Cheerleading, shibboleths and uncertainty

Gary Schwitzer

Publisher

HealthNewsReview.org

Cheerleading

“The press, on its own, if it chooses, can make the transition from cheerleaders of science to independent observers. The journalistic trumpeting of medical cures, even though accompanied by sober cautions against optimism, deserves to be severely throttled back in recognition of an unfortunate reality: though news is sold around the clock, major advances in medicine come along infrequently.”

-- Daniel Greenberg: Science, Money, and Politics, 2001

Shibboleths It’s Hebrew for a password that identifies one as a member of a cult/sect. Also refers to a longstanding belief associated with a particular group, especially one with little current meaning or truth.

Dr. Barry Kramer, NCI Director of Div. of Cancer Prevention, uses it in reference to screening tests. Director of the  

In some medical & journalism circles, a common shibboleth is the almost cult-like advocacy for screening tests and the search for weapons of mass destruction inside all of us. News about screening tests will be my main theme in this talk.

Uncertainty

There’s a problem with news stories that convey false certainty where it does not exist.

Our criteria: Does the story explain…

• What’s the total cost?• How often do benefits occur?• How often do harms occur?• How strong is the evidence?• Is the condition exaggerated?• Is this really a new approach?• Is it available?• Are there alternative choices?• Who’s promoting this?• Do they have a financial conflict of interest?

Report card – after 6 years and 1,700+ stories reviewed

~70% of stories fail to:

✔ Discuss costs

✔ Quantify potential benefits

✔ Quantify potential harms

✔ Evaluate the quality of the evidence

Kid-in-candy-store picture of U.S. health care

Everything is terrificNothing is riskyNo price tags

The high-speed train of expensive technologies has left the station before enough evidentiary questions are answered.

Robotic surgical systemsProton beam radiation facilities Intensity-modulated radiation therapy facilities

We see a lot of cheerleading for new drugs, for new technologies, for local health care industry

Then, when questions of evidence are raised…

• Denial kicks in and such concerns are easily labeled as:

–Rationing–Anti-industry–Anti-progress–Socialism

• Have we forgotten Vioxx? Or autologous bone marrow transplants for metastatic breast cancer?”

• We seem conditioned to exaggerate benefits and deny/ignore/minimize harms

Worst, most biased coverage I’ve seen in 35 years

Dana Milbank, Wa Post “Send Task Force to the Death Panel”

Elisabeth Hasselbeck on “The View” called it “gender genocide.”

Elizabeth Cohen, CNN: "This task force is the only big group that is saying this.”

Dr. Manny, Fox News: “Mammograms should be done because they save lives. Period.”

ABC’s Dr. Tim Johnson: “I recommend sticking with the current guidelines.”

CBS’ Dr. Jennifer Ashton: "I am not telling women to deviate from their screening practices."

AP quoted one breast CA advocacy group opposing the recommendations but didn't quote two much larger national advocacy groups supporting the recommendations.

Worst, most biased coverage I’ve seen in 35 yearsWhat the Task Force actually wrote:

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.”

The editors of the Annals of Internal Medicine referred to a “media cacophony”:

“Confusion, politics, conflicted experts, anecdote, and emotion ruled front pages, airwaves, the Internet, and dinner-table conversations”

Editorial cartoons in leading newspapers drilled home common themes: (examples deleted on SlideShare)

• The task force was all about cutting costs (false)

• Task force members were stupid non-expert bureaucrats (false)

• Cartoons of women’s cemetery scenes emphasized only benefits of screening while minimizing harms of false positives, overdiagnosis, number needed to screen

The ONLY editorial cartoon mentioning evidence – Rock River Times, Rockford, IL

Veteran science journalist John Crewdson wrote in The Atlantic:

"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.”

"Are you comfortable with what you're saying? You're a nurse. What you're saying is that some lives are not worth it - that's why we're changing these recommendations. That's an incredibly frightening thing to hear from someone like yourself. Is that what you're saying?"

A viewer who is a breast cancer survivor wrote to me:

"She was basically made to defend a position that Dr. Gupta asserted as fact. It was a pretty crappy tactic.

… I hope physicians-that-are-also-journalists start realizing that by (ab)using their positions of trust as doctors to lend credibility to hit-and-run stories, they cheapen both medicine and journalism."

“Well, we’ve had a conclusion for many, many years at Susan G. Komen, almost a generation. Screening saves lives. The 5-year survival rates for breast cancer diagnosed early is 98 percent…and this is largely due to screening and early diagnosis.”

Crusading advocacy on CBS News

Fox News website, March 3, 2010

Headline: “Cancer Society Casts Doubt on Value of Prostate Cancer Test.”

Excerpt: "Dr. David Samadi, a Fox News contributor and chief of Robotics and Minimally Invasive Surgery at Mount Sinai School of Medicine in NY, said he thinks the new guidelines could cause unnecessary deaths. "In my practice, we find men in their 30s and 40s that are at high-risk and develop prostate cancer.”

Leaders of ZERO: The Project to End Prostate Cancer

When the US Preventive Services Task Force recommended against routine screening of men with the PSA blood test, CEO Skip Lockwood said the UPSTF’s advice “condemns tens of thousands of men to die this year and every year going forward…”

COO Jamie Bearse wrote about the chief medical officer of the American Cancer Society:

“Otis Brawley has killed more men by giving them an excuse to not be tested.”

“There's a lot of publicity out there - some of it by people who want to make money by recruiting patients - that oversimplifies this - that says that 'prostate cancer screening clearly saves lives.' That is a lie. We don't know that for sure…

… Many of these free screenings are designed more to get patients for hospitals and clinics and doctors than they are to benefit the patients. That's a huge ethical issue that needs to be addressed.

We're not against prostate cancer screening. We're against a man being duped and deceived into getting prostate cancer screening."

Brawley & Len Lichtenfeld of ACS have gone on offensive, even posting a YouTube video in which Brawley said:

Duped & Deceived?

Tim Glynn, lawyer, age 47 when doctor “decided I’d have a PSA test without consulting me.”

“Men should be aware of the truly terrible consequences. As a screening tool, you could do as well by throwing dice on a table.”

Profiled in Shannon Brownlee’s NYT Sunday mag piece, “Can Cancer Ever Be Ignored?”

Prizes for Prostates

In 2010 after the National Lung Screening Trial results were released, the ACS posted on its blog:

"It's only been a few days since researchers released preliminary results of a major trial of early detection of lung cancer in heavy smokers using CT scans. At the time, the American Cancer Society and others (including the authors themselves) expressed cautious optimism, with emphasis on the cautious, saying that although enormously promising, the data was not enough to call for routine use of this screening test, even in heavy smokers. ...But our greatest fear was that forces with an economic interest in the test would sidestep the scientific process and use the release of the data to start promoting CT scans. Frankly, even we are surprised how quickly that has happened."

Interviewed Dr. Peter Bach of Sloan-Kettering:

“Bach says the risk that this test will give a false positive result is about 100 times higher than the chance that it will keep someone from dying of lung cancer.”

Amidst generally weak journalism, NPR stood out:

And Dartmouth’s Bill Black:

“How long do we screen these people for? How often do we screen them? How exactly do we interpret all the findings? There's tons of questions that have to be answered.”

Evidence that consumers are skeptical about evidence-based health care. Carman et al. Health Affairs 2010

“Clearly, consumers will revolt if evidence-based efforts are perceived as rationing or as a way to deny them needed treatment. Policy makers, employers, health plans, providers, and researchers will thus need to translate evidence-based health care into accessible concepts and concrete activities that support

and motivate consumers. A necessary condition for effective communication, after all, is to start where your audience is—even if that is not where you hoped or expected it to be.”

Next few slides courtesy Woloshin & Schwartz of Dartmouth

Imagine academy awards for exaggeration .....

“Most misused statistic”

…and the winner is:

Survival Statistics & screening

2 ways to improve survival without changing mortality

*lead time bias *overdiagnosis

Screening facts: Screening mammograms for breast cancer Why is screening a decision?Screening is a tradeoff: it helps some women but harms

others. The harms are as real as the benefit.

How should I decide?

Most major medical organizations suggest women consider screening in their forties or fifties. Compare the benefits and harms in the table below to decide whether getting a mammogram is right for you.

What happens to 1,000 women who are screened every year or two for 10 years?

Benefits of screeningReduced 10 year chance of dying from breast cancer

No screeningScreeningAvoided a death because of screening

Harms of screeningFalse alarm Experience at least one false alarm that requires a biopsy Overdiagnosis Experience the diagnosis and treatment of breast cancer that would not have caused harm if never found.

Women 40-49

Women 50-59

Women 60-69

5-271-71-5

50-20050-20050-200

3.53.00.5

5.34.60.7

8.35.62.7

To treat your facts with imagination is one thing; to imagine your facts is another.

John Burroughs (1837-1921)

Journalists could help people understand and deal with the clash between:

• Science• Evidence• Data• Recommendations for

entire population• What we can prove• Grasping uncertainty and

helping people apply critical thinking to decision-making issues

Intuition Emotion Anecdote Decision-making by an

individual What we believe, wish, or hope Promoting false certainty,

shibboleths and non-evidence-based, cheerleading advocacy

Thank you.

gary@healthnewsreview.org