Dr. Deanna J. Attai is an Assistant Clinical Professor of Surgery at the David Geffen School of Medicine at the University of California Los Angeles and is currently serving as President of the American Society of Breast Surgeons. She co-moderates the #bcsm Twitter group and tweets as @drattai.
Every year the San Antonio Breast Cancer Symposium draws a lot of news coverage. Just as the American Society of Clinical Oncology meeting does and the American Heart Association annual scientific sessions and many other medical/scientific conferences. And every year we could reflect on how the Woloshin/Schwartz article, “Media Coverage of Scientific Meetings: Too Much, Too Soon?,” would be a good reference read for any journalist packing bags to go and cover this meeting. This year was no different, with two important studies garnering headlines based on their presentation at the conference.
One study, presented by Dr. Benjamin Smith, demonstrated that patients undergoing a mastectomy with reconstruction have a higher complication rate, but similar risk of breast cancer recurrence, compared with patients undergoing lumpectomy. The study also demonstrated that the cost of care was higher in the patients who underwent mastectomy and reconstruction. The second study, presented by Dr. Sabine Siesling, found that patients undergoing lumpectomy have a longer survival compared to patients undergoing mastectomy.
The choice between breast-conserving surgery and mastectomy is one of the most difficult decisions that women with breast cancer face. And some research suggests that women are increasingly opting for the more aggressive option. So it’s not surprising that studies addressing this issue would generate a lot of news coverage. I reviewed five stories representing coverage from a variety of different news organizations, including a major broadcast outlet (NPR), a health news wire service (HealthDay), a national news magazine (Time), and a consumer health information portal (Healthline).
So, how did these organizations do?
Overall, the messages were accurate, and all stories included at least one independent expert to provide context. Often these experts raised important concerns about limitations inherent in these studies. However, the stories varied in the amount of detail they provided about the design of the studies and these key limitations. For example, none of the stories addressed the limitations of using coding and billing databases to assess complication rates and costs. Not all complications are coded, and the failure to pick up uncoded complications could have influenced the results. Similarly, only HealthDay cautioned that abstracts presented at national meetings have not gone through the same level of peer review as published manuscripts, and that data may be incomplete. And not every story explained what is meant by “complications” of breast surgery — which can include severe postoperative problems that every reader should be informed about.
Here’s a story-by-story rundown of highlights (and lowlights) from each outlet:
The weakest of the five stories, Healthline’s coverage didn’t discuss any of the limitations inherent in a database review, such as not being able to control for all confounding factors. And while it noted that the Dutch study used data from a registry, the story didn’t explain to readers how this differs from a randomized controlled trial — which is a higher standard of evidence. The HealthLine story moreover contains a somewhat misleading statement about the novelty of the new research. It notes that follow-up from most randomized controlled trials evaluating mastectomy versus lumpectomy was only 5 years. However, the NSABP B-06 randomized trial has 20-year follow up demonstrating equivalent survival rates for patients who undergo breast conserving surgery compared to mastectomy. A strength of Healthline’s coverage are comments from Dr. Michaela L. Tsai, who suggests that opting for the more aggressive surgery may be “falsely reassuring, as mastectomy and reconstruction does not prevent systemic recurrence, which is what one should truly be most concerned about.”
Beyond its laudable inclusion of a caveat about the lack of full peer review for conference presentations, HealthDay also had a strong statement regarding the limitations of this kind of observational study. It noted that “the findings are based on a review of patient records” and that “the study couldn’t account for all of the factors that could have swayed each woman’s treatment decision.” It also included a statement about cost, something only TIME and NPR among the competing outlets also took the time to address.
The Post’s coverage gets off to a shaky start with a misleading headline. Since these observational studies are incapable of proving cause and effect, it’s inappropriate to suggest that breast-conserving therapy “increases” survival rates for women with breast cancer. However, the Post recovers quickly to include a very detailed look at confounding factors that might have skewed the results. The story noted that “researchers cannot sort out factors that might have affected the patient decisions and the study’s results, such as other illnesses the women might have had, their insurance coverage and their proximity to centers that offer follow-up radiation.” It also touched on the strengths of this kind of study and why the results are important to consider in clinical decision-making: “Observational studies offer the benefit of allowing an examination of data for very large groups of women … And the data used, from a Dutch cancer registry, reflect the day-to-day decisions made by women and doctors faced with the tough choices posed by an early-stage cancer diagnosis.”
NPR did an excellent job of shedding light on the psychological factors that may drive women to choose more aggressive surgery for breast cancer. For example this quote from Dr. Mary Hooks at Vanderbilt University: “There’s no doubt that people make these aggressive decisions based on their fear of cancer coming back or taking their life, regardless of the data that doesn’t necessarily support that.” It also gave a realistic portrait of the harms and complications of more aggressive breast surgery, which “include bleeding, bruising or accumulation of fluid, infection, problems with the skin graft as well as other issues that led to removal of a breast implant.” Bonus points to NPR for linking to the Smith powerpoint presentation from the conference.
In addition to addressing cost, TIME made it clear that because of study limitations, the size of any advantage for lumpectomy over mastectomy remains uncertain. Quoting Dr. Shelley Hwang, TIME noted that women who choose mastectomy may differ from those who choose lumpectomy in important ways. “Overall, this underscores the findings of prospective randomized trials which show that breast-conserving therapy is not worse [than mastectomy], but the magnitude of benefit of breast-conserving therapy is difficult to quantify since there are imbalances in the groups,” Hwang said.
In the end, it is heartening to see the level of nuance that many outlets brought to their reporting on these studies. The messages were not simplistic and spoke to the difficulty of making decisions based on imperfect evidence. But there’s always room for improvement, and some outlets glossed over key limitations, failed to address cost, and didn’t give readers a complete portrait of the harms associated with each approach. Hopefully this review will help journalists provide that much-needed context to stories filed at their next conference.