Lessons to improve our reporting on evidence - analysis of 1,600 stories over 6 years
Lessons to improve our reporting on evidence – analysis of 1,600 stories over 6 years MIT Medical Evidence Boot Camp December 8, 2011 Gary Schwitzer Publisher HealthNewsReview.org
Site stats 28 reviewers: 19 clinicians or researchers, 7 journalists, 2 breast cancer survivors Site launched April 2006 1,655 stories reviewed Blog launched in 2004 - >2,500 posts Sole funding from the Foundation for Informed Medical Decision Making here in Boston (Co-founders Jack Wennberg, Al Mulley, etc.)
After 5.5 years and 1665 stories 71% fail to adequately discuss costs. 66% fail to quantify benefit - often how small is potential benefit 65% fail to quantify harm - often how large is potential harm 63% fail to evaluate the quality of the evidence 57% fail to compare new idea with existing options
Kid-in-candy-store picture of U.S. health care 70% of ideas are terrific 70% are risk-free 70% - cost not an issue
A clear pattern News stories tend to emphasize or exaggerate the benefits of treatments, tests, products and procedures. And they tend to minimize or ignore the harms.
Other themes: Failure to convey limits of observational studies Rush to report on talks at scientific meetings Common flaws in health business stories Single source stories No independent perspectives Coverage of screening issues
Concerns about cumulative effect of health messages Daily drumbeat of news Steady diet of news from journals - disregard for publication bias for positive findings Advertising Web health info News releases from industry, academic medical centers, even from journals Misleading Twitter messages
Actual newspaper headlines on DaVinci Robotic Surgery Cancer survivors meet lifesaving surgical robot Da Vinci puts magical touch on the prostate Robotic surgeons hands never tremble Da Vinci is code for faster recovery Hospital hopes robot surgery will lure patients WHAT’S THE HARM OF THIS?
Stories about wonderful health caregifts are NOT what they appear to be.
Stories of robotic regret, complications, costs starting to pile up Long learning curve for surgeons – one analysis showed that 3 experienced surgeons needed more than 1,600 cases to achieve acceptable outcomes with robotic-assisted laparoscopic prostatectomy With 2,000 of these $ million machines in place, how many surgeons have done 1,600 prostates? A 2010 study showed robot-assisted hysterectomies were associated with longer surgical times and cost an average of $2,600 more. Bloomberg: A urologist confesses he was seduced by the robot. But now rails against hospitals “tawdry marketing more familiar on late-night infomercials by using patient testimonials. "I cannot believe how quickly I recovered," a vigorous-looking patient is quoted as saying. As a surgeon I have to ask: Where is the data?”
Story in Family Practice News 2 weeks ago… A recent explosion of interest in robotic surgery for routine hysterectomies and treatment of other non- oncologic gynecologic conditions is raising concern about the cost and comparative value of the robot over conventional laparoscopy. In 2010, for the first time, more hysterectomies were performed with the da Vinci Surgical System than any other procedure, including prostatectomy. There have not been any large-scale randomized trials of robot-assisted surgery, and the "limited observational evidence fails to show that the long-term outcomes of robot-assisted surgery are superior to those of conventional procedures."
The high-speed train of expensive,unproven technologies has left the stationand it can’t be stopped. Robotic surgical systems Proton beam radiation facilities Intensity-modulated radiation therapy facilities
In print journalism in one week we saw..... Two stories that used drug company VPs as main sources, one predicting a “breakthrough” without giving any evidence! One that was based solely on a news release on mouse research to tout a new approach to fight bone loss! One proclaimed that a "treatment may work" after it was tested on 9 pieces of tissue outside the body! Another anointed a cancer gene therapy as a "breakthrough" after it had been tested on just three tumor samples!
Were these in a student newspaper? New York Times Los Angeles Times Reuters wire service HealthDay wire service
To prevent a single prostate cancer (that may not even be a killer): 71 men x 365 days/yr. x 7 yrs. x $3/pill = $544,215 And with prostate cancer, there’s a good chance it wouldn’t have been a deadly cancer anyway!
Disease-mongeringMSNBC – Oct. 4, 2011 – Plastic surgeon wants to fix your runners face’Runners, beware. A New Jersey cosmetic surgeon has pinpointedsomething more nefarious than shin splints, stress fractures and even deadbutt syndrome: "runners face."…that skinny, Skeletor-esque look some dedicated runners may unwittinglydevelop, as theyre likely distracted with all the miles they have to cover toprepare for their next race. (The surgeon) describes the horrors thusly, in apress release issued today: Runner’s face generally occurs in both men and women ages 40+ who exercise to improve their body, and in doing so end up with a skeletal and bony face.He suggests a Botox-Restylane (or other injectable filler) combo, which willsmooth wrinkles and plump that gaunt face right back up.
Which ―benefits‖ matter?• Framing surrogate markers or intermediate endpoints(test scores, blood values, etc.) as if they were theoutcomes that people should really care about toestablish improved quality of life or longevity.• Perhaps the Avastin story is best example wherelimitations of progression-free survival were often notadequately explained. “will not make you live longer, wont make you feel better, and may have life-threatening side effects, but it will keep your cancer from worsening by an average of 1 to 2 months."
Observational studies: "Women who drank >3 cups of coffeeper day had a 20% lower risk of developing basal cellcarcinoma than women who drank <1 cup/month" WebMD: ―Coffee Fights Common Skin Cancer‖ ‖3 cups of coffee a day to help keep skin cancer away?" asks MSNBC. ‖Coffee Lowers Risk of Skin Cancer" announced Medical News Today. ‖Coffee cuts skin cancer risk,‖ stated the Washington Post The American Association for Cancer Research news release said the only thing you really can say: ―Coffee consumption associated with decreased risk for basal cell carcinoma‖ If thats too boring, then dont report the story because otherwise youre simply wrong.
Rush to report on talks at scientific meetingsLast month’s American Heart Assoc. Scientific Sessions: experimental stemcell intervention in 14 people - only 8 of whom were followed for a year. Tyranny of the anecdote: All 3 TV networks & WebMD rode the same glowing patient anecdote Money quote keeps paying dividends: The same researcher quote - "biggest advance in cardiovascular medicine in my lifetime" - appeared in the ABC and NBC stories. EXCITEMENT! WebMD reported that one researcher they interviewed could barely contain his excitement. ABC anchor Diane Sawyer discussed on the air how "excited" correspondent Richard Besser was. Is that the job of journalism to convey how excited a reporter is? Anchor Sawyer also gushed this question to Besser, "Is this the real prospect that the nations number one killer could be cured?" CBS used cure and breakthrough in the same headline.
Health business story Single source No independent perspective Reuters: Medtronic tests stent for erectile dysfunction October 20, 2011Is ―an initial feasibility study in 30 men‖ worth reporting?With a company-sponsored investigator as the only source?―30 million US men and 300 million worldwide with erectiledysfunction‖ • That counts ALL degrees of erectile dysfunction but not all = a total inability to achieve an erection. • Many different causes and vascular causes might not be safely amenable to stenting. • So, even in a business story, the "market" of "a real unmet clinical need" for a surgical procedure may have been inflated in this story.
News coverage & poor public discussion of screening issues should be most concerning.Worst, most biased coverage I’ve seen in 37 years
10 claims that many stories didn’t challenge1. This is all about saving money.2. This is about rationing.3. It’s the first sign of Obamacare.4. Government is deciding some lives don’t matter.5. Early detection always saves lives.6. The fact that I or someone I know was saved by a mammogram provesthat more testing is better.7. The shifting recommendations prove that scientists are clueless.8. This was surprising and came out of nowhere.9. The task force members must be uninformed idiots - especially sincenone was an oncologist or radiologist.10. American Cancer Society disagrees so the task force must be wrong.
What the Task Force actually wrote:“The decision to start regular, biennial screeningmammography before the age of 50 yearsshould be an individual one and take patientcontext into account, including the patientsvalues regarding specific benefits and harms.”
Annals of Internal Medicine editors called it a “media cacophony” “Confusion, politics, conflicted experts, anecdote, and emotion ruled front pages, airwaves, the Internet, and dinner-table conversations.”
The Publics Response to the U.S. PreventiveServices Task Forces 2009 Recommendationson Mammography Screening―These results are consistent with previousstudies that suggest a media bias in favor ofmammography screening."
37-year Chicago Tribune & NYTimes veteran John Crewdson wrote: “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."
A national poll suggests lingering impact of imbalanced news• 11 percent of women surveyed said theybelieve mammograms should start in the20s, even for women with no risk factors • 29 percent believe mammograms should start in their 30s.• 45 percent said the guidelines were anattempt to reduce health-care costs
Other examples: Chicago Sun-Times Wall Street Journal Washington Post New York Daily News Minneapolis Star Tribune All TV networks
The inkisn’t even dry on studies beforemarketing begins
On Twitter Men’s Health magazine: If youre a smoker, you NEED to get a CT scan. Body of story: ―But dont run out and ask for one.‖ (as it discusses issues of costs and false positive test results) American Association of Retired Persons: Are you a smoker? CT scan those lungs Body of story: 371 words of caveats.
HealthDay wire service didn’t challengeresearcher promoting universal pancreaticcancer screening for everyone over 50. After study of tissue from 7 people!
Why don’t we deliver this message?“All screening testscause harm;some may do good.”But much health journalism consistently emphasizesbenefits & minimizes harms
And that’s the message I think we’re missing That there’s a harm behind screening promotions that are not based on evidence and that do not fully inform readers/consumers/would-be patients That there’s a harm in selling sickness…in selling the search for weapons of mass destruction inside all of us Communication of the evidence about tradeoffs – about harms - is a key health policy issue
2007 Cochrane Review of randomized clinical trials of screened versus not screened –only small benefits from screening mammography
Breast Self Exam 2 randomized controlled trials have shown no benefit from breast self exam in decreasing mortality Breast self exam does lead to the discovery of more benign masses
Screening - Myth and Truth Myth: if women go for their recommended screening, their breast cancer will be caught early when it is 98% curable Truth: Many breast cancers are not picked up on screening Screening decreases the risk of dying of breast cancer by only 15-30% Screening best finds the slower growing less aggressive cancers with better prognosis Faster growing, more aggressive tumors (biology!) are more likely to be found between screens and higher numbers have metastasized prior to diagnosis
The National Breast Cancer Coalition talks about ―changing the conversation‖ Measure real progress, not by counting how many women have been screened or what the five-year survival rates are but by seeing significant reductions in incidence and mortality rates.
With screening messages, we see a clash between… Science Intuition Evidence Emotion Data Anecdote Recommendations for Decision-making by an entire population individual Grasping uncertainty Promoting false certainty What we can prove What we believe, wish, or hope
―I honestly believe it is better to know nothingthan to know what ain’t so.‖ Josh Billings (pen name of humorist Henry Wheeler Shaw, 1818 – 1885)
Pitfalls of a steady diet of journal stories PLoS Med 2005; 2(8): e124
The problem begins with the public’s rising expectations ofscience. Being human, scientists are tempted to show thatthey know more than they do. The number of investigators—and the number of experiments, observations and analysesthey produce—has also increased exponentially in manyfields, but adequate safeguards against bias are lacking.Research is fragmented, competition is fierce and emphasis isoften given to single studies instead of the big picture. Muchresearch is conducted for reasons other than the pursuit oftruth. Conflicts of interest abound, and they influenceoutcomes.
Spinning results of randomized clinical trialsBoultron et al, JAMA May 26, 2010, 303 (20): 2058In this representative sample of RCTs published in2006 with statistically non-significant primaryoutcomes, the reporting and interpretation of findingswas frequently inconsistent with the results.
Reporting bias in medical research - a narrative review McGauran et al. Trials 2010, 11:37 We identified reporting bias in 40 indications comprising around 50 different pharmacological, diagnostic, and preventive interventions. Many cases involved the withholding of study data by manufacturers and regulatory agencies or the active attempt by manufacturers to suppress publication. The ascertained effects of reporting bias included the overestimation of efficacy and the underestimation of safety risks of interventions.
Reason for optimism New models such as ProPublica, Kaiser Health News Smart bloggers – including physicians, scientists, hospital administrator Training This boot camp NIH Medicine in the Media workshops Association of Health Care Journalists USC Annenberg California Endowment fellowships
Regular columns analyzing evidence LA Times’ monthly ―Healthy Skeptic‖ column (Seeing Through Skin Supplements’ Claims) New York Times ―Really?‖ weekly column (The Claim: Chewing Gum Can Prevent Ear Infections) WSJ ―Research Report‖ biweekly column – 6 studies each time Washington Post ―Quick Study‖ weekly column (Vibrating machines seem to offer no benefit for older women’s bones )