I've seen a lot of awful news coverage on breast cancer screening in the past month or so, but the award (so far) for the worst, most useless, misinformation goes to the CBS Early Show.
I've seen a lot of awful news coverage on breast cancer screening in the past month or so, but the award (so far) for the worst, most useless, misinformation goes to the CBS Early Show.
The National Breast Cancer Coalition is offering an online webcast tomorrow to clear up confusion on the recent USPSTF breast cancer screening recommendations.
They ask that interested parties register today.
The webcast is Thursday, December 17 at 3 pm Eastern time.
I would ignore this except that it's in the Washington Post and despite the fact that they're closing bureaus in Chicago, Los Angeles and New York, what's in what remains of the paper is still influential.
So I feel compelled to address Dana Milbank's column in the Post about the US Preventive Services Task Force breast cancer screening recommendations.
He characterized the USPSTF recommendations as a "cruel and clumsy blow" that "wiped out much of the progress" in breast cancer detection.
It got worse, as he wrote:.
"With a drumbeat of recommendations raising doubts about various cancer screenings, the public could easily get the mistaken impression that all cancer screening is a waste of time and money."
Stop the foolishness.
The USPSTF said nothing about any cancer screening being a waste of time and money. In fact, it recommends biennial screening mammography for women aged 50 to 74 years. It recommended against routine screening mammography in women aged 40 to 49 years, stating "The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms."
How "cruel" to try to ensure that women are fully informed about benefits and harms, and to state that this should be an individual decision based on individual values.
If the public can get the impression that all cancer screening is a waste of time and money from those statements, then Milbank might better spend his time educating the public on how to read.
It got worse. Much worse. As he continued:
"Luckily, Congress has a simpler solution at hand: It can abolish the task force and turn it into a group that is more accountable to the public. Under the House version of health-care legislation, the task force, whose members need not subject themselves or their opinions to public comment or public hearings, would be reorganized as a federal advisory committee subject to oversight. Their scientific judgments would stay independent, but the group would no longer be able to go rogue with surprise recommendations."
Oh, that would be a grand idea. Make science accountable to the public? Let's make science ignore the evidence and tell us fairy tales that we want to hear. That everything is terrific, risk-free and without a price tag? And let's make the independent task force subject to federal government oversight. Then we can make science ignore the evidence and only spew out what is politically popular at the moment.
Milbank believes his ideas mean that the task force would no longer be able to "go rogue with surprise recommendations." Read your own paper, Dana.
Dan Eggen and Rob Stein reported that "The findings underscore a decades-long debate in the medical community about the benefits and risks of routine breast cancer screening for younger women." So this is not "rogue" and not "surprising" to anyone who has made any attempt to follow the issue.
Why did he choose to give only Nancy Brinker's side of the story? His own paper reported this praise for the USPSTF recommendations:
"It's about time," said Fran Visco, president of the National Breast Cancer Coalition, a Washington-based patient advocacy group. "Women deserve the truth -- and the truth is the evidence says this is not always helpful and can be harmful."
But it's really sick when a columnist suggests that task force members be sent to Gitmo and that they be sent "to the Death Panel for a humane end."
If he thought this was humorous, it wasn't. If he thought his column clarified anything, it didn't. Confusion and rhetoric will reign as long as we continue to get one-sided, vacuous, inaccurate columns like this. If, indeed, anyone is reading it.
While some critics of the US Preventive Services Task Force made wild and nonspecific charges that members of the task force must have conflicts of interest, a new post on the Hastings Center's Bioethics Forum identifies specific potential conflicts of interest in some of the critics.
Dr. Adriane Fugh-Berman MD of Georgetown University Medical Center, and director of PharmedOut.org and Alicia M. Bell, project manager of PharmedOut and member of the board of directors of the National Women's Health Network, write:
"Vague, fact-free, emotionally charged statements are the language of public relations, not scientific discourse. The striking similarities in word choice among these critics could be entirely coincidental. Perhaps the congruence in their conflicts of interest is coincidental as well.
U.S. Preventive Services Task Force members are not allowed to have "substantial conflicts of interest, whether financial, professional, or other conflicts, that would impair the scientific integrity of the work of the USPSTF." Organizational or personal conflicts of interest, however, are common among critics.
Donors to the American Cancer Society Cancer Action Network (ACS CAN), the "nonprofit, nonpartisan advocacy affiliate of the American Cancer Society", include Hologic, which makes breast imaging products, and Johnson and Johnson, which makes an image-guided breast biopsy product. Donors to the American College of Radiology Imaging Network (ACRIN) Fund for Imaging Innovation include Siemens, GE Healthcare, Phillips, Hologic, and many others that make mammography machines or related products.
According to the American College of Radiology Web site, "the leaders of the ACR and ACRIN have been meeting with industry leaders from key donors to the ACRIN Fund to strengthen the relationships between the organizations and better determine how both parties can maximize this relationship." The Society of Breast Imaging is an organization managed by the American College of Radiology.
The Access to Medical Imaging Coalition is run by Tim Trysla, who works for the Alston and Bird law firm and is counsel to the "largest complex diagnostic imaging manufacturers, physician groups and providers regarding Medicare reimbursement." He directs the "Coalition of Diabetic Providers and Manufacturers opposing Medicare competitive bidding for durable medical equipment." Daniel Kopans holds patents on imaging systems. Robert Schmidt reports receiving royalties from, and being a shareholder in Hologic.
...None of these conflicts of interest have been mentioned in news coverage.
...When critics with conflicts of interest are banned from the argument, the controversy vanishes."
The disconnect between the facts and women's beliefs about breast cancer was shown again in a USA Today story. Excerpts:
"A vast majority of American women plan to ignore controversial new recommendations about mammograms, a USA TODAY/Gallup Poll shows. The poll also shows that most women sharply overestimate their risk of developing the disease. ...
Forty percent of women estimate that a 40-year-old's chance of developing breast cancer over the next decade is 20% to 50%. The real risk is 1.4%, according to the National Cancer Institute."
Is it any wonder that women say they'll ignore the USPSTF recommendations when they over-estimate their own risk by such a huge degree! And such over-estimation of risk is not new - having been reported consistently through the years.
The story includes this chart, with figures that get lost in the rhetoric.
Paul Scott has an opinion piece in the Rochester Post-Bulletin in which he criticizes what he calls the Mayo Clinic's "vague and surprisingly unprepared" response to the US Preventive Services Task Force's mammography recommendations.
"Taking unspecified issue with "the modeling data used in the analysis," it stated "a substantial number of women who receive biopsies because of a screening mammogram are found to have cancer." Mayo's Dr. Sandhya Pruthi added "there are many stories about younger women who have found cancer early as a result of screening."
I'm not sure why she made mention of stories. Dr. Pruthi is surely a talented clinician, but in supporting mammograms for women in their 40s here she is citing anecdotes, not data. It would have been better for her to acknowledge that when it comes to population-wide recommendations about screening and illness, medicine always eventually draws a line in the sand somewhere. People invariably will fall on either side of that line wrongly, but if we don't draw a line somewhere, you have to screen everybody for everything, and screening sets in motion the potential for new harms."
It seems that anyone who opposes the USPSTF recommendations trots out personal anecdotes to bolster their argument. Scott countered and concluded with an anecdote of his own:
"I would like nothing more than for our society to prevent the incidence of breast cancer. It took the life of my mom, who identified a tumor on her own at 37, was treated surgically at Mayo in the mid 1970s, and who then lived another 26 years. But my mom believed in science, and in trusting science, and in this case, the science says what it says. I hope that Mayo can do the same, even when doing so runs against that which is popular."
The first online comment posted in response to Scott's opinion piece stated that "there isn't one single oncologist on the US Preventive Services Task Force." I've heard that curious argument before. Evidence is evidence - regardless of whether you're a primary care doc, an oncologist, an epidemiologist, an ob-gyn or a breast surgeon. Evidence-based medicine should be guided by the best evidence, not by the personal experiences or preferences of any specialty group.
"The current controversy over the task force's report owes much to the media's confusing coverage, some of which has been misinformed, including by TV doctors who ought to know better.
The confusion has been abetted by the American Cancer Society, whose position appeared to have softened, then hardened again, in recent weeks.
There are multiple reasons women are ill-informed about breast cancer. The fault lies primarily with their physicians, the cancer establishment, and the news media--especially the news media. Until coverage of breast cancer rises above the level of scary warnings mixed with heartwarming stories of cancer survivors, women are likely to go on being perplexed."
Washington Post media columnist Howard Kurtz strayed beyond media observations and injected his own comments about the US Preventive Services Task Force breast screening recommendations.
He calls the task force recommendation a "don't-worry-be-happy-till-you're-50 finding."
He defines "the essential problem with such studies" as "in the end it's a very personal decision."
Exactly. And that was the entire point of the USPSTF recommendation - that women need to weigh the harms and benefits in consultation with their doctors. But Kurtz must not have read that far.
And then he goes on to cite a list of journalists who wrote about their own personal opposition to the recommendations.
But he didn't quote even one person who wrote in a more balanced way about the evidence behind the recommendations. So, while his column was headlined, "A battle over breasts," he didn't present much about "the other side" in this battle.
Then again, Kurtz has exhibited an advocacy stance for the screen-screen-screen mentality in the past in his handling of a friend's promotion of prostate cancer screening.
My friend Robert Davis writes about five popular falsehoods he's seen this week in the "the widespread confusion, consternation, and even anger that the new (US Preventive Services Task Force mammography) guidelines have unleashed." His five:
1. This is all about saving money.
2. This is about rationing.
3. Early detection saves lives.
4. The fact that I or someone I know was saved by a mammogram proves that more testing is better.
5. The shifting recommendations prove that scientists are clueless.
Read his entire column. He's a smart guy and his summary is insightful.
I am a frequent critic of TV health news - and especially of much of this week's TV coverage of the US Preventive Services Task Force mammography recommendations. So I want to make special note this week of some of the fine work by Dr. Nancy Snyderman on this issue. I've seen several examples where she offered more explanation and context than her network TV competitors.
Case in point: this clip on yesterday's NBC Today Show.
In it, Snyderman said: "What we as a population were unwilling to accept - which has become very apparent in the last 48 hours - is that we didn't like the message." Yet she emphasized that the message was what the science shows.
She said HHS secretary Sebelius threw the task force under the bus and oversimplified the message by telling women "keep doing what you're doing."
She said "emotion, anecdote, lobbying, advocacy groups, doctors and patients" led to a political reversal.
She said "This is the role of scientists to take the emotion out of the science. That was their charge - look at the hard numbers and give recommendations back."
While she editorialized on Sebelius, her even-handed comments on the work of the task force stood in sharp contrast to some of what was broadcast on ABC, CBS, CNN and Fox.
For a long time, I've urged health care journalists to refer to the recommendations of the US Preventive Services Task Force and to educate readers/viewers about how the group operates.
Perhaps one of the reasons the task force's recommendations this week caught so many people by surprise is that journalism hasn't done a good enough job of:
• explaining the uncertainties that still exist and always have existed about mammography
• explaining the work of the USPSTF
All of their work - how they do it - what they base their recommendations on -who they are - is available online - and has been.
Since they're an independent group of experts from across the country, they have no PR machine like the American Cancer Society does. So it's easy for the ACS to rule the airwaves and the columns when they disagree with something the USPSTF states.
But I think journalists have failed badly in explaining this work. And the harm done to evidence-based medicine this week may be lasting.
More on the reactions to the US Preventive Services Task Force mammography recommendations. Susan Perry writes on MinnPost.com about:
"... the rampant, breathless fear-mongering rhetoric that has framed much of the media's response to the recommendations. ...
On ABC's daytime talk show "The View," co-host Elisabeth Hasselbeck made the stunning claim that the recommendations were "gender genocide."
I can't tell you how many times I've used that line in interviews recently.
So it was refreshing to see someone else - Steven Pearlstein - use it today in the Washington Post. (* Actually, either he or the copy desk butchered the quote, leaving out the "not." Surely they meant well, but the quote and the point makes no sense without it, and indeed, is NOT what the standard line is. I've added it in the following excerpt with a * and hope the Post corrects this soon.)
"I should acknowledge that I have no idea who should and should not get routine mammograms. But I know enough about statistics to say that the issue is not settled just because you know of someone in her 40s whose breast cancer was detected by a mammogram and cured. As economists and medical researchers are fond of saying, the plural of anecdote is *(not) data. ...
As is often the case in such matters, those raising the most fuss were those with greatest financial interest in mammography (the radiologists and the makers of mammography machines) and the disease groups (in this case, the American Cancer Society), which tend to resist recognizing limits on how much time, money and attention is devoted to their cause.
"How many mothers, sisters, aunts, grandmothers, daughters and friends are we willing to lose to breast cancer while the debate goes on about the limitations of mammography?" Otis Brawley, chief medical officer of the American Cancer Society, asked in an op-ed article in Thursday's Washington Post. Dr. Brawley cleverly didn't answer his own question, but the clear implication of his question was that the only acceptable number should be zero. And it is that very attitude, applied across the board to every patient and every disease, which goes a long way in explaining why ours is the most expensive, and one of the least effective, health-care systems in the industrialized world."
Not only did Dr. Sanjay Gupta of CNN show his imbalanced perspective on the US Preventive Services Task Force breast screening recommendation. But CNN's non-physician medical correspondent, Elizabeth Cohen, also offered her opinion on the air.
"This task force is the only big group that is saying this. There are lots of groups that disagree with this. So for me, a woman in her 40s who has to make this decision, I look at it this way. I say, alright, government task force says I don't necessarily need a mammogram. On the other hand, the American College of Obstetrics and Gynecologists says I should get one. The American Society for Clinical Oncology says I should get one. The American Cancer Society (a chuckle and smirk now appear in her voice and on her voice) say I should get one. I think you can see how that decision - how that weighs out."
No, Elizabeth, I don't see from what you cited how that decision should play out.
Because you haven't explained any evidence to me.
You haven't explained the need for shared decision-making between informed patients and their health care providers.
You've merely drawn a red state/blue state map for me - except that your map was incomplete. What do you mean by "big group"? Do you mean the organizations with big PR machines that usually spin their stories through you?
Because the National Breast Cancer Coalition, Breast Cancer Action, and the National Women's Health Network are among the "little groups" - as you must define them - who support the US Preventive Services Task Force recommendations.
CNN, what have you done to educate viewers on this issue?
What have you done to explain the data?
And why should I care about what Elizabeth Cohen decides?
Why should I care any more about her decision than about the story of women who regret that they ever were screened? (A story she chose not to tell.)
You can hear what Cohen said and how she said it in the clip below from Newsy.com.
You'll also see the comments from Fox News' "Dr. Manny." Perhaps CNN has achieved its goal. In an attempt to catch Fox News in the ratings, it has become just like Fox News.