My talk to University of Wisconsin event, "Science Writing in Age of Denial"

Cheerleading, shibboleths and uncertaintyGary SchwitzerPublisherHealthNewsReview.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.

UncertaintyThere’s a problem with news stories that convey falsecertainty 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 terrific  Nothing is risky  No price tags

We see a lot of cheerleading for newdrugs, for new technologies, for localhealth care industry The high-speed train of expensive technologies has left the station before enough evidentiary questions are answered.  Robotic surgical systems  Proton beam radiation facilities  Intensity-modulated radiation therapy facilities

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 groupthat 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 deviatefrom their screening practices." AP quoted one breast CA advocacy group opposing the recommendations but didnt quote two much larger national advocacy groups supporting the recommendations.

Worst, most biased coverage I’ve seen in 35 years What 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 patients values regarding specific benefits and harms.”

The editors of the Annals ofInternal 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 newspapersdrilled home common themes: (examplesdeleted 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 JohnCrewdson wrote in The Atlantic: "The current controversy over the task forces report owes much to the medias confusing coverage, some of which has been misinformed, including by TV doctors who ought to know better.”

"Are you comfortable with what youre saying? Youre anurse. What youre saying is that some lives are not worth it -thats why were changing these recommendations. Thats anincredibly frightening thing to hear from someone likeyourself. Is that what youre saying?"

A viewer who is a breast cancersurvivor 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."

Crusading advocacy on CBS News “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.”

Fox News website, March 3, 2010Headline: “Cancer Society Casts Doubton 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 CancerWhen the US Preventive Services Task Force recommendedagainst routine screening of men with the PSA blood test, CEOSkip Lockwood said the UPSTF’s advice “condemns tens ofthousands of men to die this year and every year going forward…”COO Jamie Bearse wrote about the chief medical officer of theAmerican Cancer Society: “Otis Brawley has killed more men by giving them an excuse to not be tested.”

Brawley & Len Lichtenfeld of ACS have gone on offensive, even posting a YouTube video in which Brawley said: “Theres a lot of publicity out there - some of it by people who wantto make money by recruiting patients - that oversimplifies this - thatsays that prostate cancer screening clearly saves lives. That is a lie.We dont know that for sure… … Many of these free screenings are designed more to get patientsfor hospitals and clinics and doctors than they are to benefit thepatients. Thats a huge ethical issue that needs to be addressed.Were not against prostate cancer screening. Were against a manbeing duped and deceived into getting prostate cancer screening."

Duped & Deceived?Tim Glynn, lawyer, age 47when doctor “decided I’dhave a PSA test withoutconsulting me.”“Men should be aware of the Profiled in Shannon Brownlee’struly terrible consequences. NYT Sunday mag piece,As a screening tool, you could “Can Cancer Ever Be Ignored?”do as well by throwing dice ona table.”

Prizes for Prostates

In 2010 after the National Lung ScreeningTrial results were released, the ACS postedon its blog:"Its only been a few days since researchersreleased preliminary results of a major trial ofearly detection of lung cancer in heavysmokers using CT scans. At the time, theAmerican Cancer Society and others(including the authors themselves) expressedcautious optimism, with emphasis on thecautious, saying that although enormouslypromising, the data was not enough to call forroutine use of this screening test, even inheavy smokers. ...But our greatest fear wasthat forces with an economic interest inthe test would sidestep the scientificprocess and use the release of the data tostart promoting CT scans. Frankly, evenwe are surprised how quickly that hashappened."

Amidst generally weakjournalism, NPR stood out: 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.” 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? Theres tons of questions that have to be answered.”

Evidence that consumers are skeptical aboutevidence-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 fewslides courtesyWoloshin &Schwartz ofDartmouth

Imagine academy awards forexaggeration .....…and the winner is: Survival Statistics & screening 2 ways to improve survival without changing mortality *lead time bias *overdiagnosis“Most misused statistic”

Screening facts: Screening mammograms for breast cancer Screening is a tradeoff: it helps some women but harms others.Why is screening a decision? 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? Women Women Women 40-49 50-59 60-69Benefits of screeningReduced 10 year chance of dying from breast cancer No screening 3.5 5.3 8.3 Screening 3.0 4.6 5.6 Avoided a death because of screening 0.5 0.7 2.7 Harms of screening False alarm Experience at least one false alarm 50-200 50-200 50-200 that requires a biopsy Overdiagnosis Experience the diagnosis and treatment of breast cancer that would not have caused harm if never found. 1-5 1-7 5-27

To treat your facts withimagination is one thing; toimagine your facts is another. John Burroughs (1837-1921)

Journalists could help people understand and deal with the clash between:• Science  Intuition• Evidence  Emotion• Data  Anecdote• Recommendations for  Decision-making by an entire population individual• What we can prove  What we believe, wish, or hope• Grasping uncertainty and  Promoting false certainty, helping people apply shibboleths and non-evidence- critical thinking to based, cheerleading advocacy decision-making issues

Thank you.gary@healthnewsreview.org

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My talk to University of Wisconsin event, "Science Writing in Age of Denial"

by Gary Schwitzer

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My talk to University of Wisconsin event, "Science Writing in Age of Denial" Presentation Transcript