibitor Merck removed from the market in late 2004.According to agency documents that were released last week, the committee will include Robert Levine, a gastroenterologist at the State University of New York, who owns between $25,000 and $50,000 in Merck stock. The FDA identified four gastroenterologists willing to take the slot, but two had more extensive conflicts than Levine. The FDA also granted a waiver to Kenneth Saag, a rheumatologist at the University of Alabama at Birmingham, who receives somewhere between $10,000 and $50,000 a year from Merck. Saag, the FDA said, is expert in analyzing large databases (Merck has tested the drug in over 35,000 patients) and the agency “was unable to find anyone as qualified.” However, the agency admitted that it only scrutinized its current roster of advisers and employees of the National Institutes of Health to identify candidates. Committee chair Dennis Turk, an anesthesiology professor at the University of Washington, also received a waiver for the $10,000 a year or less he earns from a company that competes with Merck on unrelated issues.
The Wall Street Journal reports:
Merck tested Arcoxia in a massive study, called Medal, that included 34,701 patients enrolled in three trials. The study showed a similar cardiovascular risk for Arcoxia and an older drug, diclofenac. But FDA committee members may question the use of diclofenac as the comparator, because while diclofenac is not categorized as a Cox-2 drug, experts including the American Heart Association view it as closer to the Cox-2s than other painkillers in its class. "What they did is say, our Cox-2 is similar to another Cox-2," says Bruce Psaty, a professor at the University of Washington who wrote about the issue in a recent New England Journal of Medicine commentary. "That's not terribly reassuring."Steven Nissen, immediate past president of the American College of Cardiology, also pointed out that more patients on certain Arcoxia doses dropped out of the study due to high blood pressure. "I do not believe that [Arcoxia] should be approved," he said.
Wanna bet on the outcome?
See a Boston Globe story on how health care consumers are not getting the kind of "report card" information they need when exploring health care options.
Excerpt:
"...many of the Massachusetts residents surveyed said they want information that is unavailable because it's difficult to collect or standardize comparisons between providers or has not yet been developed. Publicizing information has also met with objections from doctors and hospitals., which in some cases have has slowed the process.In choosing a doctor, people surveyed said the most important information is the doctor's experience treating a specific medical condition, the average amount of time the doctor spends with each patient, and patient satisfaction ratings."
The Washington Post reports that the American College of Physicians "is challenging the widely accepted recommendation that women routinely undergo mammograms in their 40s, saying the risks of the breast exams may outweigh the benefits for many women."
Some Post quotes and excerpts:
"We agree that mammography can save lives," said Douglas K. Owens of Stanford University, who chaired the committee that wrote the guidelines, being published in the Annals of Internal Medicine. "But there are also potential harms. We don't think the evidence supports a blanket recommendation.""I think it's right on target," said Russell Harris of the U.S. Preventive Services Task Force, which issues the federal government's official recommendations on preventive medicine. "I would like to see more women stop and think about the decision."
The new guidelines come less than a week after the American Cancer Society issued guidelines that, for the first time, recommend that women at greatest risk of breast cancer also undergo annual MRI exams. That triggered a similar debate over the risks and benefits of aggressive screening.Owens acknowledged that the conflicting recommendations may confuse some women, but he said the panel concluded that it is important to present a realistic assessment.
"All we're saying is that women should be informed about the risks and benefits so they can make a decision based on all the facts," Owens said.
"We would all want this to be a simple issue, but it is not," said Carolina Hinestrosa of the National Breast Cancer Coalition, a Washington-based advocacy group. "Women need to know the truth and deserve it from their physicians."Doctors and researchers were similarly divided. While some endorsed the guidelines, others said drawing a sharp distinction between the 40s and 50s is arbitrary.
"I think it's an outrage," said Daniel B. Kopans, a professor of radiology at Harvard Medical School. "This really is misleading women."
This news is not shocking. As the Post points out, the mammography recommendations for women in their 40s "have long been mired in controversy, with some researchers saying that the benefit in that age group is marginal and that the testing subjects thousands to overdiagnosis and overtreatment."
I've written a new Publisher's Note on HealthNewsReview.org, and I'm posting part of it here.
Stories about Elizabeth Edwards’ breast cancer and Tony Snow’s colon cancer have led some news organizations to offer recommendations about cancer screening. Unfortunately, some of the recommendations are simply not based on evidence.
On the NBC Today show on March 28, Matt Lauer said the Edwards and Snow cases put “a huge spotlight on the importance of early detection.” Did they? The Edwards and Snow cases were not about early detection; they were recurrences. Theirs were not stories about cancer screening in the general population of people without symptoms. They were stories about follow up testing and recurrence in people who already had been treated for cancer. That’s an important distinction, glossed over in the kind of introduction Lauer used.
And to use the Edwards and Snow cases to stir up enthusiasm for early detection in ways that fall outside the boundaries of the best evidence is troubling.
Lauer brought on NBC News chief medical editor Dr. Nancy Snyderman and the two of them reviewed recommendations for screening tests for breast cancer, colon cancer, lung cancer and prostate cancer. But the discussion weaved in and out of the boundaries of evidence.
In discussing colon cancer screening, Snyderman explained that because she has a family history, she started having colonoscopies at age 40 in two to three year intervals. She says now that she’s over 50 she gets one every year. “And I get one more than my doctors really recommend because I just get a little nervous about it,” Snyderman said.
It’s fine for her to choose whatever path makes sense to her. But it is troublesome to use a national TV platform to leave even the perception that this is an evidence-based course. The frequency of her screening is far more aggressive than the intervals described by the U.S. Preventive Services Task force for most people in the viewing audience.
Annual FOBT (fecal occult blood testing) offers greater reductions in mortality rates than biennial screening but produces more false-positive results. A 10-year interval has been recommended for colonoscopy on the basis of evidence regarding the natural history of adenomatous polyps. Shorter intervals (5 years) have been recommended for flexible sigmoidoscopy and double-contrast barium enema because of their lower sensitivity, but there is no direct evidence with which to determine the optimal interval for tests other than FOBT. Case-control studies have suggested that sigmoidoscopy every 10 years may be as effective as sigmoidoscopy performed at shorter intervals.
Snyderman wrote off the value of sigmoidoscopy, saying it doesn’t go far enough (her words), and said that viewers must have colonoscopy.
But the U.S. Preventive Services Task Force recommendation says:
It is unclear whether the increased accuracy of colonoscopy compared with alternative screening methods (for example, the identification of lesions that FOBT and flexible sigmoidoscopy would not detect) offsets the procedure's additional complications, inconvenience, and costs.
Next, Snyderman turned her pro-screening enthusiasm to prostate cancer, advising men: “You turn 50, you just have to have a rectal exam to feel that prostate. And you get a prostate-specific antigen, a PSA test.”
Contrast that with the evidence-based guidelines:
The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend for or against routine screening for prostate cancer using prostate specific antigen (PSA) testing or digital rectal examination (DRE).
http://www.ahrq.gov/clinic/uspstf/uspsprca.htm
Journalists should not be advocates, especially if their advocacy is based on personal opinion, not evidence or fact.
A good source for an evidence-based assessment of these issues: “Should I Be Tested For Cancer? Maybe Not and Here’s Why,” by H. Gilbert Welch, M.D., MPH. (University of California Press, ISBN 0-520-23976-8).