June 12, 2009

WCBS physician-reporter promotes free brain scans. Evidence be damned.

This is how NOT to cover health care news. It is one more example in a long list of major media in this country promoting screening tests in the absence of evidence.

Dr. Holly Phillips of WCBS-TV in NY reports about a van that ...

..."travels around New York City and offers free MRI brain scans to virtually anyone. Neurosurgeon Dr. Patrick Kelly spearheaded the campaign and believes catching brain tumors early will save lives.

"We've scanned over 1,300 people and we have found some astounding things," he told CBS 2.

Nearly a million Americans are walking around with a brain tumor and don't even know it. About 25,000 of them are in New York City alone, and by the time brain tumors cause symptoms, often times it's too late for treatment."

This, on the other hand, is how you practice quality health care journalism:

The Cancer Letter (subscription or day pass required) did the same story, but reported that "Skeptics say these folks should have their heads examined. Screening experts ... say there's no evidence to support brain scans for asymptomatic people."

One of those skeptical experts said, "“The question is what is the best use of resources to deal with the brain tumor population? The incidence of brain tumors in a population per year is in the range of 6 to 10 per 100,000 population. So what you would have to do is perform MR scans on 100,000 people to find somewhere between 6 and 10 brain tumors, and of those 6 to 10, about half of those lesions would be benign. It wouldn’t seem to be a reasonable expenditure of resources.”

Things to think about as you compare the two stories:

• The first was done by a physician who has been put on the air as a journalist.
• What is her training in journalism?
• Does she think first like a journalist, or like a doctor?
• If the latter, then her inclination, from her medical training, is probably to test, test, test.

• The Cancer Letter is written by serious journalists.
• They think about evidence, harms along with benefits, and costs.

The latter type of journalism prepares us to think about health care reform.

The former exacerbates the mess we're in.

Posted by schwitz at 10:46 AM | Comments (2)
StumbleUpon Toolbar Stumble It!

June 10, 2009

Patients uninformed about potential harms of CT scans

Next time you see an ad promoting CT scans, look for any disclosure of potenial harms. Good luck finding any.

A study in this week's Archives of Internal Medicine (non-subscribers get free access only to an abstract), Medical Decision Making Regarding Computed Tomographic Radiation Dose and Associated Risk: The Patient’s Perspective, suggests that patients are inadequately informed about the potential risks of ionizing radiation form CT scans.

• 47% of patients believed that the decision to undergo CT imaging had been made entirely by their physician.

• Despite the amount of physician involvement in the decision to obtain a CT scan, patients knew little about ionizing radiation and the risks associated with medical imaging, which was demonstrated by the fact that only 6% of respondents knew that the radiation associated with CT increased the lifetime risk of cancer.



Posted by schwitz at 12:39 PM | Comments (0)
StumbleUpon Toolbar Stumble It!

June 7, 2009

Questioning the wisdom of executive physicals

This doesn't happen very often: a Minnesota researcher and a Minnesota journalist questioning the wisdom of the kinds of "executive physicals" performed so often at the Mayo Clinic.

"Unnecessary testing may cause more harm than good, owing to false positive findings, unwarranted follow-up visits and costs, needless worry, and harmful side effects of the tests themselves," wrote Dr. Brian Rank of HealthPartners about the practice.

Mother Mayo doesn't like to be questioned in this way - especially within its own home state.

Posted by schwitz at 11:12 AM | Comments (0)
StumbleUpon Toolbar Stumble It!

June 1, 2009

Another counter to conventional wisdom on early detection

From the New York Times (HT @ivanoransky):

"In a finding that is likely to shake up medical practice, researchers reported here that early detection of a relapse of ovarian cancer with a widely used blood test does not help women live longer.

The finding goes against the common presumption that early detection and treatment of cancer is better. It could force doctors and patients to re-evaluate the need for the periodic testing that has become an anxiety-inducing but also reassuring ritual for many women who have had ovarian cancer.

Most women who are in remission from ovarian cancer take the test, which measures levels of a protein called CA125, every three months or more frequently. The test can detect the recurrence of the cancer months before symptoms appear, allowing patients to start chemotherapy earlier.

But the new study, presented at the annual meeting here of the American Society of Clinical Oncology, found that women who started chemotherapy early based on a test result did not live longer than women who waited until symptoms appeared."

Posted by schwitz at 8:05 AM | Comments (0)
StumbleUpon Toolbar Stumble It!

May 14, 2009

More vested interest vilification of virtual colonscopy decision

The Colon Cancer Alliance has distributed a statement of disappointment over Medicare’s decision not to pay for virtual colonoscopy.

Let's do a reality check on what they say in that statement.

"This decision now leaves millions of older Americans exposed to a higher risk of colon cancer.”

• Nope. Not one bit higher than it was the day before the decision was made. The risk is the same. Ridiculous fear-mongering rhetoric.

“It also exacerbates an unequal standard of care between Medicare beneficiaries, who do not have the choice to undergo a virtual colonoscopy, and those with private insurance who do.”

• Euphemism for rationing – battle cry of almost any anti-health care reform movement.

"By denying coverage for virtual colonoscopy, CMS is sending the signal that increased screening amongst the Medicare beneficiary population is unimportant.”
• Hmmm. I didn’t get that signal at all. I heard a signal of “show me the evidence in a Medicare population.” Period. There's no denial of payment for methods WITH solid evidence in a Medicare population.

By the way, the Colon Cancer Alliance is sponsored by a host of drug companies and by GE Healthcare, which makes and sells virtual colonoscopy machines.

Let's be clear: I don't have a dog in this hunt. I have nothing to gain or lose by Medicare's payment decisions - no more than any other taxpayer. But I can't stand the rhetoric. And I'm going to write about it whenever I have the chance.

Posted by schwitz at 2:02 PM | Comments (1)
StumbleUpon Toolbar Stumble It!

May 13, 2009

Medicare makes evidence-based decision on virtual colonoscopy

The great hue and cry about rationing and about socialized medicine has begun following Medicare's decision yesterday that it would not pay for so-called "virtual" colonoscopies.

The agency concluded that "the evidence is not sufficient to conclude that screening CT colonography improves health benefits for asymptomatic, average risk Medicare beneficiaries."

I haven't seen one news account yet, though, that actually explored in detail what that evidence was.

This was a bold move by Medicare administrators - in the face of intense industry pressure to approve the scans.

The American College of Radiology has posted a statement that says the decision will "cost lives" and mentions a study but doesn't address the very issue that Medicare acted on - evidence in "asymptomatic, average risk Medicare beneficiaries." The ACR statement then even plays the race card, saying the test "can help overcome the disparity in colorectal care that exists in minority communities."

I wish news stories and press releases would skip the rhetoric and explain the evidence. Otherwise the rationing rhetoric is bound to continue - without advancing true public understanding of the issues at play. It's another early bellwether of what any true comparative effectiveness research effort will be up against.

Posted by schwitz at 8:48 AM | Comments (1)
StumbleUpon Toolbar Stumble It!

May 12, 2009

Do people need their heads examined regarding brain scans?

See Paul Goldberg's piece in The Cancer Letter, "Van Brings Free Brain MRIs To Capitol Hill; Experts See Enormous Potential for Harm" (subscription or day pass required). Excerpts:

"Over the past several months, over 1,000 New Yorkers have inserted their heads in an MRI unit mounted inside a truck operated by The Brain Tumor Foundation, a nonprofit started by a prominent neurosurgeon at New York University. Earlier this week, the truck was parked at the base of Capitol Hill, and about 60 people—among them six legislators—stepped in to receive free scans.

Skeptics say these folks should have their heads examined. “This is crazy,” said Steven Woloshin, senior research associate in the Veterans Affairs Outcomes Group of White River Junction, Vt., and
associate professor of medicine and of community and family medicine at Dartmouth Medical School. “No
professional organization recommends this, and there is no credible evidence that this does more than good than harm, and there are lots of reasons to worry about harm. False alarms in the brain leading to biopsies can’t be good for you.” ...

Critics say that Kelly’s campaign is another manifestation of the American belief in screening and insistence on the worst possible care at the highest possible price. “At a time when we are worried about
healthcare costs, one must be responsible in screening and treatment recommendations,” said Otis Brawley, chief medical officer of the American Cancer Society."

Posted by schwitz at 10:00 AM | Comments (0)
StumbleUpon Toolbar Stumble It!

May 6, 2009

MD Anderson brags about doing prostate screening in a 31 year old?!?

Medical centers love celebrities. And America loves football. So it must have seemed a natural for the PR department of the University of Texas MD Anderson Cancer Center to write a news release about prostate cancer screening in NFL retirees. Excerpt:

"They may be retired National Football League players and coaches but clearly, they still enjoy the camaraderie of a team atmosphere. Even at M. D. Anderson's Genitourinary Center.

Recently, M. D. Anderson and the American Urological Association (AUA) teamed up to screen 37 NFL retirees from the Houston area as part of a 10-city series that the NFL Player Care Foundation initiated to address the medical needs of retired players.

"We screened 37 men between the ages of 31 and 77 at this event and, as former NFL players and coaches, they have tremendous potential to carry the message of the importance of screenings."

M. D. Anderson recommends that men, beginning at age 50, have an annual digital rectal exam (DRE) and a prostate-specific antigen (PSA) blood test. For men with a family history of prostate cancer or African-American men, screening should begin at age 45 because of the increased risk."

Reaction:

1. MD Anderson's screening recommendation is in conflict with that of the US Preventive Services Task Force, which states that:
• The current evidence is insufficient to assess the balance of benefits and harms of prostate cancer screening in men younger than age 75 years.

• The USPSTF recommends against screening for prostate cancer in men age 75 years or older.

2. MD Anderson's screening of the 31-year old is in conflict with its own stated recommendation.

Maybe the guy was fully informed and still wanted to be screened. Maybe he was at especially high risk - something that then should have been stated in the news release to explain this extraordinarily young age to begin prostate screening.

Or maybe neither of the above.

Maybe, as the release stated, it was just to "enjoy the camaraderie of a team atmosphere." Bend over and take a digital rectal exam to feel part of a team. And roll up your sleeve for the "simple blood test" whose results may leave your head spinning because you've just been screened outside the boundaries of evidence-based wisdom.

Posted by schwitz at 9:23 AM | Comments (5)
StumbleUpon Toolbar Stumble It!

April 24, 2009

UK bioethics panel explores marketing of screening tests

Science reports:

"Ordinary folk can now try to be masters of their own health, as private companies offer online DNA tests and full-body CT or MRI scans. But these services, which often offer health information without a doctor’s guidance, have stirred up much controversy in the medical community, with claims that the results the companies provide can be inaccurate or misleading to the average layperson. In response to this issue, the U.K.’s Nuffield Council on Bioethics launched a consultation today on the ethical, legal, social, and economic issues behind these commerical health services."

Posted by schwitz at 9:18 AM | Comments (0)
StumbleUpon Toolbar Stumble It!

April 20, 2009

The virtual colonoscopy conundrum

Good LA Times piece: "Virtual colonoscopy at center of policy debate: Will Medicare pay for the procedure even though there's no consensus about its effectiveness?" Excerpts:

In an extensive, year-long, review of virtual colonoscopy, Medicare officials scoured medical journals, convened doctors and health policy experts and reviewed more than 400 opinions submitted in two public comment periods. colo-ct-082.jpg

Though many urged Medicare to cover virtual colonoscopies, others counseled caution.

"You have to be really, really careful when it comes to preventive services because you are starting with asymptomatic people who appear to be healthy," said Dr. David Shih, senior director of medical affairs at the American College of Preventive Medicine.

...

On Feb. 11, the federal agency drew a simple conclusion: "The evidence is inadequate." It recommended Medicare not cover virtual colonoscopy.

The move sparked an immediate backlash.

"There are those who believe we have to have absolute gold-plated evidence to OK a procedure," said Dr. Len Lichtenfeld, deputy chief medical officer at the American Cancer Society. "But the fact is that we are not getting the job done when it comes to colorectal screening. . . . We have an obligation to give the benefit of the doubt to Medicare beneficiaries."

Working with a Washington lobbying and public affairs firm, interest groups organized a briefing last month for lawmakers in the Capitol.

More than 50 members of Congress mounted a letter-writing campaign to the Medicare agency.

To some health policy experts, that kind of political pressure is one of the reasons the nation's healthcare system has become so inefficient. Few expect it change, however. .

"The issue is: Who is going to make the decisions about what we do and what we don't do in medicine," Lichtenfeld said. "Let's not kid ourselves: That is a political question."

Posted by schwitz at 10:38 AM | Comments (4)
StumbleUpon Toolbar Stumble It!

April 10, 2009

Bill to teach teens breast self-exam gets political support, scientific opposition

The Cancer Letter gives an update on a story I first blogged about weeks ago.

Politicos are lining up to co-sponsor - 260 so far.

Who could oppose more funding for early breast cancer intervention? Those who want evidence that it does more benefit than harm, that's who.

I understand this has created quite a rift within breast cancer advocacy circles - one camp crusading for more attention of any kind, the other camp being more evidence-based.

How unfortunate and, as I wrote before, misguided for politicians to enter the fray where they are in over their heads.

Posted by schwitz at 3:51 PM | Comments (0)
StumbleUpon Toolbar Stumble It!

April 3, 2009

Bernadine Healy and the President's prostate

Should Obama Get a PSA Test? On Prostate Cancer Screening and Comparative Effectiveness. That's the headline of Dr. Bernadine Healy's blog entry on the US News & World Report website.

I felt obliged to respond online with a comment in reaction. I wrote:

Dr. Healy writes: "Prostate cancer mortality rates have plummeted in the United States over the past 20 years, coinciding with the widespread use of PSAs. (No such drop has occurred in Europe, where PSA screening, by policy, is uncommon.) This suggests—though it certainly doesn't prove—that PSA screening saves lives."

However, if more silent cancers that never would have killed American men are now being found because of more American PSA testing, then by default, the mortality rate would plummet. You're now calling more things "cancer" – many of which wouldn't have killed a man anyway. Dr. Barry Kramer of the National Institutes of Health calls it a pseudo-epidemic. So Dr. Healy’s example certainly DOESN'T prove that PSA screening saves lives.

And the entire premise of the article about whether the President should get a PSA test - while provocative and probably meant to catch eyeballs - misses the conclusion most experts reached after the recent studies. When evidence raises so many questions about PSA screening, it becomes essential that a man discuss the potential benefits AND harms with his own caregiver. It's not an item up for debate by a magazine or by a urologist who won't even see the President.


Posted by schwitz at 3:11 PM | Comments (0)
StumbleUpon Toolbar Stumble It!

April 2, 2009

To Screen Or Not To Screen - That Is The Question

My Canadian friend and colleague Alan Cassels (along with two other colleagues) has published a new analysis warning "that private clinics selling high-tech services to screen healthy people for disease could be harming Canadians and placing an undue burden on the public health system. ...The results of the study found that there are prevalent misconceptions about the safety and regulation of CT and PET screening technologies."

He's also written a consumer guide, "To Screen Or Not To Screen, That is the Question," available at the same link above.

Alan is publisher of the Media Doctor Canada website - the Canadian counterpart to our HealthNewsReview.org project. Alan will join me and David Henry - the original publisher of the Media Doctor Australia website - in a panel at the Association of Health Care Journalists conference in Seattle in two weeks, where we will try to teach journalists about how to do a better job reporting on research and studies.


Posted by schwitz at 7:37 AM | Comments (0)
StumbleUpon Toolbar Stumble It!

April 1, 2009

MD editorial: I probably have prostate cancer but almost certainly won't die from it

See Gil Welch's thoughtful opinion piece in the LA Times.

His conclusion:

"There is no imperative to be screened, or not screened, for prostate cancer. The only imperative is that men be informed about the consequences of either choice."

It's interesting how evidence-based arguments never try to steer a screening decision one way or another - just toward informed decision-making. Yet crusaders tend to push for only one way - screen at all costs.


Posted by schwitz at 2:54 PM | Comments (0)
StumbleUpon Toolbar Stumble It!

March 31, 2009

Is the UK having better debate about mammography benefits and harms than US?

We need more stories like the one in today's New York Times that addresses legitimate questions about mammography now being raised in the UK.

It started with an article in the BMJ about the inadequacy of British informational brochures on mammography. Then a letter to The Times of London entitled, "Breast cancer screening peril: Negative consequences of the breast screening programme."

Legitimate questions - and demands for better information to be given to women.

In the Times story I'm particularly struck by the 75-year old woman diagnosed with DCIS - which creates anxiety and confusion for thousands of women. She says: "You don't know about all the uncertainty until you're one of the unlucky ones."

The story details leading experts' questions about whether mammography has been oversold to American women as well.

Dartmouth's Dr. Lisa Schwartz wraps up the Times article with this:

“You’re not crazy if you don’t get screened, and you’re not crazy if you do get screened. People can make their own decision, and we don’t need to coerce people into doing this. There is a real trade-off of benefits and harms. Women should know that.”

I can already hear the rabidly screen-everybody-all-the-time advocates screaming about this story. But before they scream too loudly, they should walk a mile in that 75-year old woman's shoes.

Posted by schwitz at 3:14 PM | Comments (0)
StumbleUpon Toolbar Stumble It!

March 28, 2009

Politicians' prostates

Former US Senator David Durenberger (R-Minn.), in his weekly newsletter this week, commented on the latest evidence raising questions about prostate cancer screening with the PSA blood test. And he reflected on a bit of prostate history on the Hill, writing:


"The first Senate PSA's were performed on Bob Dole and Ted Stevens and they quickly passed legislation which had the effect of setting national blood testing standards for men at 40 which has resulted in billions of dollars in new income for the medical industry. And got Bob Dole a job selling erection enhancing drugs."

dole2.jpg stevens.png

Yeah, those political prostates can be profitable.

Posted by schwitz at 12:18 PM | Comments (3)
StumbleUpon Toolbar Stumble It!

March 27, 2009

Sioux Falls Paper Violates Ethical Standards, Endorses Calcium Scans

The Argus Leader newspaper of Sioux Falls recently reported that two local hospitals were offering $50 heart screenings to check for excess calcium buildup.

argusleader.png

Let me count the ways this story was poor journalism:

1. The headline: "Cost of saving a life: $50." Cost-effectiveness has not been established for this procedure. This is a headline that only an ad agency and a client could love.

2. The story never mentioned that such screenings are not recommended by the American Heart Association nor the American College of Cardiology (despite the praising comments from a South Dakota AHA spokesman who clearly isn't up on the science). It took me about two minutes to find this guideline statement online from AHA and ACC:
"The Committee does not recommend screening of the general population using coronary artery calcium measurement."

3. The story said "Both hospitals say they lose money on the program, that the tests and consultation amount to several hundred dollars worth of services. The gains come in prevention." How naive! Talk about a loss leader! And don't think that somebody somewhere in those hospital systems isn't paying for these scans somewhere in their bill.

4. The newspaper practiced "participatory journalism" and sent its reporter in for a scan. At the end, he abandons all journalistic objectivity and announces in an online video, "I would recommend it if it does what it says it does." This is a clear violation of the Society of Professional Journalists' code of ethics.

The wisdom of the crowd - in some of the online comments following the story are far more skeptical. One says, "Don't confuse science with marketing. What we're seeing here is marketing."

Health care reform is going to be very difficult to achieve in this country if we continue to set unrealistic expectations in the minds of the public, feed the worried well, drive up demand for unproven technologies, and promote technologies outside the boundaries of evidence-based recommendations.

On this scorecard, this story failed Sioux Falls readers horribly.

Posted by schwitz at 8:41 AM | Comments (0)
StumbleUpon Toolbar Stumble It!

March 23, 2009

CBS Cares - about non-evidence based colonoscopy campaign

The March madness over colon cancer screening continues. And CBS leads the league with this campaign.

CBS Cares colonoscopy.png

But as Dr. Wes Fisher points out on his blog, this sweepstakes campaign lures in anyone aged 40-79 and there is no evidence-based recommendation supporting colonoscopy in 40 year olds who are not at high risk. His blog goes on to raise other questions about the campaign as well.

Posted by schwitz at 7:08 AM | Comments (0)
StumbleUpon Toolbar Stumble It!

March 20, 2009

Prostate CA screening decision guide available online

With all of the questions swirling around the issue of prostate cancer screening, there has never been a greater need for shared decision-making between physicians and their patients.

To set the scene for an informed physician-patient encounter, the Foundation for Informed Medical Decision Making - through its partner Health Dialog - now offers free online access to its excellent Shared Decision Making program, "Is a PSA Test Right For You?"

Disclosures: The Foundation funds my work on the HealthNewsReview.org project. And I worked for that Foundation throughout the 90s, and produced the original version of this prostate cancer decision aid 15 years ago.

The Foundation has been urged to make this program available to the general public for years. I'd be interested in hearing any reactions after you view it.

Posted by schwitz at 7:03 AM | Comments (0)
StumbleUpon Toolbar Stumble It!

March 18, 2009

Another major trial raises questions about the value of prostate CA screening

For years I have tried to reach journalists who unquestioningly promote prostate cancer screening in all men 50 or older - some have promoted it in all men even 40 or over. But the National Cancer Institute trial - the results of which were published today - shows that questions must be asked.

Read the study.

Read the news release from the National Cancer Institute.


Posted by schwitz at 3:37 PM | Comments (0)
StumbleUpon Toolbar Stumble It!

March 17, 2009

Here come the lobbyists - a hint of what health care reform faces

CQ HealthBeat reports that more than 40 members of Congress have signed a letter asking Medicare to reverse its tentative decision to end coverage for virtual colonoscopies, or CT colonographies. Last month Medicare announced its decision citing a lack of evidence that virtual colonoscopies result in improved health for Medicare beneficiaries who do not have symptoms of and have average risk for colon cancer.

This is what's going to happen at every step of any serious health care reform discussion we have in the next few years - or ever. Evidence-based decisions will be labeled as creating rationing. Government officials will be accused of practicing cookbook medicine. Critics will ask consumers, "Do you want long lines like they have in the UK and Canada?"

What fun this will be.


Posted by schwitz at 2:15 PM | Comments (0)
StumbleUpon Toolbar Stumble It!

March 16, 2009

DCIS and primum non nocere

Two letters in this week's BMJ reflect on a recent article that focused on the inadequacy of patient information in the UK's National Health Service breast cancer screening program. But both letters focused on mammograms finding DCIS or ductal carcinoma in situ - a non-invasive breast lesion that may or may not progress to invasive cancer.

A breast surgeon wrote:

"The failure to disclose information on ductal carcinoma in situ has aptly been described by a patient representative as a "closely guarded state secret." Ductal carcinoma in situ constitutes up to a fifth of screen detected cancers but only 2-5% of symptomatic tumours before national screening. Its occurrence in 15-39% of routine autopsy studies suggests that some non-invasive lesions detected mammographically and subsequently excised would have been of no clinical consequence during their lifetime.

... Undoubtedly some patients with low grade lesions undergo surgery for a condition which would never have progressed to life threatening disease. This so called pseudodisease represents overdiagnosis in the screening programme, which is effectively tapping into a reservoir of indolent non-progressive ductal carcinoma in situ.

Such overdiagnosis and inconsistent labelling of proliferative lesions discovered on biopsy after recall have undermined the net benefits of breast screening. A degree of psychosocial morbidity and prognostic liability has been generated which has been ignored and excluded from patient information leaflets. It must now be incorporated to satisfy the basic tenets of informed consent and conform with the principle of primum non nocere."

If you're not up on your Latin, primum non nocere = first, do no harm.

A woman who is listed as a "former patient" wrote BMJ:

"Just over four years ago I accepted my first invitation to attend for mammography breast screening and was diagnosed with ductal carcinoma in situ.

Briefly, the reality of this diagnosis has been two wide excisions, one partial mutilation (sorry, mastectomy), one reconstruction, five weeks’ radiotherapy (a 60 mile round trip and I had to pay to park), chronic infection at the donor site, four bouts of cellulitis at the donor site, one nipple reconstruction, seven general anaesthetics, and more than a year off work. I am still unable to work more than part time.

Contrast this with a friend who had "proper" cancer treated by lumpectomy and three weeks’ radiotherapy and who returned to full time work within six months of diagnosis. I also doubt that she had to deal with the "we think you should have a mastectomy" attitude.

I expect that I have been classified as a screening success. Yet, everything about my experience tells me the opposite. Screening has caused me considerable and lasting harm. It has certainly not saved or prolonged my life, which is the purpose of screening. The whole screening programme needs a complete rethink: rewriting the information leaflet will serve no purpose other than cosmetic."

That's a view from the UK. How do we do on our side of the pond?

I've interviewed dozens of women with DCIS and I think those women would say the information they got fell far short of what they needed.

Posted by schwitz at 5:27 PM | Comments (2)
StumbleUpon Toolbar Stumble It!

March 12, 2009

Today Show tries to atone for past sins on screening info

I will give the NBC Today Show some credit for trying to address the issue of too much cancer screening and the overtreatment that results.

Matt Lauer acknowledged that the segment would counter much of what the program had told viewers over the past 10 years or so. What he didn't say is that the questions about cancer screening are NOT new and that the Today Show had actually misinformed viewers in many of their earlier messages.

But despite the good effort, today's program was given too little time, was too loosely organized, and probably left viewers horribly confused.

Thank goodness they had one of the best evidence-based minds on the set to address the topic - Dartmouth's Dr. Gil Welch.


Lauer half-promised there would be more segments in the future on this topic. I hope they live up to that.

Posted by schwitz at 11:24 AM | Comments (2)
StumbleUpon Toolbar Stumble It!

Let's hope journalists got the PSA lesson this time

Studies like this one explain why I rail against journalists who unquestioningly promote screening tests in their stories.


Posted by schwitz at 11:06 AM | Comments (0)
StumbleUpon Toolbar Stumble It!

March 10, 2009

Reader’s Digest stops drinking the Cure Kool-Aid

Get out and buy the April issue of RD and frame it.

RD has a history of proclaiming more cures than a ham processor. Two examples:

Reader's Digest BAck Pain cure cover.JPG Reader's Digest New Cures cover.gif

But “the little magazine that could” finally did publish an evidence-based health journalism piece.

Shannon Brownlee’s thoughtful “What’s Wrong with Cancer Tests” piece will be good bathroom reading for thousands, we hope.

Sorry I can’t offer a link. RD doesn’t offer them.

Posted by schwitz at 6:33 AM | Comments (1)
StumbleUpon Toolbar Stumble It!

March 9, 2009

Direct mail direct-to-consumer disease-mongering

I got a nice letter from former Olympic skating champ Peggy Fleming last week.

Peggy Fleming screening letter.jpg

She reminded me that she is a breast cancer survivor and that's why she believes in health screenings - although the tests she was writing about had nothing to do with breast cancer but with vascular disease (or an add-on for osteoporosis if I wanted - which I don't since I'm a man and not at high risk).

Peggy's note to me was, of course, an ad - an ad for the Life Line Screening company. And for the St. Paul Corner Drug store near me that is sponsoring upcoming screenings. All good for business. But potentially bad for consumers.

The "package of four painless stroke, vascular disease and heart rhythm screenings" - costing only $149 - are not recommended by the US Preventive Services Task Force - the gold standard in this country for preventive health recommendations.

For one of the four tests - abdominal aortic aneurysm screening - the USPSTF recommends only one-time screening in men ages 65-75 who have ever smoked. It makes no recommendation for nonsmokers. And it recommends against such screening in women.

For two of the other tests - carotid artery screening and peripheral arterial disease screening - the USPSTF recommends against screening in the general adult population.

For the fourth test - an EKG - the USPSTF recommends against routine screening in adults at low risk. And since Peggy and Life Line don't know my risk, she and they are skating on thin ice.

The Q&A flyer that accompanied Peggy's letter led with this:

Q: Who needs to be screened?
A: Anyone over 50 who wants to be proactive about his or her health.

The flyer also says "Unfortunately Medicare and insurance companies typically will not cover these stroke and vascular screenings without the presence of symptoms. This is is unfortunate since there are often no symptoms for the diseases for which we screen."

Don't make out Medicare and insurance companies as the villains here. They don't cover these tests because the leading evidence-based body in this country says there isn't evidence to support them.

Buyer beware. The story of these "low-cost, painless" screenings is a lot more complicated than it may look at first glance.

So, Peggy, I won't be going to the free screening. If it's a nice early Spring day, I may go for a walk. And if it isn't Spring here yet by then, maybe I'll take you for a spin on the local ice rink. Rather than you spinning the screening story on me.

Posted by schwitz at 9:00 AM | Comments (2)
StumbleUpon Toolbar Stumble It!

March 2, 2009

The scan scam

Gina Kolata raises many questions in her New York Times piece today, "Good or Useless, Medical Scans Cost the Same."
Besides issues of variable scan quality, she writes:

In a recent report, the Government Accountability Office said nearly two-thirds of the money Medicare paid for imaging was for scans in doctors’ offices. And, the report added, doctors were receiving an ever larger part of their income from providing scanning services. Not only were patients more likely to have scans if a doctor did this, but the quality of some of the scans was questioned.

“No comprehensive national standards exist for services delivered in physician offices other than a requirement that imaging services are to be provided under at least general physician supervision,” the G.A.O. wrote.

Private health insurers were concerned, too. “These are alarming patterns that have also been observed in the private sector,” America’s Health Insurance Plans wrote in a response to the G.A.O.

It is clear why self-referral can be tempting, said Dr. Bruce Hillman, a radiology professor at the University of Virginia.

“It’s all profits,” Dr. Hillman said, adding that a group of doctors can make an extra $500,000 to $1 million a year simply by acquiring a scanner.

Posted by schwitz at 9:28 AM | Comments (3)
StumbleUpon Toolbar Stumble It!

February 19, 2009

Caveat emptor on calcium scores

Which should you believe? Clinics like this that promote their technology, offering cool $50 coupons?

Calcium score ad.jpg

Or the U.S. Preventive Services Task Force, which states:

* The U.S. Preventive Services Task Force (USPSTF) recommends against electron-beam computerized tomography (EBCT) scanning for coronary calcium for either the presence of severe coronary artery stenosis (CAS) or the prediction of coronary heart disease (CHD) events in adults at low risk for CHD events.

* The USPSTF found insufficient evidence to recommend for or against routine screening with ECG, ETT, or EBCT scanning for coronary calcium for either the presence of severe CAS or the prediction of CHD events in adults at increased risk for CHD events.

Beware of promotions of "simple 5 minute" tests. The picture - and the story - is much more complicated than the enticing ads admit.

Beware of anyone telling you to "know your score." Know the facts before you worry about putting another score, another measurement, another reason to be anxious in your head.


Posted by schwitz at 7:39 AM | Comments (3)
StumbleUpon Toolbar Stumble It!

February 17, 2009

Disease-mongering by the Washington Post: here we go again

There are WMD’s lurking inside your body. And you better find them ASAP.

In its health section today, the Washington Post gives men of all ages screening test advice – much of it not grounded in the best medical evidence or at least not reflecting real controversies in health care.

They do one of those “What To Do In Your 20s, 30s, 40s, 50s…” columns that news organizations find so appealing and that I find so incomplete.

Sanjay Gupta and CNN have done the same thing

So has the Star Tribune and many other news organizations.

Among the questionable advisories from the Post:

• Telling men in their 30s to “sign up for complete physicals”
• Telling men in their 40s to get a complete physical every two years

There was no mention of the controversies surrounding such recommendations - some experts calling it wasteful.

• Telling men in their 40s to start skin cancer screening.

Aren’t they aware that the US Preventive Services Task Force just last week stated :

“ the current evidence is insufficient to assess the balance of
benefits and harms of using a whole-body skin examination by a
primary care clinician or patient skin self-examination for the
early detection of cutaneous melanoma, basal cell cancer, or
squamous cell skin cancer in the adult general population.” ???

They go on to tell men in their 50s to have prostate cancer screening. (They do say the pros and cons should be discussed, but the recommendation for such screening stands nonetheless.)

Again, the USPSTF states: “the current evidence is insufficient to assess the balance of benefits and harms of prostate cancer screening in men younger than age 75 years.”

What the Post promotes may be one doctor’s – or some doctors’ - opinion(s). But for a major newspaper to state these as if they were handed to Moses on stone tablets is wrong. There are uncertainties. There is controversy. Screening tests can cause harm - not just benefit. And good journalism should reflect that.

Posted by schwitz at 2:12 PM | Comments (2)
StumbleUpon Toolbar Stumble It!

February 15, 2009

Virtually no news about virtual colonoscopy questions

Newer is not always better. Evidence is important. Simple themes, oft forgotten in health journalism.

Back in October, an Atlanta Journal-Constitution story talked of the wonders of virtual colonoscopy, saying it replaced the dreaded colonoscope and lessened patient risk. It used these words to refer to the technology: "science fiction, Star Wars, video game, Disney World."

AJC virtual colonoscopy.png

Also in October, the Wall Street Journal promoted the growing popularity of virtual colonoscopies.

WSJ virtual colonoscopy.png

Neither story mentioned the fact that the U.S. Preventive Services Task Force had stated that same month that “The evidence is insufficient to assess the benefits and harms of computed tomographic colonography as a screening modality for colorectal cancer.?

Last week's announcement that Medicare may stop paying for virtual colonoscopies also got little news attention. At least the New York Times reported it. Excerpts:

The Centers for Medicare and Medicaid Services said in a decision posted on its Web site that there was “insufficient evidence? to conclude that virtual colonoscopy “improves outcomes in Medicare beneficiaries.?

…the United States Preventive Services Task Force, which advises the government on prevention, said last year that there was insufficient evidence to assess the benefits and harms of the CT technique. Some private insurers pay for the tests; others do not.

In its analysis, Medicare said many studies supporting virtual colonoscopy were done in people with a mean age around 58, so results might not fully apply to Medicare’s older population.

For instance, older people are more likely to have polyps. So the proportion of people who would have to have a conventional colonoscopy after a virtual one would be greater. That would make the CT scan less cost-effective.

Posted by schwitz at 9:28 AM | Comments (2)
StumbleUpon Toolbar Stumble It!

February 11, 2009

Too many "check engine" lights on the human body

"You are pre-diseased." That's the title of a CBC radio program with Alan Cassels exploring "the gestalt of our time in a world where, it seems, more and more overdiagnosis is becoming the norm, where everyone is, more or less, prediseased."

(Part one airs tomorrow night - part two next week.)

Cassels interviews Dartmouth's Gil Welch, who says:

"I think the generic problem is somewhat like the "check engine" lights on your car. Do you have check engines lights? My first car was a '75 Ford Fairlane. There were only two things monitored: my oil pressure and my engine temperature. I now drive a Volvo that is 10 years old, but it is checking about 25 different engine functions. And sometimes a check engine light comes on, and you’re really glad to know, and it leads to something you want to do something about. Sometimes the check engine light is just a nuisance, and it just keeps flashing on and off and the mechanic can’t fix it. And some of the audience might have this experience where they went to get it fixed and it made matters worse. And if you had that experience, you’ve had some of the experience of overdiagnosis and that’s what I’m worried about. We’re putting more and more check engines lights on the human body. We have to ask ourselves if that is really the best way to get to a healthy society. We’re constantly monitoring for things to be wrong. Is that really the best way to achieve health?"

Posted by schwitz at 9:50 AM | Comments (1)
StumbleUpon Toolbar Stumble It!

February 8, 2009

Wow! A front-page evidence-based screening story!

Kudos to Chen May Yee and the Star Tribune for a front-page story on how screening tests offered by for-profit companies may cause more harm than good and may be a waste of money.

I slammed the Strib almost exactly one year ago for a non evidence-based article promoting screening tests.

So let this blog posting be further evidence that I'm not out to bash all health care news - just the schlock.

Today's Strib story - by a smart, dedicated journalist - showed enterprise, depth, and a concern for how readers may be misled and hurt by profit-driven screening promotions.

Posted by schwitz at 9:05 AM | Comments (1)
StumbleUpon Toolbar Stumble It!

February 3, 2009

Women still not given enough, nor correct, mammography info

A team from the Nordic Cochrane Center has an article in this week's BMJ that begins:

Three years ago, we published a survey of the information given to women invited for breast screening with mammography in six countries with publicly funded screening programmes. The major harm of screening, which is overdiagnosis and subsequent overtreatment of healthy women, was not mentioned in any of 31 invitations. Ten invitations argued that screening either leads to less invasive surgery or simpler treatment, although it actually results in 30% more surgery, 20% more mastectomies, and more use of radiotherapy because of overdiagnosis.Pain caused by the procedure was mentioned in 15 invitations, although it is probably the least serious harm, as it is transient.

Since then, little has changed.

The researchers say most info predominantly discusses benefits with no discussion of harms. And they remind readers:

• If 2000 women are screened regularly for 10 years, one will benefit from the screening, as she will avoid dying from breast cancer.

• At the same time, 10 healthy women will, as a consequence, become cancer patients and will be treated unnecessarily. These women will have either a part of their breast or the whole breast removed, and they will often receive radiotherapy and sometimes chemotherapy.

• Furthermore, about 200 healthy women will experience a false alarm. The psychological strain until one knows whether it was cancer, and even afterwards, can be severe.

They conclude: "The one sided propaganda about breast screening is a global phenomenon that has resulted in misconceptions about its effects."

Posted by schwitz at 12:08 PM | Comments (2)
StumbleUpon Toolbar Stumble It!

December 19, 2008

Conflicting and crusading news coverage of colonoscopies

An important study was published this week showing some of the limitations of colonoscopy.

Journalists' reactions to the story were - predictably - all over the map.

The New York Times reported under the headline, "Colonoscopies miss many cancers, study finds." Excerpt:

"Instead of preventing 90 percent of cancers, as some doctors have told patients, colonoscopies might actually prevent more like 60 percent to 70 percent.

“This is a really dramatic result,? said Dr. David F. Ransohoff, a gasteroenterologist at the University of North Carolina. “It makes you step back and worry, ‘What do we really know?’ ?

Dr. Ransohoff and other screening experts say patients should continue to have the test, because it is still highly effective. But they also recommend that patients seek the best colonoscopists by, for example, asking pointed questions about how many polyps they find and remove. They also say patients should be scrupulous in the unpleasant bowel cleansing that precedes the test, and promptly report symptoms like bleeding even if they occur soon after a colonoscopy.

But ABC News didn't care for the Times story, posting this online: "Our medical experts were not convinced that there was the need for the urgent sense of the story providing us with scary news about a test that is pretty darn effective." The ABC posting was under the headline, "The Case for Keeping Colonoscopy."

Who ever said anything about not keeping colonoscopy? Seems like a false dichotomy if I've ever seen one.

And CBS News, predictably, with colonoscopy-advocate Katie Couric at the helm, again crossed the line into non-journalistic crusading, with Couric ending a segment on the study preaching, "And don’t use this study as an excuse not to get screened."

Huh? Is that journalism?

Healthy skepticism is a missing element in much health news coverage. It is very difficult for some journalists to question the effectiveness of screening tests. And they do a disservice to their audience by touting opinions, not evidence. The classic clash between intuition and science.

Posted by schwitz at 10:18 AM | Comments (3)
StumbleUpon Toolbar Stumble It!

November 10, 2008

Some words of caution about cholesterol study

I awake to all kinds of breathless news coverage about breakthroughs and paradigm shifts regarding the statin study called Jupiter.

But Merrill Goozner offers a terrific analysis on his site, reminding us about costs, about number needed to treat, and about what ISN'T emphasized in the study and in the news coverage. Excerpts:

Its lead investigator, Paul Ridker of Brigham and Women's Hospital in Boston, owns a patent on the $20 test that measures CRP, and the trial was funded by AstraZeneca, whose $3.45-per-day or $1,250-per-year statin (rosuvastatin or Crestor), was used in the trial. If they can get two million more "apparently healthy men and women" on rosuvastatin, it's an additional $2 billion-plus in sales for AstraZeneca. If they can test 10 million people to find the estimated two million with elevated CRP levels (they had to screen nearly 90,000 people to find the 17,800 eligible for the trial), it's $200 million in test sales, which, if the royalty is only 1 percent, amounts to a hefty $2 million a year in extra income for Dr. Ridker.

and

We can look at the benefits another way -- in terms of the number of people who need to be treated to avoid a serious event. In this trial, 120 patients had to be treated for 1.9 years to prevent one serious cardiac event. Remember what rosuvastatin costs? $1,250 a year. That's $285,000 per event prevented just for the statin pills. The physician visits, CRP tests and lab work add additional thousands more.

and


So there you have it. A possibly unethical trial with marginal results gets trumpeted in the media as showing "wide benefit" (New York Times). Based on the laudatory quotes coming from the leaders of the American College of Cardiology, this off-label use of statins will quickly find its way into clinical practice guidelines and drug compendia. Within a few years, health care payers will be forking over billions more dollars to the statin drug makers in the name of preventing heart disease.

Meanwhile, our health care outcomes -- including cardiovascular disease -- will still rank somewhere between Romania and Poland. Health care costs will still be rising at twice the rate of overall inflation. And those truly at risk of heart disease still won't be getting the counseling that might save their lives.


Posted by schwitz at 7:01 AM | Comments (2)
StumbleUpon Toolbar Stumble It!

October 29, 2008

Journalists' screening bias piece on The Daily Beast

I'm pleased to be able to contribute a piece for The Daily Beast on the rash of stories that fail to tell the whole story about screening tests. Daily Beast.png

I write in that piece:

"A few simple reminders could guide journalists and the public:

* Newer isn’t always better.
* More isn’t always better.
* Screening doesn’t make sense for everyone.
* Many screening tests do good; many also do harm.

Such stories stoke the fears of the “worried well.? They raise undue demand for unproven technologies. They raise unrealistic expectations of what screening—and health care—can achieve.

And they overlook evidence, harms and costs.

Trudy Lieberman wrote a column for the Columbia Journalism Review asking if journalists deserve some of the blame for the high cost of health care when they write stories like this.

We spend more on health care than any other country on the globe, yet we have outcomes for some conditions that are worse than developing countries. And we still have more than 40-million neighbors who are uninsured.

That might be a better reference point for a discussion on health care reform and health policy than what we get from stories that make us all think that we should be screened because we all have something silent lurking inside us that should be found and treated."


Posted by schwitz at 10:52 PM | Comments (0)
StumbleUpon Toolbar Stumble It!

October 28, 2008

Why is an evidence-based statement being ignored?

The Wall Street Journal today has a big splash, "CT Scans Gain Favor as Option for Colonoscopy." But in this 1,300-word article, there isn't one mention of the recent statement by the U.S. Preventive Services Task Force "that the evidence is insufficient to assess the benefits and harms of computed tomographic colonography" and that "there is potential for both benefit and harm. Potential harms arise from additional diagnostic testing and procedures for lesions found incidentally, which may have no clinical significance. This additional testing also has the potential to burden the patient and adversely impact the health system."

This insistence by journalists to trumpet new technologies and their refusal to acknowledge an independent, evidence-based conclusion is very troubling.

I just don't get it.

The USPSTF statement was issued just 3 weeks ago, so it isn't like it gathered dust or is outdated.

And it's written by independent experts from various fields with no skin in the game - not by radiologists or gastroenterologists or by any interest group.

Evidence insufficient. Harms may occur. Newer isn't always better. Why isn't that part of the story?

Posted by schwitz at 6:59 AM | Comments (1)
StumbleUpon Toolbar Stumble It!

October 10, 2008

Hopelessly devoted to imbalanced advice on network TV

The CBS Early Show let actress-singer Olivia Newton-John appear on their program this week to promote a commercial product without a balanced review of the evidence. olivia.png

In fact, the anchor led in to the relevant part of the interview by prompting the celebrity, “Tell us about your crusade.?

(Newton-John:) “I’d like to introduce the Liv Aid, which is a Breast Self Examination kit to encourage women to do regular breast self-examination, because early detection is key.?

Newton-John went on to remind viewers that she found a lump during breast self-exam 16 years ago. She said she was working with the Curves chain to try to get these LivAid kits to one million women.

But a recent review of the scientific literature by the Cochrane Collaboration stated:

"Data from two large trials do not suggest a beneficial effect of screening by breast self-examination but do suggest increased harm in terms of increased numbers of benign lesions identified and an increased number of biopsies performed. At present, screening by breast self-examination or physical examination cannot be recommended."

There was never a mention of this in the CBS program - only free airtime for a "crusade" - and a commercial one at that.

Shame on CBS for providing one-sided, incomplete information to its viewers.

Posted by schwitz at 10:27 AM | Comments (0)
StumbleUpon Toolbar Stumble It!

October 9, 2008

Rush to market with ovarian screening test gets warning

American medicine's infatuation with screening tests - even sometimes in defiance of the evidence on harms and benefits - creates a crusading environment in which "Screen...screen...screen...earlier...earlier...earlier" is the mantra.

Now, the Wall Street Journal Health Blog reports the latest on the rush to market an ovarian cancer test. Excerpts:

"The FDA has warned clinical-test giant LabCorp that it has been marketing an ovarian cancer test (OvaSure) without approval, vindicating skeptics of the assay who worried it wasn’t ready for prime time.

Researchers around the world have been racing to develop a test that will detect ovarian cancer early, because it usually isn’t found until it has already spread outside the ovaries, when it is very often fatal.

Some cancer specialists fear OvaSure could yield too many false positives — causing women to undergo unnecessary exploratory surgery or to have their ovaries removed as a precaution — and false negatives, reassuring them when they might still be at risk.

“When you make a test available, then people are likely to make decisions based on the test,? said Rebecca Sutphen, a spokeswoman for the National Ovarian Cancer Coalition and director of genetic counseling and testing services at H. Lee Moffitt Cancer Center and Research Institute in Tampa, Fla. “Obviously, everyone is on the same page in terms of wanting such a test. But women may be using this information prematurely to make decisions, and the decisions may not be in their best interests.?

The Society for Gynecologic Oncologists also issued a statement in July saying additional research was required before OvaSure was offered to women outside of research settings."

Posted by schwitz at 8:45 AM | Comments (2)
StumbleUpon Toolbar Stumble It!

October 7, 2008

Caveat emptor when it comes to your colon

Many people will see the news that the U.S. Preventive Services Task Force now states that routine colorectal cancer screenings can be stopped in patients over the age of 75.

But what may be missed - because news organizations like the New York Times didn't include it in their stories - is that the USPSTF also stated:

Patients who are considering virtual colonoscopy or DNA-based stool testing should understand that not enough information exists to know the definite role of these tests in colorectal cancer screening.

In other words, for all populations, evidence is insufficient to assess the benefits and harms of screening with computed tomographic colonography and fecal DNA testing.

That should not be lost in news stories because virtual colonoscopy has received so much hype-filled news coverage in recent years.

For now, this even-handed, independent, no-axe-to-grind scientific body says the evidence isn't in to support the hype.

Caveat emptor when it comes to your colon.

Posted by schwitz at 9:52 AM | Comments (0)
StumbleUpon Toolbar Stumble It!

September 8, 2008

Not standing down yet on "Stand Up To Cancer"

If you thought I had criticisms of Friday night's "Stand Up To Cancer" telethon, read Sandy Szwarc's much more in-depth analysis on her JunkFood Science blog.

Don't look for this kind of critical analysis in any of the mainstream media; many of them were "partners" in the deal.

Posted by schwitz at 8:40 AM | Comments (0)
StumbleUpon Toolbar Stumble It!

September 6, 2008

Everybody Loves Raymond's prostate

Yesterday I wrote about some questions concerning the "Stand Up To Cancer" telethon fundraiser. anchors.png I will always be troubled by journalists - such as Charlie Gibson, Brian Williams and Katie Couric - lending their support to advocacy causes. It calls their editorial judgment and independence into question. Indeed, there are serious issues to discuss about cancer research in this country. But journalists are undoubtedly less likely to pursue such questions when they're involved in glad-handing endorsement of a cause.

But the anchors, by their presence, also endorsed one of the messages of the program which is simply not supported by evidence. This is becoming a tired but predictable theme: non-evidence-based advocacy of screening tests that may result in more harm than good.

RT_garrett_080903_mn.jpg On the telethon, "Everybody Loves Raymond" star Brad Garrett - in a highly promoted move - appeared to fake having a digital rectal exam on the air. Meantime, the program pronounced that every man over age 50 should have an annual prostate exam. The program urged viewers to "Push Your Dad To Get a Prostate Exam," and used this cartoon on its website.
push your dad.png

The U.S. Preventive Services Task Force states:"The USPSTF concludes that for men younger than age 75 years, the benefits of screening for prostate cancer are uncertain and the balance of benefits and harms cannot be determined."

So, producers of "Stand Up For Cancer", you encouraged viewers to push their Dads to get an exam for which the benefits are uncertain and the harms are known.

And Big 3 TV anchors, you not only crossed a line from journalism into advocacy, but you did so for a cause that gave some very questionable and potentially harmful advice to whoever watched the big show.

Congratulations to all concerned.

Posted by schwitz at 8:44 AM | Comments (5)
StumbleUpon Toolbar Stumble It!

August 30, 2008

Debate on British plan to screen people at high-risk of cardiovascular problems

The BMJ this week offers another of its provocative debates - this time about the British government's plan to begin vascular screening for high-risk individuals aged 40-74 beginning in 2009-10. Their Department of Health suggests that up to 9,500 heart attacks and strokes and 2,000 deaths could be prevented each year by vascular screening and managing high-risk individuals aged 40-74 in England.

Professor Rod Jackson and colleagues from the University of Auckland in New Zealand say, YES, this screening program will be cost effective and result in significant health improvements if appropriately targeted. They argue that if half of these high-risk patients were given triple therapy with aspirin, statins and blood pressure lowering drugs, there would be a 10% fall in the national coronary disease event rate in less than 10 years.

But Professor Simon Capewell from the University of Liverpool, says NO - arguing that public health approaches targeting the whole population are both cheaper and more effective than medicines. He says the inherent message of such a screening program is that "the doctor can fix it". But contrary to expectations, he says, even with continuing treatment, over half the cardiovascular risk remains. The proposed strategy would also label over 80% of English men aged 65-74 as high risk. It will therefore commit the majority of middle aged adults to life-long drug treatment and a lower quality of life, at huge cost, he says.


Posted by schwitz at 11:30 AM | Comments (0)
StumbleUpon Toolbar Stumble It!

August 12, 2008

Young men and prostate cancer screening

Just a week after the U.S. Preventive Services Task Force published new recommendations questioning the use of the PSA blood test in even more men, a new survey suggests that many young men are getting the test.

HealthDay News reports:

One in five men in their 40s has had a prostate-specific antigen (PSA) test in the past year, and young black men are more likely than young white men to have undergone the test, a new analysis shows.

The findings are published in the Sept. 15 issue of Cancer.

"That is a pretty amazing statistic, but not so hard to understand given the intense marketing of PSA testing for so many years," responded Dr. Steven Woloshin of Dartmouth Medical School and the VA Outcomes Group in an e-mail.

Woloshin reminds readers that we just don't know if screening does more good than harm.

He writes, "One thing that is often missing in the PSA discussion is the level of risk men face. This is of course crucial information: how else can you weigh the potential benefits and known harms if you don't know your chances to begin with? Unfortunately, the risk information isn't usually part of the discussion, or when it is it's usually given in aggregate terms. For example, you will read that 220,000 men were diagnosed last year or 28,000 died. Those numbers hide the fact that the risk changes dramatically with age; the numbers also do not provide context (ie, competing risks of death) for interpreting the risk."

To give people that context, Woloshin and colleagues Lisa Schwartz and Gilbert Welch recently published a paper in the Journal of the National Cancer Institute (JNCI). He explains, "The paper shows how we developed risk charts which present the 10-year chance of death from various causes (and all causes combined) at different ages. With regards to prostate cancer the charts show that for younger men there isn't a lot of risk to reduce with screening: out of 1000 men, less than 1 will die of prostate cancer in the next 10 years. Another way of saying that is more than 999 will NOT die of prostate cancer during this time."

You can see the risk charts yourself in the JNCI article.

Men are often told that this is just a simple blood test. Nothing could be further from the truth.

Posted by schwitz at 9:44 AM | Comments (0)
StumbleUpon Toolbar Stumble It!

August 7, 2008

Yes, still another case of "journalist" pro-screening bias

Over on the HealthNewsReview.org website, we've reviewed another example of a journalist giving pro-screening test advice that is not supported by medical evidence.

This time it was the CBS Early Show, using physician-"reporter" Dr. Holly Phillips from WCBS-TV in New York to do a followup on actress Christina Applegate's diagnosis of breast cancer.

We said in that review:

The story engages in disease-mongering in its conclusion: "What's most important is to screen. One in eight women nowadays is going to get a breast cancer in her life, so as long as you get in for screening, I'm happy." The 1 in 8 statistic requires explanation. It is a lifetime incidence estimate. Many women misinterpret this to think that they have 1 in 8 chance right now at this time in their life. It is one of the misused and most misunderstood statistics in health care. The National Cancer Institute estimates that a typical 40-year old woman has less than a 2% (1 in 50) chance of developing breast cancer before 50, and less than a 4% (1 in 25) chance of developing it before age 60.

But the story also states, "But generally, we start home breast exam at age 20. I suggest every month, at the same time of the month, examine your breasts at home and get into your doctor for a breast exam at least every three years, earlier if you can." This is not an evidence-based recommendation and involves a physician-reporter giving personal advice and perhaps forgetting that she is now a reporter.

There is little evidence that breast self-examination (BSE) lowers deaths from breast cancer, and SBEs are not recommended by themselves for detecting breast cancer, especially in higher-risk women.

Experts disagree that mammography screening "should begin at 40", especially for women at low to average risk. See: http://www.annals.org/cgi/reprint/146/7/I-20.pdf .

The story had many of the elements of today's TV health stories:

• a young female celebrity angle
• a young female physician-reporter
• fear and promotable content.

Unfortunately, as with many of today's TV health stories, it also lacked details on evidence.

Posted by schwitz at 3:13 PM | Comments (0)
StumbleUpon Toolbar Stumble It!

August 5, 2008

New prostate recommendations - new lessons for crusading journalists

Just four days ago, in response to an NBC News story in which reporter George Lewis recommended that all men over age 50 get annual prostate exams including the PSA blood test, I cited the statement of the U.S. Preventive Services Task Force to show that Lewis' advice was not based in evidence:

The 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). Although the Task Force found evidence that screening can find prostate cancer early and that some cancers benefit from treatment, the Task Force is uncertain whether the potential benefits of prostate cancer screening justify the potential harms.

The potential harms of prostate cancer screening include fairly frequent false-positive results from PSA screening, which may lead to unnecessary anxiety and biopsies. In addition, early detection and treatment may result in complications from treating some cancers that may never have affected a patient's health.

Yesterday the USPSTF updated its recommendation and it makes Lewis’ on-the-air statement to all of NBC’s viewers all the more problematic in its crusading advocacy that is not supported by evidence:


In men younger than age 75 years, the USPSTF found inadequate evidence to determine whether treatment for prostate cancer detected by screening improves health outcomes compared with treatment after clinical detection.

In men age 75 years or older, the USPSTF found adequate evidence that the incremental benefits of treatment for prostate cancer detected by screening are small to none.

The USPSTF found convincing evidence that treatment for prostate cancer detected by screening causes moderate-to-substantial harms, such as erectile dysfunction, urinary incontinence, bowel dysfunction, and death. These harms are especially important because some men with prostate cancer who are treated would never have developed symptoms related to cancer during their lifetime.

There is also adequate evidence that the screening process produces at least small harms, including pain and discomfort associated with prostate biopsy and psychological effects of false-positive test results.

The USPSTF concludes that for men younger than age 75 years, the benefits of screening for prostate cancer are uncertain and the balance of benefits and harms cannot be determined.

For men 75 years or older, there is moderate certainty that the harms of screening for prostate cancer outweigh the benefits.

Older men, African-American men, and men with a family history of prostate cancer are at increased risk for diagnosis of and death from prostate cancer.1 Unfortunately, the previously described gaps in the evidence regarding potential benefits of screening also apply to these men.

The yield of screening in terms of cancer cases detected declines rapidly with repeated annual testing. If screening were to reduce deaths, PSA screening as infrequently as every 4 years could yield as much of a benefit as annual screening.

Journalism is supposed to be about evidence and facts, not crusading advocacy.

"We don’t have any studies that show prostate cancer screening saves lives," explains Dr. Otis Brawley, chief medical officer for the American Cancer Society.

Posted by schwitz at 7:44 AM | Comments (0)
StumbleUpon Toolbar Stumble It!

June 29, 2008

To hell with evidence

Read this terrific piece of journalism in the New York Times - "Weighing the Costs of a CT Scan's Look Inside the Heart."

It analyzes important questions about the lack of evidence for these tests, the costs, the radiation risks, and the conflicts of interest of many who promote them.

The story includes a quote from a physician who is a heart CT scan promoter - "It's incumbent on the community to dispense with the need for evidence-based medicine."

To hell with evidence. To hell with science.

This attitude always reminds of me of the saying, "It ain't what a man don't know that gets him into trouble. It's what he knows for sure that just ain't so."

Posted by schwitz at 5:23 PM | Comments (1)
StumbleUpon Toolbar Stumble It!

June 13, 2008

NY Daily News unhealthy Father's Day prostate promo

Add the New York Daily News to my list of news organizations taking an unhealthy advocacy stance for screening tests.

A promotion in the paper screams out, "Get your free prostate cancer screening, courtesy of the Daily News":

Beginning on Father's Day, New York's hometown newspaper offers these free tests every year, because we believe we should help New Yorkers take care of themselves.

So far more than 120,000 men have taken our free tests, and almost 10,000 have found that they need further action.

The screening is quick and easily performed.

Let's stop and break that down. More than 120,000 men have taken the free tests and almost 10,000 found they need further action? How many were false positives? How many faced further testing, treatment and anxiety that lead to nothing?

The screening is quick and easily performed? Does that mean that the decision about whether to have it should be quick and easy? Or should a man slow down and consider some of the cascading consequences of this "quick and easy blood test?"

Back to the newspaper promo:


The American Cancer Society recommends that men take the screenings from the age of 50, but high-risk males who include African American men and those with a family history of prostate cancer.

The Cancer Society may recommend that, but the group viewed as the "gold standard" in making preventive health recommendations, the U.S. Preventive Services Task Force, does not. USPSTF states:

The USPSTF found good evidence that PSA screening can detect early-stage prostate cancer but mixed and inconclusive evidence that early detection improves health outcomes. 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.

Why, oh why, don't news organizations tell the other side of this story? Why don't they tell the evidence-based side of the story, instead of playing on peoples' fears to help sell newspapers?

Posted by schwitz at 8:09 AM | Comments (0)
StumbleUpon Toolbar Stumble It!

April 23, 2008

Another screening controversy - another online debate

The BMJ has published a number of intriguing online debates recently. Last week they posted another: Will screening for aortic aneurysm be effective? An aortic aneurysm is a dilation (ballooning) of part of the aorta - the main artery carrying blood from the heart to the lower part of the body.
18072.jpg

The YES argument is posted here. In a nutshell:

"Around 90% of people with a ruptured aortic aneurysm die. But if the aneurysm is discovered before it ruptures and is repaired by an experienced vascular surgeon, mortality is around 7.4%, the argument goes. Around 5% of men aged between 65 and 74 have abdominal aortic aneurysms, but they rarely cause symptoms, so screening in this age group would potentially ensure that most aortic aneurysms are diagnosed and repaired.

This side argues that a national screening program has the potential to save up to 2000 lives a year in England and Wales at a similar cost to other screening programs.

They point to a large body of scientific evidence that shows that aneurysm screening programs are effective. For example, an analysis by the Centre for Reviews and Dissemination at the University of York concludes that the likelihood of such a screening program being cost effective is greater than 95%.

Furthermore, recent data from four trials in the UK, Australia and Denmark showed that uptake of invitations to be screened ranged from 63% to 80%. And a review of the data from all four trials showed a highly significant reduction in aneurysm related mortality."

The NAYS have their say here. The stand:

The case for screening is not clear-cut. There are wide variations in the mortality for surgical repair between hospitals in England. In addition, many patients will not be fit enough to have a repair-aneurysm is a disease that rarely exists in isolation. Most patients will also have hypertension, or a history of myocardial infarction, stroke or diabetes. As a result, many patients will be left with the knowledge that they have a life threatening condition that is liable to cause sudden death and that nothing can be done about it.

Aneurysms of less than 5.5cm in diameter are unlikely to burst, and because the mortality from operating on them is greater than the likelihood of rupture, people with an aneurysm of less than this size will have to be monitored and sent for regular ultrasound examinations. Many of these patients will find it intolerable to have a "timebomb" inside them which might go off at any time and without notice, he says.

In addition, screening will show up much more than aortic aneurysms, and the cost of dealing with the comorbidity needs to be included in the cost-benefit analysis, he argues.

At the very least any person being tested will need intensive counselling about the possible consequences that screening might have for their future lives and psychological wellbeing.

What kicks this off is the fact that pilot screening programs for abdominal aortic aneurysms in men aged 65 are due to be launched in England this year.

In the US, the Society for Vascular Surgery has pushed for such screening in many people older than 55. But arguments similar to those raised against screening in the UK have been raised against the US recommendation.


Posted by schwitz at 7:20 AM | Comments (0)
StumbleUpon Toolbar Stumble It!

March 26, 2008

Tobacco conflict of interest behind lung cancer study

Gardiner Harris of the New York Times has just raised important new questions about the integrity of pro-screening work promoted by a leading researcher and published by the New England Journal of Medicine. Excerpt of his story:

In October 2006, Dr. Claudia Henschke of Weill Cornell Medical College jolted the cancer world with a study saying that 80 percent of lung cancer deaths could be prevented through widespread use of CT scans.

Small print at the end of the study, published in The New England Journal of Medicine, noted that it had been financed in part by a little-known charity called the Foundation for Lung Cancer: Early Detection, Prevention & Treatment. A review of tax records by The New York Times shows that the foundation was underwritten almost entirely by $3.6 million in grants from the parent company of the Liggett Group, maker of Liggett Select, Eve, Grand Prix, Quest and Pyramid cigarette brands.

The foundation got four grants from the Vector Group, Liggett’s parent, from 2000 to 2003.

Dr. Jeffrey M. Drazen, editor in chief of the medical journal, said he was surprised. “In the seven years that I’ve been here, we have never knowingly published anything supported by? a cigarette maker, Dr. Drazen said.

Well, Dr. Drazen, knowingly or not, your journal did publish the work. Now what?

This should rock the world of medical science and medical journals.

Stay tuned. Kudos to reporter Harris for digging and shining light on this episode.

Posted by schwitz at 8:38 AM | Comments (3)
StumbleUpon Toolbar Stumble It!

March 5, 2008

More on news organizations promoting unnecessary testing

A physician who teaches evidence-based medicine, and who is also a freelance health journalist, has been reading my thoughts about journalists advocating screening tests in the absence of evidence.

She wrote me: "Here's one of the more annoying recent examples, one that I actually used in class to illustrate the issue of patients coming in and requesting specific tests based on what they read in the newspaper."

So I'm adding Parade Magazine to my list of offenders.

Posted by schwitz at 7:36 AM | Comments (2)
StumbleUpon Toolbar Stumble It!

February 29, 2008

Is This Test Really Necessary?

The Star Tribune newspaper finally - 10 days after I submitted it - published my op-ed piece countering a feature story entitled, How To Be A Screen Queen. I give the paper credit for publishing my response, although they edited my submission and did not share with me in advance what the final published version would be. This is more than a little troubling to me - since what was published was not what I submitted.

One thing they left out was the broader context of such media advocacy pieces crusading for screening tests in the absence of the best evidence, something I reported on in a piece entitled, "Unhealthy Advocacy: Journalists & Health Screening Tests."

I'm going to continue to track news coverage of health screening tests and will continue to report on the results on this blog and in whatever venue I can find.

Posted by schwitz at 11:20 PM | Comments (0)
StumbleUpon Toolbar Stumble It!

February 17, 2008

Promoting obsession with health test scores

Two TV health segments that I'm sure were well-intentioned both caught my eye this week for how they might lead viewers to obsess about still another score, still another test result, still another number that they don't fully understand.

The CBS Early Show had a series entitled, "Early Intervention: Cardiac Arrest." Their reporter went around to food courts in shopping malls "seeking people eating unhealthy foods, or who were overweight, or who had other potentially problematic signs, and offered to check out their heart disease risk. They agreed to undergo CT scans to help assess their heart health. The doctors checked the images the scans produced for signs of calcium, which indicates the presence of artery-clogging plaque."

Before it was all over, the series made it sound like most of us should be running in for a CT scan and that we should certainly know our "calcium score" - a test result that was drummed into viewers over and over. Only briefly did I hear the caveat that these tests are only for people with risk factors including a family history of heart disease. But the caveat was rushed and unclear. CBS' website even states:

If you live in the Memphis area and want to have a scan to check on the calcium levels in your cardiac arteries, call (901) xxx-xxxx. (I have no intention of furthering the promotion by providing the phone number as CBS did.)

That sounds like an all-out invitation to all viewers, doesn't it?

Then CNN's Housecall program this weekend reported on one of the many tests being developed to screen for early Alzheimer's disease. The story said:

"Researchers are hoping to get the Detect system into doctor's offices as early as this fall. It will be used as an early screening tool starting around the ages of 45 to 50. The goal here would be to get a baseline of your cognitive skills early on, so doctors can act early if a drop in score is detected."

Well, sure they're hoping to get it into doctor's office this fall to start screening everyone around 45-50. What a huge new market. And let's get hundreds of thousands of more Americans worrying now about their baseline "cognitive skills score" or whatever it would be called. Meantime, there was no discussion of the sensitivity or specificity of the test. It was still another example of accepting claims about a new screening test without exploring any of the pitfalls, the downsides, the things that come from such screening that can have harmful effects on peoples' lives.

Calcium scores and cognitive skills scores: two more things to worry about, two more ways to promote fear in all of us and to "sell sickness." And two more examples of journalists not asking enough tough questions.

There's an old line that the only well person left in America is simply someone who hasn't been tested enough. Because the more you look, the more you'll find.

Posted by schwitz at 9:08 AM | Comments (5)
StumbleUpon Toolbar Stumble It!

February 10, 2008

The overdiagnosis & overtreatment of prostate cancer

The New York Times this week had a column on "a troubling new report from the Agency for Healthcare Research and Quality, which analyzed hundreds of studies in an effort to advise men about the best treatments for prostate cancer. The report compared the effectiveness and risks of eight prostate cancer treatments, ranging from prostate removal to radioactive implants to no treatment at all. None of the studies provided definitive answers. Surprisingly, no single treatment emerged as superior to doing nothing at all."

Read the full study.

An AHRQ news release said, “Considerable overdetection and overtreatment may exist."

Posted by schwitz at 10:51 AM | Comments (0)
StumbleUpon Toolbar Stumble It!

January 8, 2008

More journalistic screening bias: "a matter of faith not science"

Last year I published an article documenting several instances of U.S. journalists' apparent bias in favor of certain screening tests - in the absence of evidence supporting such tests in they way they were being promoted.

Now it's just come to my attention that an Australian team published an article in November describing an analysis of Australian news coverge of prostate cancer screening. Their conclusion:

"Australian men are exposed to unbalanced and often non-evidence-based appeals to seek PSA testing. There is a disturbing lack of effort to redress this imbalance."

Of special note is how the authors documented the "widespread, overwhelmingly negative" reaction to a statement by the head of an Australian cancer agency who told a newspaper that, at age 59, he chose not to have a PSA test.

And journalists seemed to join in the ad hominem attacks. All because the man spoke from a perspective of evidence and science, not faith and emotion.

We will continue to follow journalism's role in promoting non-evidence-based approaches and will address it whenever we see it.

Posted by schwitz at 8:59 AM | Comments (0)
StumbleUpon Toolbar Stumble It!

December 14, 2007

Despite lack of evidence, use of PSA test increases

A study in a recent issue of the Archives of Internal Medicine tracked use of the prostate specific antigen (PSA) test for prostate cancer between 1995 and 2004. It concluded: "despite the lack of clear evidence of benefit, PSA testing for prostate cancer screening has increased dramatically, especially among black men and younger men."

This week, a letter to the BMJ (subscription required for full text) from two French physicians reacts to a recent report on the feasibility of PSA testing in men ages 45-49. They write:

"Screening for prostate cancer in men older than 50 is hardly acceptable because overdiagnosis is obvious and the impact on mortality remains unproved despite the findings of numerous trials in the past 15 years.

Of 19 major medical organisations worldwide, only the American Cancer Society and the French and American urological associations recommend screening men for prostate cancer with annual measurement of prostate specific antigen (PSA). Therefore, in addition to wasting resources, the paper by Lane et al will be used to promote screening. In France 36% of men underwent prostate cancer screening (unproved and not organised), whereas only 25% underwent colorectal cancer screening (proved benefit on mortality and organised). The only demonstrated effect of prostate cancer screening is a 5-10% biopsy rate in the screened population, with a risk of septicaemia and haemorrhage. Plus, for those treated, various adverse effects (impotence, incontinence, pain, rectal ulcers, etc)."

Posted by schwitz at 8:19 AM | Comments (2)
StumbleUpon Toolbar Stumble It!

November 1, 2007

Brain MRI: the more you look, the more you find

Here's an example of a story that could confuse the hell out of readers - simply because of the way it's written.

The lead is:

Screening MRIs can uncover potential trouble in the brain, a new study suggests.

But the first quote with the principal investigator is:

"Our study shows that incidental findings are much more frequent than was thought previously."

So what should be the story's point of emphasis? Screening finds trouble? Or screening finds lots of stuff that isn't troublesome?

The end of the article starts to catch up with the real impact of the study when it states:

"(The researcher) said that general screening for these conditions wouldn't be recommended, because it's not yet clear if these asymptomatic conditions should be treated.

Dr. Arno Fried, chairman of the department of neurosurgery at Hackensack University Medical Center in New Jersey, agreed.

"Screening would probably create too many problems unless someone was experiencing specific symptoms. ... The problem is what to do about incidental findings," he noted. "What's most important is to correlate clinical status with what we see on the scan. Most of the time, we won't do anything about those incidental findings. Some people will be asymptomatic forever."

Fried suggested that people, "Don't panic when an incidental finding is seen. Many people don't need surgery." He said that while a brain tumor may sound scary, many that are small and aren't causing symptoms don't need to be removed. Aneurysms may require treatment, but if they do, it's generally better that it was discovered early.

The bottom line, said Fried, is that "technology and imaging don't take the place of good clinical judgment. If the technology is taken out of context, it may lead to surgeries that don't need to be done."

Posted by schwitz at 8:54 AM | Comments (0)
StumbleUpon Toolbar Stumble It!

October 30, 2007

The fallout from newborn screening

What could possibly be wrong with screening newborns for congenital health problems?

The same things that can go wrong with any screening progams: false positives, lack of followup, etc.

A Wall Street Journal story today does a good job explaining the unintended impact of recent widespread newborn screening programs.

Posted by schwitz at 9:28 AM | Comments (0)
StumbleUpon Toolbar Stumble It!

October 26, 2007

Questions about the annual physical

The Boston Globe has an interesting story about questioning the value of annual physical exams. Excerpts:

"...annual exams are still phenomenally popular: A study released last month found that 64 million Americans a year get a physical or gynecological exam, costing $7.8 billion and outpacing visits for respiratory conditions or high blood pressure.

But researchers and some health plans increasingly voice deep skepticism about the value of scheduling a separate annual exam for a healthy person. There's little scientific evidence, they maintain, to justify the time, money, and expertise being invested in a ritual that consumes appointment slots, especially when patients with immediate aches and pains can't squeeze into a doctor's frenzied schedule."

Posted by schwitz at 9:56 AM | Comments (0)
StumbleUpon Toolbar Stumble It!

October 12, 2007

Support for new guidelines on mammography for women in 40s

An editorial (pdf file - pages 3 & 4) in the BMJ this week comments on the "muted" reaction to the new guidelines on screening mammography for women in their 40s that were released by the American College of Physicians in April. Rather than calling for universal screening, they recommend that women make an informed decision after learning about the benefits and harms of mammography.

The authors support the guidelines because, they say, no right choice exists and because screening has mixed effects – some women will benefit (by avoiding death from breast cancer) but others will be harmed by unnecessary treatment. So the next step is to ensure that women understand what is likely to happen if they do or do not undergo screening.

The authors say that for every 1000 women screened over the next 10 years less than one life will be “saved? for younger women and about three lives will be saved for older women.

But screening has several harms, say the authors. False positives – abnormalities detected at mammography that often cause women to undergo repeat testing (or perhaps biopsy) to rule out cancer - are the most familiar and can cause short term anxiety, inconvenience, and sometimes unnecessary biopsies. But they think that overdiagnosis is the most important harm of screening.

Overdiagnosis is the detection of lesions that meet the pathological criteria for cancer but would not progress to cause symptoms or death, they explain. Women who are overdiagnosed can only be harmed by treatment – they cannot benefit because no treatment was needed. Harms include disfiguring surgery, side effects of chemotherapy or hormonal therapy (such as nausea, fatigue, and hair loss), and injury from radiation.

Calculating the chance of overdiagnosis is challenging, but the authors estimate that, for every 1000 women screened over the next 10 years, up to five aged 40-49 and up to nine aged 50 and over may be affected.

Posted by schwitz at 7:45 AM | Comments (0)
StumbleUpon Toolbar Stumble It!

October 3, 2007

Genetic tests marketed to consumers

Shari Roan of the Los Angeles Times reports on another new aspect to direct-to-consumer health marketing.

"Without even trying, consumers may soon hear more about genetic tests for breast cancer.

After quietly offering the test for a decade, the primary supplier of the service, Myriad Genetics, has launched a direct-to-consumer advertising campaign. The test still requires a doctor's order, but the campaign is intended to urge people to talk to their doctors about their risk, the company said. Another company, DNA Direct, has been offering the test directly to consumers for several years, via a website. DNA Direct's test does not require a doctor's order, but the company encourages consumers to discuss the test with their doctors.

Some health professionals worry that people who aren't at high risk for breast or ovarian cancer will overreact to the advertisements and think they should get the test. The test isn't meant for the general population, only for families who have reason to suspect they are at high risk. It's also expensive and usually only covered by insurance if there is a family history of cancer.

Others worry that consumers ordering the test online or asking their doctors for a lab order will bypass a discussion with a doctor or genetic counselor about what the test entails and how to interpret the results."

Posted by schwitz at 9:49 AM | Comments (0)
StumbleUpon Toolbar Stumble It!

October 2, 2007

Cancer scare survivors

Scott Allen of the Boston Globe wrote an important story, "Cancer scares grow as screening rises." Excerpt:

"For every cancer survivor, there are several "cancer scare survivors" ... who have been told, based on imperfect tests, that they may have cancer when they do not.

False alarms are not only stressful, but they also often force patients to undergo uncomfortable follow-up tests or even surgery, only to discover that they are cancer-free. Doctors perform an estimated 2 million biopsies, in which a needle is inserted to extract a tissue sample, on healthy breasts in women and prostate glands in men each year because of suspicious test results.

In one study, more than 500 women with no symptoms of ovarian cancer underwent unnecessary abdominal surgery because a blood test wrongly suggested they had the disease.

Unfortunately, in a nation where "early detection" is a mantra and where new high-tech screening tests are being promoted for lung and breast cancer, despite high error rates, it is increasingly possible that everyone will experience a cancer scare."


Posted by schwitz at 11:46 AM | Comments (0)
StumbleUpon Toolbar Stumble It!

June 13, 2007

Journal article imbalance on mammography's benefits vs. harms

A study in the journal BMC Medicine concludes that scientific articles on mammography screening tend to emphasize the major benefits over its major harms. Not surprisingly, the imbalance is related to the authors' affiliation. In other words, benefits (not harms) were emphasized by authors who worked with screening.

The authors also wrote:

"Overdiagnosis and overtreatment were often downplayed as negligible by authors working with screening, but they are not. Assuming a reduction in breast cancer mortality of about 15%, as estimated in the two most recent systematic reviews, and 30% overdiagnosis as indicated by the randomised trials, screening 2000 women over 10 years would prevent one breast cancer fatality but turn 10 healthy women into cancer patients unnecessarily."

"Scientific articles on mammography screening favour information on the mortality reduction, and prefer to present this as a relative risk reduction rather than an absolute risk reduction. A relative risk reduction appears more impressive, but tends to make lay people, as well as health professionals, overestimate the obtainable benefit. This problem is known from scientific articles in general, and is particularly important in a screening setting as so few will benefit of the total number screened."

Since news stories are often based on journal articles, it is easy to see how easily journalists fall into this pattern of emphasizing benefits and minimizing harms of screening. It's a journalistic trend we've reported, and it's one that does not serve the public well.

Posted by schwitz at 6:39 AM | Comments (0)
StumbleUpon Toolbar Stumble It!

May 15, 2007

Unhealthy advocacy: journalists and screening tests

The Poynter Institute website has published my overview of some journalists' apparent pro-screening bias in coverage of some screening tests. The incidents I've tracked involve screening for cancer (prostate, breast, lung, colon) but also for cardiovascular disease and diabetes.

Poynter graphic.jpg

The piece documents more than a dozen incidents of pro-screening stories and gets perspectives from some health journalists about why this is happening.

Posted by schwitz at 7:34 AM | Comments (0)
StumbleUpon Toolbar Stumble It!

May 8, 2007

The true harms of a false positive test

The London Daily Mail reports on a man diagnosed with cancer who was told he had less than a year to live.


"The 62-year-old council worker quit his job, sold his car, stopped paying his mortgage and dug into his life savings so he could treat himself and relatives to expensive restaurant meals.

He even sold all his clothes but for the black suit in which he expected to be buried.

A year later, however, with no sign of the Grim Reaper coming to call, he went for tests - which gave him a clean bill of health. He had never had cancer at all."

I've written before on this blog about journalists who seem to have a pro-screening test bias, never mentioning the harms that can occur from some tests. While this story was about a diagnostic test, not a screening test, it nonetheless should serve as a reminder that there are harms of false positives - which occur often in mass screening campaigns which some journalists endorse in the absence of the best evidence.

Posted by schwitz at 9:59 PM | Comments (1)
StumbleUpon Toolbar Stumble It!

May 1, 2007

News coverage of a new prostate cancer test

For a look at how two different news organizations covered the news of a potentially more accurate test for prostate cancer, see the HealthNewsReview.org review of a weaker ABC News story in contrast with the review of a stronger Baltimore Sun story.

However, neither story adequately addressed the fact that while a more accurate test may tell who has prostate cancer better, it still does not tell which men need treatment in their lifetime and which men don't, which is the real problem in prostate cancer screening. So, both stories left readers and viewers with an overly optimistic view of what screening can do.

Posted by schwitz at 11:33 AM | Comments (2)
StumbleUpon Toolbar Stumble It!

April 25, 2007

Chicago Sun-Times' imprudent prostate campaign

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.

Posted by schwitz at 7:33 AM | Comments (3)
StumbleUpon Toolbar Stumble It!

April 19, 2007

More pro-screening bias by some journalists

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.

Posted by schwitz at 8:13 AM | Comments (1)
StumbleUpon Toolbar Stumble It!

April 8, 2007

CNN's one-sided view of mammography controversy

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.

Posted by schwitz at 8:58 AM | Comments (3)
StumbleUpon Toolbar Stumble It!

April 3, 2007

New (old?) questions about mammography in the 40s

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."

Posted by schwitz at 10:19 AM | Comments (0)
StumbleUpon Toolbar Stumble It!

April 1, 2007

Journalism or advocacy? Evidence or opinion?

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.

http://www.ahrq.gov/clinic/3rduspstf/colorectal/colorr.htm

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).

Posted by schwitz at 9:35 AM | Comments (1)
StumbleUpon Toolbar Stumble It!

March 13, 2007

How Two Studies on Cancer Screening Led to Two Results

The headline above is the headline of an essay in the New York Times today by my former Dartmouth colleagues Gil Welch, Lisa Schwartz and Steve Woloshin. They address possible consumer confusion over how two studies - one in the New England Journal of Medicine last October and one in the Journal of the American Medical Association this month - could reach two such different conclusions on the possible benefits (and harms) of CT scan screening of smokers for lung cancer.

With their usual clarity, the three authors do a terrific job explaining how this could be - and I won't duplicate what they said here. But here's how they ended the essay:

"But neither study is definitive, because neither was a randomized trial. And both required assumptions. Given the potential benefit (so many people die from lung cancer) and the potential harms (some die from treatments), no one should have to assume anything.

Luckily, two randomized trials are under way — one a Dutch-Belgian collaboration, the other sponsored by the National Cancer Institute. Recent experience, notably with hormone replacement in postmenopausal women, has demonstrated how presuming benefits in the absence of randomized trials can cause real harm. To avoid repeating these mistakes, we should not screen for lung cancer unless the trials demonstrate a reduction in mortality."

Posted by schwitz at 3:56 PM | Comments (0)
StumbleUpon Toolbar Stumble It!

March 7, 2007

New Mayo study questions value of lung cancer CT scans

The screen-at-all-costs mentality takes an intellectual hit with the publication of a new study in the Journal of the American Medical Association. The conclusions of those authors: "Screening for lung cancer with low-dose CT may increase the rate of lung cancer diagnosis and treatment, but may not meaningfully reduce the risk of advanced lung cancer or death from lung cancer. Until more conclusive data are available, asymptomatic individuals should not be screened outside of clinical research studies that have a reasonable likelihood of further clarifying the potential benefits and risks."

Back in October, another study claimed quite the opposite, and many journalists failed to report with balance on those findings. (See summary on 8 stories on HealthNewsReview.org.) One journalist on the listserv of the Association of Health Care Journalists (AHCJ) has already pointed out this morning that some news organizations will have difficulty explaining the apparent flip-flopping findings today - if they did a naive job in October. Mike Taibbi of NBC News even went on the air in the fall reporting on his own CT scan after a life of smoking, and ended with a personal endorsement of the procedure. No spots on his lungs but now egg on his face.

One who wouldn't have a tough time explaining the latest study is former Miami Herald reporter Jacob Goldstein, who was recognized on HealthNewsReview.org for his excellent story in October. We've just learned that his excellence led the Wall Street Journal to lure him away as their first health news blogger.

Posted by schwitz at 8:13 AM | Comments (0)
StumbleUpon Toolbar Stumble It!

January 2, 2007

An epidemic of diagnoses

Dartmouth and VA researchers Gil Welch, Steve Woloshin and Lisa Schwartz have an essay in the New York Times that begins: "For most Americans, the biggest health threat is not avian flu, West Nile or mad cow disease. It’s our health-care system."

They go on to state: "More and more of us are being drawn into the system not because of an epidemic of disease, but because of an epidemic of diagnoses." They describe the "medicalization of everyday life," wherein "everyday experiences like insomnia, sadness, twitchy legs and impaired sex drive now become diagnoses: sleep disorder, depression, restless leg syndrome and sexual dysfunction. Perhaps most worrisome is the medicalization of childhood. If children cough after exercising, they have asthma; if they have trouble reading, they are dyslexic; if they are unhappy, they are depressed; and if they alternate between unhappiness and liveliness, they have bipolar disorder. While these diagnoses may benefit the few with severe symptoms, one has to wonder about the effect on the many whose symptoms are mild, intermittent or transient."

They look at increasing questionable use of CT scans, ultrasounds, M.R.I. and PET scans.

And they address the lower thresholds for defining disease. "Thresholds for diagnosing diabetes, hypertension, osteoporosis and obesity have all fallen in the last few years. The criterion for normal cholesterol has dropped multiple times. With these changes, disease can now be diagnosed in more than half the population."

They conclude: "Perhaps someone should start monitoring a new health metric: the proportion of the population not requiring medical care. And the National Institutes of Health could propose a new goal for medical researchers: reduce the need for medical services, not increase it."

Posted by schwitz at 8:30 AM | Comments (0)
StumbleUpon Toolbar Stumble It!

December 20, 2006

Push for herpes testing = push for herpes drug use?

It's another story of questionable promotion of a screening test, of "off-label" promotion of a drug, of risk-benefit decisions, and of behind-the-scenes drug company wrangling for broader use of one of its drugs.

The Wall Street Journal (subscription required) reports on a controversial push by some doctors for testing all pregnant women for genital herpes to reduce infections in newborns. Of course, it would also mean a boost for GlaxoSmithKline, which has a herpes drug, and which supports the "continuing medical education" lectures promoting the screening.

The WSJ reports: "Advocates of screening point to a stark reality: Babies born to a woman whose herpes infection is active can end up blind or with cerebral palsy, and some die. An estimated one-quarter of pregnant women in the U.S. carry the herpes virus in their bodies.

Yet only a small fraction of these women are at any risk of passing the virus to their babies. It's not clear whether treating infected women with herpes drugs would reduce this number. Meanwhile, most pregnant women who have the virus don't even know it. And they aren't routinely tested to find out.

Federal health agencies that have studied the possibility of universal screening of pregnant women for genital herpes have come down against it. So has the American College of Obstetricians and Gynecologists. Opponents see little benefit but potential risks if large numbers of women tested positive and began taking herpes drugs. Their side effects can range from allergic reactions to hypertension.

Glaxo says it doesn't market its herpes drug, called Valtrex, in any way for pregnant women. The company couldn't promote the drug to prevent neonatal herpes in any case, because the Food and Drug Administration hasn't approved it for that purpose.

Doctors, however, aren't restricted in how they use an approved drug, nor in what they can say about it in talks to other medical professionals. And currently, about 10 doctors are fanning out across the U.S. making the case for universal genital-herpes screening of pregnant women. Glaxo funds these talks by giving grants to hospitals and other institutions that host them."

One Ob-Gyn in the story said, "A screening program will be horribly inefficient and almost entirely ineffective and highly cost-ineffective. There are a few people who have made careers out of neonatal herpes and they are the ones pushing screening."

It's a messy story, well-reported by the WSJ.

Posted by schwitz at 7:32 AM | Comments (1)
StumbleUpon Toolbar Stumble It!

December 12, 2006

Cross-media comparisons on lung CA CT scan story

On the HealthNewsReview.org website, we're making a new effort to compare how different news organizations did in covering the same story. Our broadest analysis yet is now posted in a Publisher's Note on that site.

It covers eight different stories by seven different news organizations on the recent study published in the New England Journal of Medicine on CT scan screening of smokers.

Summary:

* 6 of 8 failed to adequately discuss potential harms of such screening, which can include radiation exposure, needless anxiety after receiving a potentially false positive result and significant medical complications associated with biopsies.

* 6 of 8 stories failed to adequately address the availability of CAT scan machines that can be used for the lung cancer screening described.

* 4 of 8 stories failed to discuss the costs of such screening, which were discussed in the journal article upon which the stories were based. Estimates range from $200 to $1,000 per scan, so this is a significant issue that half the stories ignored.

* 5 of 8 stories relied on a single source (relying only on authors of the published study) and/or failed to present balanced, independent perspectives.

Posted by schwitz at 8:27 AM | Comments (0)
StumbleUpon Toolbar Stumble It!

November 22, 2006

Egregious spinning of lung cancer screening news

In the latest edition of The Cancer Letter (Nov. 22, 2006, Vol. 32 No. 42), Editor & Publisher Kirsten Boyd Goldberg and Editor Paul Goldberg, publish an extremely important and troubling followup to the lung cancer CT scanning study published in the New England Journal of Medicine several weeks ago. They obtained documents distributed by the the International Early Lung Cancer Action Program – or I-ELCAP - the organization that conducted the study published in the NEJM. The documents give “talking points? to be used in media interviews about the study. Physicians who put patients on the study were urged to repeatedly use the word “compelling? to describe the results being published, refrain from mentioning ongoing randomized trials, and urge people to get screened. The “talking points? also urged interviewees to avoid using the terms “observational or noncomparative? to describe the design of the trial – even though those are accurate terms for the study design, seen as a limitation by some critics.

In the article, ethicist Heidi Malm says “Why instruct other researchers not to state factual claims? This limits informed consent by suggesting that this kind of study has the same merit as other studies. [Claudia Henschke, I-ELCAP principal investigator and lead author of the study] is blocking the terms that would make it clear that it isn’t the same kind of study, so people might just assume that it has the same evidentiary quality as a randomized clinical trial. This limits informed consent from the public. They are assuming this has been shown to be effective in terms of saving lives and not just in terms of finding new cancers. It feeds into the misassumption by the public that finding more cancers is the same as saving more lives and that’s what we need the randomized trial to show.?

I am also quoted in the article: “I consider myself well-informed on the latest methods of ‘managing the media’ by different sources in the dissemination of health, medical and science information. I consider myself quite skeptical. Yet I am shocked by what is written in these I-ELCAP ‘soundbites.’ The admonition to ‘stay on the high ground’ begs the question of ‘what is the low ground?’ To me, the low ground is the deception that is recommended in these talking points. The advice is to avoid discussing the trial design. Here are scientists urging each other to mislead journalists into doing an inferior job. The observational nature of the trial is critical to consumer understanding. But the I-ELCAP PR machine advises spokespersons to run from the truth.?

A copy of the "talking points" spin document is included in The Cancer Letter article. While the Letter is a subscription-only publication, Editor & Publisher Kirsten Boyd Goldberg says she will send a free copy to anyone who writes to her at: kirsten@cancerletter.com.

Posted by schwitz at 8:45 AM | Comments (0)
StumbleUpon Toolbar Stumble It!

July 3, 2006

Katie Couric colon campaign may be improving

I have helped lead the criticism of Katie Couric's often troublingly non-targeted colon cancer screening campaign. By that I mean that her messages often did not discriminate between people at an age at which a benefit of screening has been proven and people at an age at which the benefit is not so clear and evidence for possibly greater harm exists. She was using her fame and her platform to crusade for screening - sometimes giving troubling advice to all readers and viewers when the message should have been targeted to sub-groups.

Maybe that's getting better. I saw the poster below in Boston Logan airport this weekend. The last line reads: "If you're 50 or older, talk to your doctor and get screened for colorectal cancer." That age category has been missing from many of her previous messages. Maybe it's her partners in this campaign - from the CDC - who injected the evidence-based guideline into this message.

Screening test decisions should be based on evidence, not on emotion. Good things can happen and bad things can happen from what are often framed as "simple tests."

IMG_0312.JPG

Posted by schwitz at 8:57 AM | Comments (0)
StumbleUpon Toolbar Stumble It!

June 26, 2006

Media advocacy without all the facts

The New York Daily News boasts on its website about the community service it is providing with its seventh annual week-long free prostate cancer screenings.

They profile a 45-year old African-American man who came in for screening because his father was diagnosed with prostate cancer a few years ago. His race and his family history do put him at higher risk.

But then the News says that man “is one of thousands of men who have sat down for a simple blood test.? What they don’t tell you is that most of those thousands are not at high risk of a cancer that could kill them. But the News goes on to quote a local urologist who says, "You save one person, you're doing a good job."

Yes, you are. But at what cost? The doctor and the newspaper should have explained how many men need to be screened in order to save one life. How many will have false-positive tests, telling them they have a problem when they really don’t? How many will endure the anxiety, discomfort and expense of a biopsy needlessly? And how many men who do have true elevated PSA levels actually have a cancer that will hurt them in their lifetimes?

That’s why whenever someone calls this a “simple? test, I shudder. There’s nothing simple about it, nor about the decision to have it or decline it.

The U.S. Preventive Services Task Force doesn't recommend annual PSA screening. These are the facts that should have been provided.

But advocacy journalism is sometimes blind to the facts that people need to make good health care decisions. Rather than sponsoring week-long free screenings, the paper would provide a bigger public service by sponsoring open, balanced, evidence-based discussions of the harms and benefits of various screening tests. That would make consumers smarter. And it would hurt no one.

Posted by schwitz at 7:06 AM | Comments (0)
StumbleUpon Toolbar Stumble It!

March 24, 2006

Potential harms of breast cancer screening

Scandinavian researchers report in the BMJ this week on their study suggesting a 10% over-diagnosis of breast cancers from a mammography screening program.

"Over diagnosis" means finding early cancers or "pseudo-cancers" that would not have caused harm in the woman's lifetime.

Others reacting to the study think it underestimated the rate of overdiagnosis -- that it may be more like 24 - 30%.

There's been an interesting progression to the discussion in the BMJ recently. As editor Fiona Godlee points out, "Three weeks ago an editorial in the BMJ concluded that despite limitations, breast cancer screening does save lives. But in the same issue of the journal we published an analysis ... of the letters inviting women for screening. None of the letters mentioned the major harms of screening, and the authors concluded that organisers of screening programmes have a serious conflict of interest in wanting high uptake, which compromises their ability to provide balanced information about benefits and harms."

Posted by schwitz at 8:23 AM | Comments (0)
StumbleUpon Toolbar Stumble It!

March 3, 2006

More balanced info needed on breast CA screening

It may be difficult for people to understand how there could be any problem with having a screening test. We've been trained that "early detection leads to better chance of cure." Journalists often promote this theme without knowing there's much more to the story.

Articles in this week's BMJ push for more discussion about the negative side effects of screening for breast cancer. One study suggests that breast cancer screening could result in a 10% rate of over-diagnosis.

Researchers say that the information given to women needs to be more balanced to ensure women are adequately informed about the benefits and harms. Research has shown that women generally exaggerate the benefits and are unaware of the harms of screening such as overtreatment.

An excellent resource on this topic is Dr. Gil Welch's book, "Should I Be Tested for Cancer? Maybe Not and Here's Why."

Posted by schwitz at 7:47 AM | Comments (0)
StumbleUpon Toolbar Stumble It!

January 3, 2006

The science and politics of colorectal cancer screening

Two Norwegian researchers offer a very thoughtful essay in the current PLoS Medicine.

They describe different countries' differing policies on colorectal cancer screening -- from simply screening everyone or none at all. Meantime, the benefits of screening and the ideal screening method, have not been clearly established.

Or nations could do what the Finns have done -- with a stepwise, randomized trial, allowing evaluation of its fecal occult blood test screening program after five years before deciding what their next step of action should be. The authors write: "The people behind the Finnish strategy deserve credit for persuading their politicians to choose this cautious, stepwise model, and the politicians and health authorities deserve credit for listening. In the Finnish model, half of each age cohort is randomised to screening or no screening. The Finnish model must have required a lot of explanation to authorities that this approach was clearly the best way to proceed. It was, of course, risky for politicians to voluntarily throw away half (or more) of their target candidate supporters by declaring, in essence, 'We believe in (colorectal cancer) screening, but aren't sure about it, and half of you will be offered screening while the other half will not.' "

Finally, with a shot at celebrities like Katie Couric who use their platform to promote screenings for which not all the evidence is in, the authors write: "Health policymakers must also remain sceptical of the role of celebrity endorsements. Communication on complex decisions such as cancer screening, with an aim to inform rather than persuade, is not an obvious task for celebrities."

Posted by schwitz at 5:02 PM | Comments (0)
StumbleUpon Toolbar Stumble It!

September 2, 2005

Brits warn against unnecessary screening & scanning

The British Medical Association's Board of Science issued a warning unlike anything their American counterparts have done. They've told consumers they may be putting themselves at unnecessary riskwithout much chance of benefitby having some scans and genetic tests.

The group asked the British government to address the growing problem of unregulated screening that is offered outside the formal screening programs of the British National Health Service. It's estimated that almost $120 million was spent in Britain last year on private screening.

One spokesman said unregulated screening was often provided for profit. "It is often marketed to certain sections of the population but not necessarily those suffering from disease. It is not quality assured."

Posted by schwitz at 8:59 AM | Comments (1)
StumbleUpon Toolbar Stumble It!