Health News Review

It started when somebody wrote a book review of the book by Dr. Otis Brawley, Chief Medical Officer of the American Cancer Society, “How We Do Harm: A Doctor Breaks Ranks About Being Sick In America.”  In it, the reviewer wrote:

“Brawley isn’t an asshole, but he is a loudmouth, in the best possible sense. One of his favorite words is “shit”. He calls out colleagues cozying up to lobbyists and the pharmaceutical industry, naming cancer support groups whose funding comes from numerous drug companies and Kimberley Clark, manufacturer of Depends adult diapers. He spells out how for-profit medical centers drive up costs, then share the payout. That expense is not just dollars: it is pain, suffering, and untimely death.”

Despite that opening line, I think anyone who reads the review would find it flattering of Brawley, of his opinions, and of his book.

When David Sampson, director of Medical & Scientific Communications for the Cancer Society, saw that review, he tweeted, with sarcastic humor:

Something in that Tweet provoked a response from a biotech stock researcher on Twitter:

That, most clearly, was not a flattering comment. Then Dr. Brawley joined the Twitter exchange:

He didn’t say “shit” once in those two tweets.   But some came his way in the return volley from the biotech stock researcher:

If you’re not on Twitter, you probably didn’t know anything about this exchange.  You’re probably no worse off.  But for those of us who spend (waste?) a lot of time on Twitter, it can be a bit depressing.  At the same time, this social media avenue opens up a pathway for some to expose themselves for what they truly are – and perhaps we can all learn from that.  Often, such non-evidence-based screeds arise around screening issues. It gives one some sense of how some people think.  Read this post from just two months ago to get the full context behind this urologist’s Twitter blowup – which said, in essence, that a woman pediatrician trained in the evaluation of evidence couldn’t possibly evaluate evidence about prostate cancer because she’s a woman…and that a male primary care physician trained in the evaluation of evidence is “smug and self-congratulatory.”  When you can’t debate the evidence, roll out the ad hominem attacks. It is not always a kinder and gentler universe on “social” media.

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Comments

David Sampson posted on January 4, 2013 at 10:37 am

Great post. I have to stand up for Ben Davies, who’s painted in a pretty negative light here. Benjamin uses strong language and provocative statements in his tweets, but he is smart, reasonable, and willing to see others’ points of view when they’re also reasonable and smart. I like him.

One of the values of Twitter in my opinion is the opportunity to be sarcastic, funny, even borderline offensive to help shed light on difficult issues. I’m a strong believer that these can lead to greater understanding (see: The Daily Show and The Onion, e.g.). And yeah, it can be depressing, but as you point out, it can also be revealing.

Also, kudos to Ms. Leach; I was being anything but sarcastic when I called her review the best I’ve read on Otis’s book.

    Gary Schwitzer posted on January 4, 2013 at 10:47 am

    David,

    Thanks for your comment.

    Just a clarification: I don’t think I painted anyone in a negative light. By simply re-posting those Tweets, I merely reflected the light one shines on oneself with ill-advised Tweets.

    And thanks for correcting my mischaracterization of your comments on the Leach review as “sarcastic.”

Matthew Herper posted on January 4, 2013 at 11:50 am

Gary — I disagree. I think you did. And I think that both David Miller and Ben Davies have valid and important takes here. I like Otis Brawley, but I don’t think he of all people needs to be protected from criticism. And Miller’s not just some “biotech stock researcher” — he’s actually done a pretty good job understanding the prostate cancer market. This argument goes deep, and I think you’re in danger of creating an environment where screening opponents are automatically right.

    Gary Schwitzer posted on January 4, 2013 at 12:10 pm

    Matt:

    Thanks for your note and I welcome your perspective.

    But when you refer to “screening opponents,” you promote a false dichotomy that often arises in screening discussions. Brawley addresses that head-on in one of his posted Tweets: “I am not against screening.” Today on Twitter, Brawley pointed to his Annals of Internal Medicine piece from last summer, “Prostate Cancer Screening: What We Know, Don’t Know, and Believe.” If you haven’t read that, you should.

    His specific post on Twitter today was:
    @daviesbj @BiotechStockRsr There is responsible use of PSA my concern is mass screening. bit.ly/133CeEP

    So it is inaccurate to characterize that as the stance of a “screening opponent.”

    But don’t lose the focus of my post: the ugly, non-evidence-based comments on Twitter. Calling the chief medical officer of the American Cancer Society an “asshole.” Claiming that he gives “guys BS excuses to skip screening.” Claiming that Brawley’s “actions set back men’s health 2 dozen years.” Claiming that “a pediatrician has zero knowledge of or appreciation of prostate cancer.” Calling Tim Wilt “smug and self-congradulatory (sic).” Calling the US Preventive Services Task Force “an absurdity.”

    That is not what I’d call “valid and important takes” as you called them.

      Matthew Herper posted on January 4, 2013 at 2:42 pm

      Sure, I used an unhelpful dichotomy, and you’re using that avoid the discussion. Miller was calling Otis an asshole long before Otis was CMO of the ACS. I tend to agree with you on the data about screening, but within the context of this debate I actually think those comments were fair. There are people who think the USPTSF is an absurdity, and, until a few years ago, journalists ignored it. They’re strong words, but I think they are all bringing valid perspectives. There are a lot of doctors who believe that PSA screening saves lives. Just because you or I don’t agree doesn’t mean that they don’t deserve a voice in the debate.

Eve Harris posted on January 4, 2013 at 12:05 pm

I have been known to spend (ahem) time on Twitter but missed most of this exchange. In the words of @OtisBrawley, I, too, am against lying for a buck. And though I only occasionally dare to use #overtreatment I encourage you to join me! Gary, thanks particularly for your defense of Dr Moyer, who has been rewarded for her voluntary efforts on our behalf with specious attacks.

David Miller (BiotechStockRsr) posted on January 4, 2013 at 2:56 pm

I have sat through every screening debate at ASCO and ASCO-GU (except one year) since 2005. As to whether I have any expertise on prostate cancer, I would call it “substantial” but it is probably best to let folks like Matthew and Adam who are familiar with my work in this area speak for my knowledge level.

Otis wants to stop mass screening because he says it is harmful. This is a complete falsehood. There are no data showing a blood draw is dangerous to any detectable degree.

Anyone who has spent any time evaluating prostate cancer treatments, knows we overtreat men who screen positive. There are literally a dozen reasons to this from the benign (Gleason score creep due to better technology) to the not so benign (financial incentives like paying off expensive student loans and robot financing charges). Like almost every other cancer, we do many things to prostate cancer patients that are not validated by Type I research. That’s the urology and urological oncologist community’s dirty secret — along with the terrible way we handle communicating treatment choices about cancer diagnoses.

What Otis (and the rest of the anti-screening crowd) want to do is stop overtreatment. Another way of saying this is they want to capture control of the treatment decision that should take place between a doctor and a patient. Their chosen method of inserting themselves in this decision making process is to advise men they shouldn’t get screened unless they match the anti-screening crowd’s predetermined idea of who should be screened. Aside from being offensive, it also doesn’t solve the problem.

Overtreatment is not the fault of the PSA test. It is also not the fault of mass testing. To declare it so is logically false and morally suspect.

“Morally suspect”? Absolutely.

Otis and the USPSTF wimped out. Instead of going after their colleagues directly on the issue of overtreatment due to lack of training or financial greed, they went after patients instead. They are trying to solve overtreatment by hiding cancers from urologists and urological oncologists. You can’t overtreat, after all, what you do not know about.

Solving overtreatment — a problem that is 100% the fault of the doctor — by telling a patient he should not be screened is shameful. It officially sanctions allowing cancers to grow undetected in patients to solve a problem of greedy doctors.

I find this approach morally repugnant and anyone who advocates it will receive my scorn. In the 140-character universe of Twitter, if I have to use harsh language to get that across so be it. You will see no apology from me.

David Miller

    Gary Schwitzer posted on January 4, 2013 at 4:20 pm

    I don’t know anyone in an “anti-screening crowd.”

    I don’t know anyone who says that someone should NOT be screened.

    I don’t know anyone who says that screening can’t benefit some people.

    I do know lots of smart, caring folks who promote fully-informed shared decision-making discussions between doctors and patients about screening – discussions that delve into both benefits and harms.

      David Miller (BiotechStockRsr) posted on January 4, 2013 at 7:19 pm

      If you don’t know anyone in the anti-screening crowd, you haven’t attended enough of these screening debates or spoken to enough urologists and urological oncologists.

      Setting that aside for a moment, you’re arguing semantics. There’s an easy fix for that. You tell me what label you’d like me to use when referring to those folks who support the USPSTF’s call for eliminating population-wide screening and I’ll use whatever term you like. I’m happy to rewrite my post using that term.

      More to the point, name one harm of the PSA blood test.

      D

Susan Fitzgerald posted on January 4, 2013 at 7:13 pm

Mr Miller – I disagree with your false dichotomy between putting the burden for overtreatment on the doctor vs the patient. The more patients know, the better they can engage in an evenly slightly more informed discussion on whether to treat, once screening has occurred. When patients are fired up, they walk into the doctor’s office with reams of studies they printed off the internet. That’s at least a starting point for discussion, which can put the brakes on some of the bracket creep and unnecessary treatment.

Patients should know the risk/benefit profile, and if the doctors don’t tell them, the USPTF will. And did. For which it gets nothing but grief from those who do make a lot more than a buck on overtreatment.

And while I don’t have a prostate (as you’ll have deduced from my ID), I do have a couple of other assets that doctors and hospitals want me to get screened regularly, and I’m grateful to the USPTF for its work on mammogram frequency.

    Matthew Herper posted on January 5, 2013 at 10:56 am

    Susan — your the one setting up the false dichotomy. The essential argument behind a lot of USPTSF recommendations and, more than that, their portrayal in the press, is that tests have harms because they result in the patient getting other procedures that do harm. Miller’s argument is that this is the system, and the doctors fault, and that the ideal solution is to still screen but to be more comfortable not doing anything.

    I think that limiting screening makes sense because its a simple solution, and giving patients the idea that they might be better off not knowing could be part of better disclosure. But I think Miller has a point, and I think a lot of this discussion represents journalists taking sides in the name of objectivity,

    Gary’s post, to me, has a tone that two professionals (a urologist and an investment advisor) are stepping way over the line, not just with their language but by attacking Otis. A search of my stories would reveal I’m an Otis fan, but that’s not fair. I don’t think this post reads as saying merely “I wish Benjamin and David wouldn’t use such foul language.” I think it reads “I wish Benjamin and David wouldn’t challenge this heroic guy.”

      Gary Schwitzer posted on January 5, 2013 at 1:37 pm

      Matt,

      I think you need an audiology appointment because you are tone deaf.

      But if your current day job folds, you may have a future in creative fiction writing.

      All I can do is sit back in amazement at the imagination you employ in somehow finding “I wish you wouldn’t challenge this heroic guy” in anything I wrote.

      It’s not there. It wasn’t intended. And you’re stretching the believability of anything you write by suggesting it.

      Swing and a miss.

    David Miller posted on January 7, 2013 at 10:23 am

    The USPSTF does exactly the oppsite from what you say. Their recommendation hides information from the patient — namely the fact they have cancer. I agree information is necessary. That’s why everyone should be screened. I also agree we need to have much better discussions about options, risks, and benefits once the screening process indicates cancer may be present.

    USPSTF should have focused recommendations where it matters, which is patient counseling. THAT would have been useful. What they did instead is immoral.

Greg Pawelski posted on January 5, 2013 at 9:56 am

The efficacy of screening for prostate cancer (or even breast cancer) depends not only upon test accuracy, but upon the efficacy of proceeding with definitive diagnosis and therapy versus the efficacy of doing nothing at all. This is the problem with both mammography for breast cancer and PSA testing for prostate cancer.

There is no doubt that screening mammography and screening PSA can identify cancer at an earlier stage than in the absence of screening. But so what? Biologically, it appears that many cancers diagnosed at an earlier stage with screening are so aggressive that, even at the time of the time of earliest possible detection, there are already micrometastases, meaning that earlier extirpation of the primary tumor does not influence ultimate outcomes in a meaningful way.

More commonly, tumors are so indolent that metastases would not have occurred, even had diagnosis been delayed by one, two, or several years (i.e. until the lesion became palpable and was diagnosed in the former, pre-screening manner). So the only patients helped by screening are those who (1) are accurately detected by the screening exam and (2) which have a “Goldilocks” biology — not too aggressive/not too indolent.

Maybe, what men should concern themselves more than the PSA test is whether they have long index fingers or not. A study led by The University of Warwick and The Institute of Cancer Research found men whose index finger is longer than their ring finger were one third less likely to develop the disease than men with the opposite finger length pattern. Their study results show that relative finger length could be used as a simple test for prostate cancer risk, particularly in men aged under sixty.

It presumes that finger pattern could potentially be used to select at-risk men for ongoing screening, perhaps in combination with other factors such as family history or genetic testing. So, how reliable is questioning men and showing them pictures of different finger length patterns and then asking them to identify the one most similar to their own? Previous studies have linked finger length to aggression, fertility, sporting ability and confidence and reaction times.

How many of you are sizing up their fingers right now? Or Twitting this?

    David Miller posted on January 7, 2013 at 10:18 am

    I chose my PCP because he had long, thin fingers… so there’s that.

    Beyond that you’re wrong. The “efficacy” of screening is whether it detects potential cancer. You want to lay the efficacy of treatment squarely on the screening test. That’s logically wrong, leads to damaging things like the nonsense USPSTF decisions, and does a disservice to patients.

Matthew Herper posted on January 5, 2013 at 4:08 pm

Gary, I’m sorry if I overstepped. But here is what I reacted to that you said:

“Often, such non-evidence-based screeds arise around screening issues. It gives one some sense of how some people think. Read this post from just two months ago to get the full context behind this urologist’s Twitter blowup – which said, in essence, that a woman pediatrician trained in the evaluation of evidence couldn’t possibly evaluate evidence about prostate cancer because she’s a woman…and that a male primary care physician trained in the evaluation of evidence is “smug and self-congratulatory.” When you can’t debate the evidence, roll out the ad hominem attacks. It is not always a kinder and gentler universe on “social” media.”

You said that Davies wasn’t debating the evidence — it’s in that paragraph — and that’s just not true. It’s certainly said more politely — like in this NEJM piece co-authored by Jerome Groopman:

http://www.nejm.org/doi/full/10.1056/NEJMc1212298

It’s not creative writing. Maybe I got carried away, but I really feel there are other legitimate voices here, and that Miller’s and Davies’ opinions are among them. Fine, I guess, to criticize them for their potty mouths.

Anyway. I love what you do here. I didn’t mean to come off as trying to discredit it.

Matthew Herper posted on January 5, 2013 at 4:12 pm

And you’re probably right about that their vulgarity is totally uncalled for. But the opinions their expressing do actually have some evidence base. And my apologies again if I got carried away — there’s a lot of danger in living, as we now do, in an unfiltered world.