This was, I believe, the fifth time I've been asked to speak at this event in Cambridge. Other speakers: Drs. Steven Woloshin and Lisa Schwartz of Dartmouth, Dr. Barry Kramer of NCI, and Dr. Marty Makary of Johns Hopkins.
We have an increasing number of media organizations actually partnering with screening advocates for non-evidence-based promotions. State Fairs big in MN where Victor and I come from…Not sure if this last photo depicts anything about the screening process itself
The NYT and USNWR were two of the only news orgs to tell this story
Like robotic surgery….or
Knight Science Journalism Fellowships at MIT Medical Evidence Boot Camp 2013
Adjunct Assoc. Prof., Univ. of Minnesota School of Public Health
Knight Science Journalism Fellowships at MIT
Medical Evidence Boot Camp
December 3, 2013
Journalistic peaks of excellence
But the valleys between these occasional
peaks are becoming wider and deeper…
…the daily drumbeat of dreck
Two elements to our work – common theme
Review news stories that
make claims about
Comment on health care
advertising, marketing, public
relations, broader communications
issues at intersection of medicine
• Like most blogs - more
• Allows us to show broader
influence of industry - pharma,
device manufacturers, hospitals
– on the public dialogue
Our criteria: Does the story
story reviews –
• What’s the total cost?
• How often do benefits occur?
• How often do harms occur?
• How strong is the evidence?
• Are there alternative choices?
• Is the condition exaggerated?
• Is this really a new approach?
• Is it available?
• Who’s promoting this?
• Do they have a financial conflict of interest?
News stories often paint a
of U.S. health care
Common flaws: too much stenography – not
independent vetting of studies in journals
Glorifying journals - Publication in a medical journal does not guarantee
the findings are true (or even important).
Not ready for prime time. Never intended to be sources of daily news –
journals meant for conversation among scientists
So if you’re going to feed off them daily, you simply must be aware of the
Publication bias for positive results. Rose-colored view of
progress in research.
Retractions, research fraud, fabrication, falsification of data
Unpublished data (BMJ special edition on “the extent, causes
and consequences of unpublished evidence”)
Ghostwriting of journal articles (The Public Library of Science
hosts a “Ghostwriting Collection” on its website.)
Tip: Set up Google Alert for John Ioannidis
about pitfalls of steady diet of journal
PLoS Med 2005; 2(8): e124
Journals complicit in miscommunication
• Editors of the HEART Group journals stated that
“inappropriate word choice to describe results can
lead to scientific inaccuracy.”
– J AM COLL CARDIOL, Vol. 60, No. 23, 2012
• “Are we making a mountain out of a mole hill? A
call to appropriate interpretation of clinical trials
and population-based studies”
– Am J Obstet Gynecol, published online 11/29/12
• “Spin and Boasting in Research Articles.”
- Commentary in Arch Pediatr Adolesc Med:
[published online October 2012]
Risk reduction must be stated in
absolute, not just relative, terms
• NBC News reported, “In women, aspirin reduces the rate of stroke
blood clots in the brain, the most common type, by 24% but had
little effect on heart attack risk. In men, the daily aspirin cuts heart
attack risk by 32 percent but had little effect on stroke risk.”
– HealthNewsReview.org comment: “24 percent of what? And 32
percent of what? The journal article upon which the story is
based did state the absolute values for both benefits and risks.
Those absolute values show that, over about a six and half year
period, daily aspirin is predicted to result in 2 fewer strokes and
2.5 more major bleeds per 1000 women; and 8 fewer heart
attacks and 3 more major bleeds per 1000 men. To many
viewers, those numbers will mean more than 32% or 24%.”
The limits of observational studies
should always be stated clearly
• The Associated Press reported “lots of red meat increases mortality
risk.” HealthNewsReview.org noted: “The language of the story
suggests that cause-and-effect has been established when this kind
of observational study simply can not establish causation. It can
only point to statistical association.”
• When CNN reported, “Coffee may cut risk for some cancers,”
frustrated readers reacted with these comments posted online:
– "The statistics book in a class I’m taking right now uses coffee as an
example of statistics run amok. It seems coffee has caused all the
cancers and cures them at the same time."
– "…correlation IS NOT causation!!!! So people that drink 4 or more cups
of coffee have a lower incidence of two certain types of head and neck
cancers, and this is supposed to mean that coffee is actually ‘warding
off’ these cancers???”
The tyranny of the anecdote
• Stories may use only positive, glowing patient anecdotes but fail to
capture trial dropouts, compliance problems, patient dissatisfaction or the
choice to pursue less aggressive options.
• In one example, ABC, CBS, NBC, WebMD all used the same “breakthrough”
patient anecdote of one man’s reported improvement from a heart failure
stem cell experiment.
– This suggests another common problem: public relations people spoon-feed
journalists the patient anecdotes that put an intervention in the most positive
Single source stories & journalism via
news release are unacceptable
ABC’s Good Morning America asked, “Could a cure for obesity be just a pill away?”
HealthNewsReview.org analyzed the sourcing in this story:
– “In a bizarre twist, the reporter used the potential conflicts of interest of the doctor he
interviewed in the studio as evidence of his expertise. He noted that the doctor is a
consultant to the manufacturer of the pill and then said, “You’re the right man to talk
to.” Really? In a recent journal publication, this researcher listed financial ties to 17 drug
and device makers, including the maker of the (pill in question)… viewers were not
clearly told that all of the results reported in the story came from a trial controlled by
the company that has not been independently reviewed.”
The Wall Street Journal reported, “Depression treatment Cymbalta effective as pain reliever,
Lilly says.” HealthNewsReview.org wrote:
– “This 189-word story failed on almost every count:
– no independent perspective;
– a quote apparently lifted from a company news release;
– The company news release actually did a better job of explaining the study than did this
Failure to explain limits of surrogate
• USA Today: “New drug ‘may turn back the clock on heart disease.’ ”
– HealthNewsReview.org analysis: “The story focuses excessively on the
‘unprecedented’ changes in cholesterol achieved with the drug. …
these are surrogate markers that may not reflect any real benefit on
the outcomes that matter to patients.”
• WebMD: “Beet Juice Good for Brain: Drinking Beet Juice Increases
Blood Flow to Brain and May Fight Dementia.”
– HealthNewsReview.org analysis: “Surrogate endpoints do not
necessarily reflect on overall health outcomes. And especially not
from a study of 14 people over four days. And from this we get the
headline that ‘drinking beet juice may fight dementia’ ???”
• HealthNewsReview.org linked to 10 stories that framed a tiny shortterm study of a biochemical marker of bone turnover as if it were
definitive advice to women that, for example, “Two glasses of wine
a day ends menopause misery.”
Screening stories should explain the
tradeoffs of benefits and harms
The worst single episode was news coverage of the November 2009 revised
mammography recommendations from the U.S. Preventive Services Task Force.
We wrote: “There is an undeniable and clear bias in many news stories, reporters
and news organizations for promoting screening – evidence be damned.”
The HealthNewsReview.org story, “A clear pattern of imbalanced screening stories
by ABC News,” identified 10 examples in recent years involving cardiovascular
screening, and screening for lung, prostate and breast cancer
The HealthNewsReview.org story, “Prevention magazine editor promotes ovarian
cancer screening despite lack of evidence,” explained that neither the American
Cancer Society nor the National Cancer Institute support the transvaginal
ultrasound screening advocated by the magazine.
We have criticized the Chicago Sun-Times, the New York Daily News, the NBC
station in Minneapolis, and other news organizations for promoting public prostate
cancer screening events, disregarding evidence-based recommendations.
The project has also identified imbalanced screening stories by CNN, CBS, Fox
News, NBC News, Minneapolis Star Tribune, Saint Paul Pioneer Press, Chicago SunTimes, Washington Post, and HealthDay among others.
Unquestioning news coverage of
disease awareness campaigns
• Prostate cancer awareness is one focus of the
“Movember” publicity campaign subtitled
“Changing the Face of Men’s Health.” In the
WCCO-TV (CBS owned-and-operated) television
station newsroom, several members of the news
staff grew mustaches “in support of the cause.”
Exactly which cause, and how growing a
mustache helps, is unclear. This campaign has
spawned countless prostate cancer screening
events, conflicting with many evidence-based
Mo’ Movember “awareness”
• The NBC station in
Atlanta had newsmen
wear johnnies to
• The Chicago Sun-Times
from Dr. Laura Berman,
of “In The Bedroom
with Dr. Laura Berman.”
Fawning coverage of new technologies
(proton beam therapy & robotic surgery)
• KERA public radio in Dallas reported on both
technologies in its “Battlefield Breakthrough” series.
– Headline: “Zapping Cancer With A Ray-Gun.” We wrote:
“The story presents not one word of caveats, concerns or
limitations. There was no independent source, no data
about efficacy.” Instead, there was fascination: “looks like
something out of Star Wars.”
– Headline: “Robots Slice Time Under The Knife.”
We wrote: “Star Wars was a theme in that one as well. In fact, the
formula was the same as for part one with proton – more battlefield
breakthroughs. … Maybe we need to wait a bit to see how this arms
race plays out with evidence and data before proclaiming battlefield
breakthroughs just yet.”
Going easy on health business stories
– Headline: Medtronic tests stents for erectile dysfunction. Our comment: “An initial feasibility study
in 30 men is worthy of news coverage? With a company-sponsored investigator as the only source?
Not in our view.”
– Headline: Area firm’s pneumonia treatment passes test. Our comment: “It features the company
president’s positive assessment of the study results but does not seek independent comment. … It
fails to make clear that the results of the trial have not been peer-reviewed or published and that
results of a related trial have not been released at all.” 56
New York Times
– Headline: “Test of Eye Drug Is Said To Show Success in Elderly.” Our comment: “The piece …
should’ve slapped a bigger warning label on this cocktail of leaked summaries of secret results,
speculation, and an inadequate dash of independent evaluation.”
Wall Street Journal
– Headline: “AstraZeneca Says Brilinta Beats Plavix in Clinical Trial.” Our comment: “… lets a drug
company get away with making superiority claims without releasing data. … All information in the
story appears to come from company sources.”
Los Angeles Times
– Headline: “Drug for menstrual cramps in the works.” Our comment: “This story reports that data
were presented at a scientific meeting. But it didn’t tell readers what the data showed. But it did
allow a company VP – the only person quoted – to say this could be a ‘breakthrough.’ Wow.”
Minneapolis Star Tribune
– HealthNewsReview.org found four stories within six weeks in which the Star Tribune established a
clear pattern of writing nice things about local medical device industries, but did not lead in
reporting negative stories.
Whom to believe? Framing matters.
• Dueling news stories on brain wave scan for ADHD.
Important tool? Or waste of money?
– NJ Star-Ledger, Fox News, NY Daily News, Bloomberg – all gushing praise such
as “this should be an important tool” quote from MD in the study
– NY Times quoted independent expert “skeptical about the test”
– LA Times quoted independent expert “The current scientific research really
doesn’t support (this) as a diagnostic tool. I would caution people.”
– ABC News quoting independent expert: “I don’t know that this going to
help...it’s going to make people spend money needlessly. They can charge for
it and it gives you a pseudo-scientific basis for diagnosis.”
Whom to believe? Framing matters.
Dueling news stories on melanoma detection device.
Helping doctors? Or causing dissent/polarizing the field?
• Cleveland Plain Dealer: “helps doctors detect deadly cancer”
• WTVF Nashville & KFSN Fresno – among the stations using a syndicated news
service’s story that claimed “the Cleveland Clinic named the device one of its
top medical innovations of 2013.”
• KDVR Denver allowed a doctor to call it the biggest advance in melanoma in
his 26-year career
• NY Times quoted 3 independent experts:
1. “This should still be considered to be in the developmental stage.”
2. A dermatologist on the FDA panel who voted against approval
3. Biostatistician: “(The test) just says everything is positive. I don’t think it
helps an aggressive doctor and unaggressive doctors could do just as
well if they were more diligent without the device.”
Whom to believe? Framing matters.
• Dueling news stories on meds for mild-moderate depression.
Give pause about prescribing? Or no reason to avoid meds?
– HealthDay: “Severely depressed gain most from antidepressants: But
that’s no reason to avoid meds for moderate cases.”
– LA Times: “Study finds medication of little help to patients with mild,
– USA Today (quoting independent expert): Such findings “demonstrate
a failure in the system: These drugs were not thoroughly tested in mild
to moderate depression prior to their approval.”
Whom to believe? Framing matters.
• Dueling news stories on Alzheimer’s drug. BY
THE SAME NEWS SOURCE! Reverses disease in
mice? Or a flop?
– MedicalDaily.com: “Cancer drug may help reverse
– “Targretin a flop: Potential Alzheimer’s drug fails
Whom to believe? Framing matters.
• Dueling news stories on limitations of colonoscopy.
Miss many cancers? Or concerns overblown?
– NY Times: “Colonoscopies miss many cancers, study finds.”
– ABC News: “The Case for Keeping Colonoscopy: Cancer Experts
Say Concerns Over Colonoscopy Effectiveness May Be
– CBS News’ Katie Couric: “Don’t use this study as an excuse not
to get screened.”
Whom to believe? Framing matters.
• Dueling news stories on prostate cancer screening study.
Reduces deaths? Or isn’t saving lives/value questioned?
– MSNBC: “Regular prostate screening reduces deaths”
– HealthDay: “PSA testing cuts cancer death risk”
– Bloomberg: “PSA screening reduces deaths”
– Associated Press: “prostate cancer screening isn’t saving lives,
– CNN.com: “Value of mass prostate cancer screenings
• Star Tribune: “Boy, 12, dies after historic
transplant to treat HIV, leukemia.”
– “He was in line to become the second person in
the world to be cured of both deadly illnesses by
the extraordinary type of bone marrow transplant,
– Maybe. But in fact he was in line to die from a
transplant that was not historic because it did not
treat his HIV & leukemia.
THE WINNER IS:
(often involving this gland)
Award for best supporting roles:
I am not anti-screening
• But I do criticize:
– Stories that don’t discuss tradeoffs involved in all
screening test decisions
– Framing screening as a mandate, not a choice
– Stories/journalists taking an advocacy stance
– Stories that are inaccurate, imbalanced,
All screening stories would be better if they simply stated:
“All screening programs do harm;
some do good as well.”
- Dr. Muir Gray
The tyranny of the anecdote
in screening news stories:
Whom do we model?
those who make
a rational choice
not to be
screened – or
those who were
Dr. Otis Brawley, chief medical officer,
American Cancer Society
“I’m very concerned. 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…
…We’re very concerned about a number of clinics that are
offering mass screening where informed decision making is
not happening. Many of these free screening things 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
“Duped & deceived”
Tim Glynn, lawyer, age 47
when his 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.”
Sharon Begley in Newsweek:
“Dr. Stephen Smith, Professor emeritus of
family medicine at Brown University
School of Medicine, tells his physician not
to order a PSA blood test for prostate
cancer or an annual electrocardiogram to
screen for heart irregularities, since
neither test has been shown to save
lives. Rather, both tests frequently find
innocuous quirks that can lead to a
dangerous odyssey of tests and
“I can only hope my story will
…inspire every woman who hears it
to get a mammogram, to take a selfexam. No excuses. It is the
difference between life and death.”
1. “No excuses” promotes theme of mandate, not a choice.
2. No, it is not the difference between life and death for every
3. There are potential harms from mammography. They are
clear, well-known, supported by data.
Mammography screening also finds slowly growing or less aggressive tumors which
would never be life-threatening. But because that cannot be predicted, about 10 of
2,000 women in the screening group had their breast completely or partially
removed, though this would not have been necessary.
For years I’ve been writing about why
it’s unethical for network television
journalists to use their celebrity status
to talk about their own health care
decisions and to suggest what other
people should do.
• NBC’s Mike Taibbi had lung CT and endorsed the scans in his
• NBC’s George Lewis reported on his own prostate cancer
diagnosis/treatment and ended recommended all men have
• NBC’s Andrea Mitchell reported on her own breast cancer
diagnosis and treatment by giving advice on the air to other
• NBC’s Matt Lauer & Al Roker had digital rectal exams on the air
to promote prostate cancer screening and failed to discuss
guidelines which don’t recommend such screening.
• CBS’s Harry Smith followed colleague Katie Couric’s example
from when she was at NBC and had a colonoscopy on the air,
endorsing the practice while not mentioning other colon
cancer screening options which many people might prefer and
which the evidence supports.
Andrea Mitchell: “For you women out there and for the men
who love you, screening matters. Do it. This disease can be
completely curable if you find it at the right time.”
Katherine O’Brien – who published the ihatebreastcancer blog – wrote:
“Early detection is not a cure. …”Completely curable” is a like a fat man wearing a hockey jersey. It
covers a lot of ground. You have access to the top medical experts in the world-ask them what
“cured” means in the setting of breast cancer.”
Breast cancer patient Katie Ford Hall of the UneasyPink blog wrote to Ms. Mitchell:
“Wishing you the best Ms Mitchell. When you feel settled, I’d love to talk to you about the realities
of breast cancer “caught early” … What you said about breast cancer is harmful and untrue. You
should correct it immediately.”
One expert pointed out the misuse of the overused “1 in 8” statistic, as when she said:
“I am now among the 1 in 8 women in this country — incredibly 1 in 8 — who have had breast
As the National Cancer Institute explains:
Women born now have an average risk of 12.2 percent (often expressed as “1 in 8″) of being
diagnosed with breast cancer at some time in their lives. On the other hand, the chance that they
will never have breast cancer is 87.8 percent (expressed as “7 in 8″).
• But 1 in 8 is a lifetime risk. Risk increases with age, so the NCI provides a more helpful way of
looking at it – for all of those women watching who are of different ages:
• A woman’s chance of being diagnosed with breast cancer is:
from age 30 through age 39 . . . . . . 0.43 percent (often expressed as “1 in 233″)
from age 40 through age 49 . . . . . . 1.45 percent (often expressed as “1 in 69″)
from age 50 through age 59 . . . . . . 2.38 percent (often expressed as “1 in 42″)
from age 60 through age 69 . . . . . . 3.45 percent (often expressed as “1 in 29″)
What is the quality of
the shared decisionmaking encounter…
are promoted with
wine, cheese, fondue,
pink treats, pink
consultations, etc. ?
Sharon Begley reported for Newsweek
“Dr. Rita Redberg, professor of medicine at
the University of California, San Francisco,
and editor of the prestigious Archives of
Internal Medicine, has no intention of
having a screening mammogram even
though her 50th birthday has come and
gone. That’s the age at which women are
advised to get one. But, says Redberg, they
detect too many false positives (suspicious
spots that turn out, upon biopsy, to be
nothing) and tumors that might regress on
their own, and there is little if any evidence
that they save lives.”
• Reported on woman with DCIS – ductal carcinoma in situ
• Reported on her choice to pursue active surveillance rather
than immediate aggressive intervention such as bilateral
• Reported on the shared decision-making program at UCSF that
helped her understand the tradeoffs.
THAT IS GOOD JOURNALISM
• Began with virtual colonoscopy – after routine physical.
• But scan also showed something on kidney, liver, and lungs.
• Kidney and liver issues benign after liver biopsy, PET scan and more CT scans. But lung
questions led to major lung surgery
“I awoke in the recovery room after 5 hours, with a chest tube, a Foley catheter, a
subclavian central venous catheter, a nasal oxygen catheter, an epidural catheter, an
arterial catheter, subcutaneously administered heparin, a constant infusion of
prophylactic antibiotics, and patient-controlled analgesia with intravenously
administered narcotics…..Excruciating pain.”
• No malignant disease – all “incidentalomas”
• Total cost > $50,000
• All precipitated by a screening test
Repeat: it’s not anti-screening….
• …when you cite the evidence.
• …when you educate people about tradeoffs.
• …when you help people avoid “avoidable
• We shouldn’t be telling anyone not to be
screened just as we shouldn’t be telling anyone to
be screened. We should inform about the
tradeoffs so people can make informed decisions.
If we don’t improve discussion on screening, we may
never improve public dialogue on expensive new
technologies – “Gizmo Idolatry”
JOSH BILLINGS (PEN NAME OF HUMORIST
HENRY WHEELER SHAW, 1818 – 1885)
Because there are harms in making people more
hopeful or more frightened than evidence and
rational thinking would warrant.