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.
See our review of stories by ABC, CNN, CBS and Houston Chronicle: http://www.healthnewsreview.org/blog/2009/12/failure-to-scrutinize-claims-about-screening-all-us-sixth-graders-hearts.html
What's up with all of the aggressive heart screening programs in Texas? (For example, see this past blog entry: http://blog.lib.umn.edu/schwitz/healthnews/2009/09/texas-law-manda-1.html.)
Don't they have a lot of uninsured they should be thinking about?
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 American College of Physicians - the largest medical specialty organization and the second-largest physician group in the United States - has issued this statement:
The U.S. Preventive Services Task Force (USPSTF) recommendations on mammography, which were published in ACP's flagship journal, the Annals of Internal Medicine, have regrettably been used by some critics of the health reform bills being considered by Congress to make baseless charges that the bills would lead to rationing of care. Other critics have made unfair and unsubstantiated attacks on the expertise, motivations, and independence of the scientists and clinician experts on the USPSTF.
ACP believes that it is essential that clinicians and patients be able to make their own decisions on diagnosis and treatment informed by the best available scientific evidence on the effectiveness of different treatments and diagnostic interventions. The USPSTF is a highly regarded, credible and independent group of experts that performs this role, on a purely advisory basis, to the Department of Health and Human Services, as it relates to interventions to prevent or detect diseases. As is often the case with evidence-based reviews, the USPTF's recommendations will not always be consistent with the guidelines established by other experts in the field, by professional medical societies, and by patient advocacy groups. Such differences of opinion, expressed in a constructive and transparent manner so that patients and their clinicians can make their own best judgment, are important and welcome. It is not constructive to make ill-founded attacks on the integrity, credibility, motivations, and expertise of the clinicians and scientists on the USPSTF.
Some critics have erroneously charged that the USPSTF's recommendations were motivated by a desire to control costs. According to the Agency for Health Care Research and Quality, "the USPSTF does not consider economic costs in making recommendations." The Agency continues, "it realizes that these costs are important in the decision to implement preventive services. Thus, in situations where there is likely to be some effectiveness of the service, the Task Force searches for evidence of the costs and cost-effectiveness of implementation, presenting this information separately from its recommendation" and the "recommendations are not modified to accommodate concerns about insurance coverage of preventive services, medicolegal liability, or legislation, but users of the recommendations may need to do so." [emphasis added in bold]
Under the bills being considered by Congress, the USPSTF will have an important role in making evidence-based recommendations on preventive services that insurers will be required to cover, but the bills do not give the Task Force -- or the federal government itself -- any authority to put limitations on coverage, ration care, or require that insurers deny coverage. Specifically, the House and Senate bills would require health plans to cover preventive services based in large part on the evidence-based reviews by the USPSTF, but no limits are placed on health plans' ability to offer additional preventive benefits, or in considering advice from sources other than the USPSTF in making such coverage determinations. Accordingly, patients will benefit by having a floor - not a limit - on essential preventive services that would be covered by all health insurers, usually with no out-of-pocket cost to them. Patients will also benefit from having independent research on the comparative effectiveness of different treatments, as proposed in the bills before Congress. The bills specifically prohibit use of comparative effectiveness research to limit coverage or deny care based on cost.
The controversy over the mammography guidelines illustrates the importance of communicating information on evidence-based reviews to the public in a way that facilitates an understanding of how such reviews are conducted and how they are intended to support, not supplant, individual decision-making by patients and their clinicians.
ACP urges Congress, the administration, and patient and physician advocacy groups to respect and support the importance of protecting evidence-based research by respected scientists and clinicians from being used to score political points that do not serve the public's interest.
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.
Many of us might rather move on and end all of the discussion about the US Preventive Task Force's mammography recommendations last week. But I think it's essential that we reflect on ten things that stand out from last week:
1. Many in the general public (most of those quoted in news stories) are not prepared for evidence to be used in making health care recommendations. They haven't been prepared by the health care industry, by their physicians, or by the news media.
2. Many in health care (many of those quoted in news stories) are too invested in their own preferences to allow evidence to make a difference in their practices.
3. There is an undeniable and clear bias in many news stories, reporters and news organizations for promoting screening - evidence be damned. I've reported on this before and last week provided overwhelming new evidence. (Mind you - I said "many", not "all.")
4. The USPSTF, which is a collection of independent experts, has no public relations arm. They simply review the evidence and publish their recommendations.
5. The public relations machinery of the American Cancer Society, the American College of Obstetrics and Gynecology - and other groups that opposed the USPSTF recommendations - helped the anti-USPSTF message rule the media all of last week.
6. Politicians chimed in - sometimes distorting the evidence beyond all recognition. The clash between politics and science at such times is predictable and disgusting.
7. The rhetoric used to oppose the USPSTF recommendations was the ugliest and most ill-founded I can remember.
8. There was some excellent journalism done on the issue last week, but it was overwhelmed by and drowned out by the drumbeat of dreck shoveled out by many news organizations - including in much (not all) of what was provided on network TV.
9. The week may have caused harm to the nation's discussion of health care reform.
10. The week was certainly a setback for the nation's understanding of science, of evaluation of evidence, of the potential harms of screening tests.
Kirsten Boyd Goldberg writes in this week's Cancer Letter:
"In the past three decades, attempts to develop rational, evidence-based screening guidelines for breast cancer in the U.S. have always generated intense controversy.
What happened this week with the new U.S. Preventive Services Task Force recommendation has happened many times before:
An independent panel of experts is assigned to rationally assess the data and evaluate the level of evidence for screening in order to minimize the role of commercial and political interests in promoting a test that might or might not reduce cancer mortality.
The moment the panel's document is released, political combat ensues. The result is a cacophony. The resulting cacophony angers politicians who don't understand why "the experts" can't agree on "one simple message."
The anger of politicians frightens federal health officials who want to protect their budgets and their ability to run programs without meddling from Congress.
The federal health officials bob and weave and distance from the expert panel's recommendations.
The expert panel becomes the focal point of the anger. Commercial and political interests make accusations about the panel's composition, experience, and potential conflicts of interest. The panel must have been politically influenced, critics charge. The specter of "rationing" health care is raised.
The beleaguered panel members either defend their recommendation or say nothing.
Rational assessment has always had a tough road to travel in the U.S., starting with the dawn of randomized clinical trials, when doctors didn't accept trial results as being valid. But that's another story."
She's absolutely correct. Those who don't learn from the past are doomed to repeat it.
"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.