I am continuing my criticism of journalists and news organizations that crusade for screening tests – seemingly oblivious to the controversies and the debates that swirl around many of these screening tests. When a news organization takes an advocacy stance for a controversial cause, it should know the facts and the facts are that some people will be hurt by their advocacy efforts.

The latest example is the Chicago Sun-Times, which is sponsoring free prostate cancer screenings throughout the Greater Chicago area this week. A Sun-Times news release states: “Men ages 40 and older are urged by the health officials to take advantage of the screenings��? which include a PSA blood test and a digital rectal exam.

But the U.S. Preventive Services Task Force (USPSTF) – perhaps the nation’s best, unbiased, balanced source on such questions concludes “that the evidence is insufficient to recommend for or against routine screening for prostate cancer using prostate specific antigen (PSA) testing or digital rectal examination (DRE).��?

But the Sun-Times didn’t stop by sending out news releases. It ran a story about its own campaign.

The story stated, under the heading “GET TESTED,��? “Men ages 40 and older can stop by one of the mobile clinics for the free, private prostate cancer testing and physical exam.��?

The USPSTF tells men that “screening is associated with important harms, including frequent false-positive results and unnecessary anxiety, biopsies, and potential complications of treatment of some cancers that may never have affected a patient's health. The USPSTF concludes that evidence is insufficient to determine whether the benefits outweigh the harms for a screened population…. Screening may result in harm if it leads to treatments that have side effects without improving outcomes from prostate cancer, especially for cancers that have a lower chance of progressing. Erectile dysfunction, urinary incontinence, and bowel dysfunction are well-recognized and relatively common adverse effects of treatment with surgery, radiation or androgen ablation.��?

John Cruickshank, Sun-Times News Group Chief Operating Officer, is quoted in his news release saying, “The program demonstrates how the Chicago Sun-Times provides our readers with important, and in this case, life-saving information for residents of the Chicago region.��?

The story should be that the Chicago Sun-Times ignores the best evidence in promoting prostate screening to all men – and in promoting it to men in their 40s, they have not only taken an advocacy stance but a radically aggressive stance that may find a few cancers but will also certainly expose some men to unnecessary harms. One can only wonder what the informed consent form looks like during these quickie exams (20 minutes, says the news release) in these mobile clinics.

There’s a saying about the some of the problems with screening tests: How much disease you find may be a matter of how hard you look.

Recently, I have evidence that how many problematic news stories on screening tests you find is only a matter of how hard you look.

I won’t repeat episodes I’ve already written about on this blog. Just click on the screening category - http://blog.lib.umn.edu/schwitz/healthnews/cat_screening.html - to see the past evidence. But here are some new examples.

1. Tom Burton, in the Wall Street Journal this week, had an article under the headline, “Three Tests May Foil Artery-Disease Deaths.��? He wrote: “Three simple tests that can potentially save thousands of lives from strokes, aneurysms or other arterial problems are getting a big endorsement today. …As of today, the Society for Vascular Surgery, representing the nation's 2,400 vascular surgeons, is for the first time recommending these three tests to screen for artery disease in many people 55 years old and over.��?

But the only professional perspectives he included were from vascular surgeons. He could have easily included a perspective such as the one I elicited from Dartmouth’s Dr. Gil Welch, in response to the story: “Screen many, to find the few --while many others get labeled at risk in the process. And thus many will be treated "wrong", have an immediate operation for which the risks exceed the benefit. To see the full effects, you need to randomize. And there has been no randomized trial showing its net effect.��?

This story was reported by a veteran, Pulitzer-winning journalist at one of the newspapers whose health coverage I respect the most. Yet he reported a one-sided story with a clear pro-screening emphasis.

2. CNN’s Elizabeth Cohen last week had a story in which she listed an entire litany of screening test recommendations for women – many of them unsupported by the best medical evidence. Perhaps the most glaring was this: “At 40 … women need to start having mammograms every year.��? Are she and CNN totally unaware of the controversy over mammography in the 40s, fired anew most recently by the American College of Physicians just two weeks ago? Her statement – as if fact – is simply not supported by the ACP or the U.S. Preventive Services Task Force, perhaps the most balanced, unbiased source on such questions.

3. Georgia Public Radio last week aired a special report, “Breast Cancer in the African American Community.��? On the air they stated, “Typically every woman should start having mammograms at age 40.��?

On their website, they stated: “The American Cancer Society recommends that every woman over 40 have a regular screening mammogram.��?

It is another example of journalists appearing to be oblivious to the contrary recommendations of other learned bodies of experts in this country.

What accounts for this apparent pro-screening bias seen in some stories? I’m going to continue to track these practices and try to investigate journalists’ rationale.

I want to give a couple of plugs for interesting new health news blogs.

The Wall Street Journal health news blog is terrific.

One recent entry was on the trial that “showed that using stents in stable patients with mild to moderate chest pain doesn’t reduce the risk of heart attacks compared with drugs alone. … The Health Blog’s take-away: The idea of clearing out clogged arteries is so appealing, and the idea of leaving them clogged so terrifying, that patients and doctors are inclined to open them up, even if the data say that won’t do much good.�

And another entry analyzed the new questions about the benefits of mammography for women in their 40s. It included a quote from a mammography expert: “The evidence shows that it does help some women [in their 40s] — but the evidence shows that it’s only six out of 10,000 over a decade.� If only some mainstream news media could analyze the data as concisely as that.

Another noteworthy blog is Pharmalot.com - “a home for lively discussion about news and trends in the pharmaceutical industry. The guy behind the curtain is Ed Silverman, a veteran journalist for The Star-Ledger of New Jersey.� Interestingly, this is Ed’s fulltime baby. He doesn’t even file for the paper anymore.

It's good to see that some news organizations are catching on to this Web thing.

CNN’s House Call with Dr. Sanjay Gupta once again showed its one-sided, pro-screening bias this weekend. Excerpt:

We're starting with a change in what's been standard medical advice for a long time. For years, women over 40 have been told they need routine mammograms. Now the American College of Physicians says women with no risk factors for breast cancer should talk to their doctors first, that perhaps they could postpone their mammogram until they turn 50.

The American Cancer Society says annual mammograms starting at age 40 are still the way to go. You know what? It's leaving a lot of women wondering who they should believe.

So here to clear things up is Dr. Larry Norton. He's director of Breast Cancer Programs at Memorial Sloan-Kettering Cancer Center.

Well, Dr. Norton doesn’t accept the College of Physicians’ reasoning, writing them off as “an organization of internists��? – not cancer specialists or surgeons. He said:

"But the fact is that every woman that I speak with would much rather have a needle biopsy, which is not such a big deal, to make sure that the thing that the mammogram finds is not cancer, than actually miss a cancer that could cost her her life, or cost her her breasts."

OK, but that's personal anecdote, not evidence. There's an old saying: the plural of anecdote is not data. One big chunk of evidence he didn’t address is DCIS – or ductal carcinoma in situ – which shows up more often in earlier mammograms and leaves women confused about whether it’s a cancer, or, as it’s often called, pre-malignant or precancerous. And there is no consensus about what to do about DCIS once you find it. Why didn’t he talk about these cases? And why didn’t Gupta ask about them?

And why did Gupta and CNN only give airtime to one side of the argument? The perspective of the American College of Physicians (ACP)- the largest medical specialty organization and the second-largest physician group in the United States, representing 120,000 members - was simply not represented.

The ACP says its "clinical guidelines are developed in an explicit, rigorous process based on extensive review of available scientific evidence. They are considered 'evidence-based' rather than “expert-opinion��? or consensus guidelines. In addition to publications from the original mammography trials, ACP reviewed 117 studies to evaluate the evidence about the risks and benefits of mammography screening for women between the ages of 40 and 49."

Yet CNN didn't give ACP a voice in this segment, and let its guest get away with saying "We still need to figure out why they made this recommendation." Why not ask them on the air?

Three times in the segment, Gupta said his guest “cleared up��? the confusion. I guess it’s easy to view something as clear if you only open your mind to what you want to believe.

CNN has shown a pro-screening, evidence-be-damned mentality before. It is not balanced. It is not complete. And it is not journalism. It is advocacy.

If you didn’t see 60 Minutes last Sunday (April 1), go to their website and read the story and watch the video link for the segment called “Under the Influence.� It’s the story of the incredible manipulation of Congress by the drug industry that took place to get the Medicare Part D legislation passed.

Excerpt:

The unorthodox roll call on one of the most expensive bills ever placed before the House of Representatives began in the middle of the night, long after most people in Washington had switched off C-SPAN and gone to sleep.

The only witnesses were congressional staffers, hundreds of lobbyists, and U.S. Representatives like Dan Burton, R-Ind., and Walter Jones, R-N.C.

"The pharmaceutical lobbyists wrote the bill," says Jones. "The bill was over 1,000 pages. And it got to the members of the House that morning, and we voted for it at about 3 a.m. in the morning."

Why did the vote finally take place at 3 a.m.?

"Well, I think a lot of the shenanigans that were going on that night, they didn't want on national television in primetime," according to Burton.

"I've been in politics for 22 years," says Jones, "and it was the ugliest night I have ever seen in 22 years."

Despite what a terrific piece this was, one wonders why it took 60 Minutes several years to catch up to this story. Some viewers wrote to CBS about how late this report came. Examples:

“Great story, AWESOME Story!!! Too bad CBS & 60 minutes waited over 3 YEARS after President Bush Jr. signed the bill into law to report on this. Perhaps if we the American people had heard this story back in early 2004, we would have made different choices when the 2004 presidential election came around.�

“CBS, where the hell were you in reporting this when it happened. Everyone else who was paying attention knew we were being screwed by this legislation, that it was just a give away to the drug companies. but like all (mainstream media), you were totally going to let it pass. Shame on you for taking so long wake up.�

I've written a new Publisher's Note on HealthNewsReview.org, and I'm posting part of it here.

Stories about Elizabeth Edwards’ breast cancer and Tony Snow’s colon cancer have led some news organizations to offer recommendations about cancer screening. Unfortunately, some of the recommendations are simply not based on evidence.

On the NBC Today show on March 28, Matt Lauer said the Edwards and Snow cases put “a huge spotlight on the importance of early detection.��? Did they? The Edwards and Snow cases were not about early detection; they were recurrences. Theirs were not stories about cancer screening in the general population of people without symptoms. They were stories about follow up testing and recurrence in people who already had been treated for cancer. That’s an important distinction, glossed over in the kind of introduction Lauer used.

And to use the Edwards and Snow cases to stir up enthusiasm for early detection in ways that fall outside the boundaries of the best evidence is troubling.

Lauer brought on NBC News chief medical editor Dr. Nancy Snyderman and the two of them reviewed recommendations for screening tests for breast cancer, colon cancer, lung cancer and prostate cancer. But the discussion weaved in and out of the boundaries of evidence.

In discussing colon cancer screening, Snyderman explained that because she has a family history, she started having colonoscopies at age 40 in two to three year intervals. She says now that she’s over 50 she gets one every year. “And I get one more than my doctors really recommend because I just get a little nervous about it,��? Snyderman said.

It’s fine for her to choose whatever path makes sense to her. But it is troublesome to use a national TV platform to leave even the perception that this is an evidence-based course. The frequency of her screening is far more aggressive than the intervals described by the U.S. Preventive Services Task force for most people in the viewing audience.

Annual FOBT (fecal occult blood testing) offers greater reductions in mortality rates than biennial screening but produces more false-positive results. A 10-year interval has been recommended for colonoscopy on the basis of evidence regarding the natural history of adenomatous polyps. Shorter intervals (5 years) have been recommended for flexible sigmoidoscopy and double-contrast barium enema because of their lower sensitivity, but there is no direct evidence with which to determine the optimal interval for tests other than FOBT. Case-control studies have suggested that sigmoidoscopy every 10 years may be as effective as sigmoidoscopy performed at shorter intervals.

http://www.ahrq.gov/clinic/3rduspstf/colorectal/colorr.htm

Snyderman wrote off the value of sigmoidoscopy, saying it doesn’t go far enough (her words), and said that viewers must have colonoscopy.

But the U.S. Preventive Services Task Force recommendation says:

It is unclear whether the increased accuracy of colonoscopy compared with alternative screening methods (for example, the identification of lesions that FOBT and flexible sigmoidoscopy would not detect) offsets the procedure's additional complications, inconvenience, and costs.

Next, Snyderman turned her pro-screening enthusiasm to prostate cancer, advising men: “You turn 50, you just have to have a rectal exam to feel that prostate. And you get a prostate-specific antigen, a PSA test.��?

Contrast that with the evidence-based guidelines:

The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend for or against routine screening for prostate cancer using prostate specific antigen (PSA) testing or digital rectal examination (DRE).

http://www.ahrq.gov/clinic/uspstf/uspsprca.htm

Journalists should not be advocates, especially if their advocacy is based on personal opinion, not evidence or fact.

A good source for an evidence-based assessment of these issues: “Should I Be Tested For Cancer? Maybe Not and Here’s Why,��? by H. Gilbert Welch, M.D., MPH. (University of California Press, ISBN 0-520-23976-8).