Dear Harry,

There's nothing wrong with advocating for more awareness of colon cancer screening - although we don't think that crusading advocacy is a role for journalism, which is supposed to independently vet claims of evidence.

So, instead of all the promotion of your live colonoscopy last week, you and CBS could have investigated the evidence about colon cancer screening.

And if you had done that, you might have reported on some of the questions about colonoscopy - instead of cheerleading for it.

In this month's journal, Gastroenterology, is an article "Colorectal Cancer Screening Guidelines: The Importance of Evidence and Transparency," by Dr. James Allison, Clinical Professor of Medicine Emeritus, University of California San Francisco.

As a network news operation, CBS should really be on top of this information, but I'm going to bet no one in the network has read this, so I'll offer some excerpts:

"The only screening test for colon cancer shown by randomized controlled trials to decrease colon cancer mortality and incidence is fecal occult blood testing (FOBT)."

Did you know that? Did you consider doing a live promotion of the stool blood test? Granted, it might have been a little gross, but we did see your colonoscopy. And it appears that this kind of colonoscopy promotion is what helped make it the most popular colon cancer screening test, despite the evidence (or lack thereof).

"Medicare data reveal that the use of sigmoidoscopy fell by 54% from 1993 to 2003 with most of that fall occurring after Congress bypassed the Centers for Medicare and Medicaid Services (CMS) and approved Medicare reimbursement for screening colonoscopy in 2001. The reasons for the decrease are multifactorial, but include gastroenterology thought leaders and the lay press.
...
Katie Couric had her own colonoscopy televised on The Today Show, and shortly after proclaimed: "It's considered the most effective test for detecting colon cancer." ...If all these admonitions and recommendations for colonoscopy screening were not enough to discourage use of flexible sigmoidoscopy, the government decreased reimbursement, thereby making the office cost for doing sigmoidoscopy above that covered by the reimbursement."

Wow, as a journalist, doesn't that sound like a good story? How about the author's questions for "the American Cancer Society, the US gastroenterology societies, and the American College of Radiology" about "to whose benefit are assertions, unsubstantiated by the evidence" that FOBT is a poor second choice to colonoscopy? Doesn't that sound like there might be a story there?

If CBS had covered the recent NIH state of the science conference on colon cancer screening last month, you would have heard some of these issues, wide open in public discussion. But, to the best of my knowledge, you didn't cover that meeting. So the following excerpt of the journal article is probably all new to you.

"Thus, the available evidence suggests that repeated screening with highly sensitive FOBT may be as effective and cost effective at preventing colorectal cancer-related deaths as screening colonoscopy every 10 years.
...
Some now question whether the effectiveness of colonoscopy is "good enough" for population-based screening. The costs of population screening with colonoscopy should be of particular concern at a time when the US federal deficit has been projected to hit a record of >1 trillion dollars. Our health care resources are not unlimited.
...
One recent editorial stated that with regards to guidelines, the public is best served by a relatively structured, comprehensive, transparent approach in which the entire body of evidence drives the recommendations. Another stated that only when likely biases of industry and specialty societies have been either removed or overcome by countervailing interests can impartial recommendations be achieved."

Even if you missed the Gastroenterology article or the NIH conference, you couldn't have missed the recent AP story that discussed the "overselling and overpromising" of colonoscopies.

So, you've now learned that you've used your television platform to promote a screening approach that, while it definitely has its merits, has never been shown to be better than a much easier, cheaper test in a randomized clinical trial. You've learned that special interests and biases may be responsible for making colonoscopy the most popular colon cancer screening approach. And you've learned that you and your media colleagues have your done part as well.

Now what are you going to do about that? A make-good perhaps? A followup? A correction? Has CBS ever reported on the issues above? If not, why not?

Not to be missed in this week's Archives of Internal Medicine is an invited commentary, "The Prostate Cancer Treatment Bazaar," by Dr. Michael Barry. After describing about a dozen different treatment options for prostate cancer, Barry writes:

"Complicating the decision, there is an embarrassing lack of comparative clinical trials among these therapies. In fact, for the majority of men who are 65 years and older when newly diagnosed as having prostate cancer, the only randomized trial suggests that arguably the most aggressive of the treatments, radical prostatectomy, and the least aggressive, watchful waiting, have similar prostate cancer-specific mortality over 12 years of follow-up.
...
Given this knowledge vacuum, the type of a physician a man consults may unduly influence his choice. Since many men with prostate cancer discovered through screening have an excellent outcome for years, even without attempted curative therapy, specialists may then naturally assume, based on personal experience, that their treatment works. But increasingly, there are complex financial motives that may lead to bias as well. Large capital investments in equipment for robotic surgery or proton beam therapy, for example, create an intense need to recoup investments by increasing patient throughput. A recent paradox has been the investment by urology groups in roughly $3 million worth of equipment for intensity-modulated radiotherapy, given very favorable reimbursement for this treatment and despite evidence that its marginal benefit over 3-dimensional conformal therapy is meager relative to its cost.
...
Fully informing men about their prostate cancer treatment options involves honestly telling men what we do not know as well as the little we do. It requires a shared decision-making process, in which patient preferences, not physician specialty and certainly not physician investment, determine the treatment course. It is time to make a real shared decision-making process for prostate cancer and other major health problems a "major appliance" in the patient-centered medical home."

Read the entire commentary.

(Disclosure: Dr. Barry is president of the Foundation for Informed Medical Decision Making, which is the sole supporter of the HealthNewsReview.org project.)

I was struck by the recurring themes in this week's health news and planned to blog about it today. But Lindsey Tanner of AP beat me to it with her story, "Experts say US doctors overtesting, overtreating."

She begins:

"Too much cancer screening, too many heart tests, too many cesarean sections. A spate of recent reports suggest that too many Americans - maybe even President Barack Obama - are being overtreated.

Is it doctors practicing defensive medicine? Or are patients so accustomed to a culture of medical technology that they insist on extensive tests and treatments?

A combination of both is at work, but now new evidence and guidelines are recommending a step back and more thorough doctor-patient conversations about risks and benefits."

I had picked up on that same theme in this week's news:

• An independent panel convened this week by the National Institutes of Health confronted a troubling fact that pregnant women currently have limited access to clinicians and facilities able and willing to offer a trial of labor after previous cesarean delivery.

• A troublingly high number of U.S. patients who are given angiograms to check for heart disease turn out not to have a significant problem, according to the latest study to suggest Americans get an excess of medical tests.

• CT scans may pose cancer risk, new research indicates: Doctors, patients should weigh risks vs. rewards of medical imaging. (Chicago Tribune story.)

• Controversy over "value-based insurance design" that tries to address the problem of underuse of proven treatments and overuse of certain surgeries and diagnostic tests that may be less valuable. (Kaiser Health News story.)

• Expensive prostate cancer treatments are winning out over the old standards, driving up the cost of treatment before there's clear evidence that they improve outcomes. (MedPageToday.com story.)

• Dr. Richard Ablin's op-ed in the New York Times, "The Great Prostate Mistake." Excerpt:

"Testing should absolutely not be deployed to screen the entire population of men over the age of 50, the outcome pushed by those who stand to profit."

• And the letter to the editor that followed:

To the Editor:

I can only wish that Richard J. Ablin's article had appeared years ago and spared me and probably many others needless pain and anxiety.

In 1997, at the urging of a couple of friends, I walked into a clinic feeling great and a bit foolish. P.S.A., 9-plus. Biopsy, of course (ouch), and I was told of a "little suspicious gray area" on a film. Lab test result, positive. Doctor recommendation: surgery or radiation.
I decided against both and never looked back, and have lived happily and healthfully ever after.

By the way, the 10 or 15 percent chance of bad side effects (I asked) from surgery is really far higher, from what I've read and heard. Watchful waiting is still the best suggestion any doctor can offer.

Robert S. Corya
Indianapolis, March 10, 2010

• CBS' Harry Smith's live colonoscopy coverage that never touched on any questions about evidence for colonoscopy and some of the questions that have been raised about the overselling of colonoscopy - perhaps resulting in the decline in use of a $20 blood stool slide test.

While Smith's colonoscopy was being televised, I was attending a meeting entitled, "First, Do No Harm," hosted by the US Agency for Healthcare Research & Quality. The purpose of the meeting was to guide future AHRQ research on how to get doctors and patients to stop pursuing approaches for which there is net harm - not benefit. Clearly, health care in the US struggles even with the clearcut issues of cutting back in the face of net harm - much less in grey areas where there is uncertainty about harms vs. benefits.

But kudos to Lindsey Tanner of AP for trying to tie together the week's news in the way she did. We could have stories like that every week. And if we did, we'd have a lot smarter health care consumer population.

Archives of Internal Medicie editor Rita Redberg writes:

"I was troubled to read that the President's physical examination included an electron beam computed tomographic (CT) scan for coronary calcium. This screening test likely exposed Mr Obama to significant radiation unnecessarily, increasing his risk of future cancer. ...In light of this radiation risk, and the lack of proven benefit in low-risk persons, the US Preventive Services Task Force (USPSTF) recommends against this test in men such as Mr Obama. In addition, the leading professional cardiology societies do not recommend coronary calcium screening for such men. ...According to news reports, Mr Obama also underwent colon cancer screening, even though this screening is not recommended in his age group. Moreover, even when he reaches age 50 next year, the recommended colon cancer screening tests are either fecal occult blood test or colonoscopy. The USPSTF does not recommend virtual colonoscopy for screening, as performed on Mr Obama, owing to the lack of supporting evidence. This CT colonography test, like the electron beam CT scan, increased his radiation exposure and subsequent cancer risk.

Inadvertently, but perhaps fittingly, the reports of Mr Obama's physical examination reflect some of the key challenges facing health care reform today--Mr Obama appears to have been administered 2 cutting edge, expensive diagnostic tests that exposed him to a radiation risk while likely providing no benefit to his care. Some might defend these tests on the grounds that the President, of all people, deserves the very best our health care system can provide, but that would miss the point: more care is not necessarily better care. If the tests have no proven benefit for patients like Mr Obama, then they have no benefit for Mr Obama himself. Worse, evidence shows that the performance of unnecessary tests is not limited to Mr Obama or some select few patients. On the contrary, Mr Obama's case is multiplied many times over at extraordinary cumulative financial cost to society and personal cost to the individuals who receive tests with known adverse effects and potential harms but without benefits.

It is unlikely that Mr Obama will have a dispute with his insurance company over the costs of the tests performed at his physical examination, whether or not they were necessary, but it is a certainty that we all will have great disputes over the spiraling costs of health care for the rest of us."

A UK parliamentary panel this week recommended against public funding of homeopathy, as Susan Perry of MinnPost.com wrote.

"[E]xplanations for why homeopathy would work are scientifically implausible," the panel said.

She cited one estimate that Americans spend $830 million on homeopathic products each year.

Meantime, British physician and writer Ben Goldacre wrote that the BBC had hit rock bottom by giving more than five minutes of airtime to a woman who claimed her cancer was cured by homeopathy. Here's the clip:

For a bit of background, go to this link to see an interesting video featuring BBC health correspondent Branwen Jeffreys explaining homeopathy.

Some websites, predictably, have pulled out the following BBC comedy spoof of homeopathy.

That's the title of an editorial in this week's Annals of Internal Medicine (subscription required - even though the article is marked as "free" on the Annals home page.)

It's a reflection on the US Preventive Service Task Force's recommendations on breast cancer screening from last fall. The Annals editors remind readers:

"Although some subspecialty organizations advocate more aggressive routine breast cancer screening, the update actually aligned the USPSTF recommendations more closely with guidelines from the American College of Physicians, the World Health Organization, and the United Kingdom's National Health Service."

Other excerpts:

"Annals posted a survey on our Web site to solicit readers' impressions. The responses suggest that clinicians are more inclined to change what they do in light of the new recommendations than are members of the general public. ...

Clinicians who offer advice compatible with the new USPSTF recommendations are likely to meet resistance. Most women who responded to the survey resolved to continue as routine the practices that the USPSTF advises against being routine. ...

The Task Force's charge is to provide evidence-based, population-level guidance. Only rarely does evidence unequivocally support a single, definite "one-size-fits-all" recommendation. As the breast cancer recommendations so vividly illustrate, clinicians must often invoke the art of medicine to apply available evidence to an individual patient. Before these most recent guidelines, many clinical encounters about breast cancer screening probably involved little more than the physician handing the patient a mammography referral. Going forward, these interactions will surely involve more discussion about risks, harms, benefits, and preference. The Task Force's intent was to motivate such rational discussion, not to ration care. ...

Because the USPSTF issued recommendations that were politically unpopular among some constituents, there have been calls to curtail this independent body's work. If the USPSTF sinks in turbulent waters whipped up by emotion, anecdotes, and politics, Americans should mourn its loss."

Finally, the Annals editors referred to "a media cacophony" - a phrase I've used in reference to coverage of this episode. They wrote that "the media and politicians presented the breast cancer screening recommendations as a major departure from existing guidelines that heralded an age of rationed care in the United States. Confusion, politics, conflicted experts, anecdote, and emotion ruled front pages, airwaves, the Internet, and dinner-table conversations."

This episode was - and still can be - a golden opportunity for informing people about evidence - and for shared decision-making. This won't be last collision between evidence and anedote/politics/emotion. Will we be any smarter next time?

Gina Kolata's NYT piece, "Results Unproven, Robotic Surgery Wins Converts," looks at how "robot-assisted prostate surgery has grown at a nearly unprecedented rate."

Excerpts from the story:

• "..robot-assisted prostate surgery costs more -- about $1,500 to $2,000 more per patient. And it is not clear whether its outcomes are better, worse or the same."

• "Meanwhile, marketing has moved into the breach, with hospitals and surgeons advertising their services with claims that make critics raise their eyebrows."

• "Medical researchers say the robot situation is emblematic of a more general issue. New technology has sometimes led to big advances, which can justify extra costs. But often, technology spreads long before investigators know whether it is worthwhile."

• "...a situation like robot-assisted surgery illustrates how patients may end up making what can be life-changing decisions based on little more than assertive marketing or the personal prejudices of their surgeon.

"There is no question there is a lot of marketing hype," said Dr. Gerald L. Andriole Jr., chief of urologic surgery at Washington University. Dr. Andriole does laparoscopic prostate surgery, and although he tried the robot, he went back to the old ways.

"I just think that in this particular instance, with this particular robot," he said, "there hasn't been a quantum leap in anything."

Terrific piece in the Wall Street Journal headlined, "A Simple Health Care Fix Fizzles Out."

It documents how the "blockbuster" COURAGE trial three years ago that questioned the effectiveness of "the most common heart surgery" - coronary artery stent placement - had a brief impact on clinical practice but "as the headlines faded," stentings soon began to rise again.

The graph at left is from the WSJ piece, showing that stenting "is now back at peak levels of about one million a year." Excerpts from the article:

"Sanjay Kaul, a prominent cardiologist and researcher at Cedars-Sinai Heart Institute in Los Angeles, estimates that the U.S. could save $5 billion of the $15 billion it spends on stent procedures each year if all doctors followed Courage's guidance--that is, putting certain heart patients on generic drugs and turning to stents only if the pains persists. ...

Ajay Kirtane, a cardiologist at Columbia University, believes that American expectations about medical "fixes" makes it hard to follow recommendations such as Courage's. If a doctor attempted to persuade a patient to delay stenting in order to see whether drug treatment would work by itself, he says, the patient would likely drop him and see another cardiologist instead."

Read the entire piece. And thanks to the WSJ for still allowing reporters to write 2,000-word articles like this.

This week the National Institutes of Health convened an "NIH State-of-the-Science Conference on Enhancing Use and Quality of Colorectal Cancer Screening."

The only story I could find on it was in the Columbus Dispatch.

But I've seen no news coverage about what a friend who attended the conference reported to me.

I've now verified with various attendees that there were clear new signs of the turf war between gastroenterologists - keepers of the traditional colonoscopy approach - and radiologists - who are more inclined to favor the new kid "virtual colonoscopy."

More than just "inside baseball" about "inside your colon," this is another war over evidence in health care.

The NIH panel was not charged with judging the relative value of different colon cancer screening methods.

But it sounds like some of the parties who attended had a different expectation and so the conference they got was not the conference they wanted.

I'm told that radiologists were upset - demanding at least more recognition of the benefits of virtual colonoscopy (or CT colonography) if not a downright endorsement. Some stated their disapproval of the U.S. Preventive Services Task Force statement that "the evidence is insufficient to assess the benefits and harms of computed tomographic colonography (ed. note: and fecal DNA testing, for that matter)." And they're upset about the subsequent decision by the Center for Medicare & Medicaid Services not to cover the newer test.

Radiologists wanted more recognition of the large American College of Radiology Imaging Network trial.

I'm told that there were several radiologists who got up and basically screamed at the panel members for being in the "dark ages". They cited the American Cancer Society recommendations that conflict with the USPSTF on the virtual colonoscopy and also evoked what they called the "mammography disaster," referring to the USPSTF mammography recommendations released last November - another time the USPSTF and Cancer Society disagreed.

One of the speakers at the NIH conference said that the Cancer Society does not use a formal process for evaluating the evidence, does not provide details about how they come to their conclusions and includes only sub-specialists on their panel - raising questions about conflict of interest in their recommendations.

So even though that's not what the meeting was about, there was scuffling over screening method vs. screening method, turf wars, and conflict of interest in the setting of guidelines or recommendations.

So this one isn't over.

And it's difficult to understand why this didn't get news coverage. It sure sounded newsworthy to me.

For some time many news organizations have trumpeted, as ABC's Good Morning America did, the "cutting-edge" healing powers of platelet-rich plasma therapy or PRP. As is often the case in stories about wonderful new therapies, evidence is cast aside in favor of sparkling anecdotes such as that of pro football player Hines Ward.

Well today evidence gets its turn. Stories by the Wall Street Journal and by the New York Times point out, as the Times put it, "the first rigorous study asking whether the platelet injections actually work finds they are no more effective than saltwater."

This study was in people with injured Achilles tendons. But as the Times explains, PRP has already been extended to so many uses - "treating muscle sprains and tendon pulls and tears, arthritis, bone fractures and surgical wounds -- that Dr. Bruce Reider, editor of The American Journal of Sports Medicine, said in a recent editorial that perhaps it should be called "platelet-rich panacea."

The lead investigator was even quoted saying, "We are sorry for the patients"

Supposedly a forthcoming study will tout PRP's benefits in elbow problems, but the Times reports that:

"Dr. Freddie H. Fu, an orthopedist at the University of Pittsburgh Medical Center, said the study stacked the deck in favor of platelet injections. ...

Although 73 percent of patients given platelet injections improved after a year, compared with 54 percent for steroid injections, Dr. Fu said that was not much success. "Any time you touch a patient, you get 70 percent success," he said, adding that even placebos give that rate over time.

... Fu said he was keeping an open mind but still did not offer platelet injections. "I just do not have the heart to ask patients to pay for an unproven therapy," he said.

Guarantee: this won't be the last you hear of PRP as it is being looked at to treat injured shoulders, knees, elbows, heels - you name it. The old medical maxim applies - to a man with a new hammer, everything looks like a nail.

I would ignore this except that it's in the Washington Post and despite the fact that they're closing bureaus in Chicago, Los Angeles and New York, what's in what remains of the paper is still influential.

So I feel compelled to address Dana Milbank's column in the Post about the US Preventive Services Task Force breast cancer screening recommendations.

He characterized the USPSTF recommendations as a "cruel and clumsy blow" that "wiped out much of the progress" in breast cancer detection.

Huh?

It got worse, as he wrote:.

"With a drumbeat of recommendations raising doubts about various cancer screenings, the public could easily get the mistaken impression that all cancer screening is a waste of time and money."

Stop the foolishness.

The USPSTF said nothing about any cancer screening being a waste of time and money. In fact, it recommends biennial screening mammography for women aged 50 to 74 years. It recommended against routine screening mammography in women aged 40 to 49 years, stating "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 patient's values regarding specific benefits and harms."

How "cruel" to try to ensure that women are fully informed about benefits and harms, and to state that this should be an individual decision based on individual values.

If the public can get the impression that all cancer screening is a waste of time and money from those statements, then Milbank might better spend his time educating the public on how to read.

It got worse. Much worse. As he continued:

"Luckily, Congress has a simpler solution at hand: It can abolish the task force and turn it into a group that is more accountable to the public. Under the House version of health-care legislation, the task force, whose members need not subject themselves or their opinions to public comment or public hearings, would be reorganized as a federal advisory committee subject to oversight. Their scientific judgments would stay independent, but the group would no longer be able to go rogue with surprise recommendations."

Oh, that would be a grand idea. Make science accountable to the public? Let's make science ignore the evidence and tell us fairy tales that we want to hear. That everything is terrific, risk-free and without a price tag? And let's make the independent task force subject to federal government oversight. Then we can make science ignore the evidence and only spew out what is politically popular at the moment.

Milbank believes his ideas mean that the task force would no longer be able to "go rogue with surprise recommendations." Read your own paper, Dana.

Dan Eggen and Rob Stein reported that "The findings underscore a decades-long debate in the medical community about the benefits and risks of routine breast cancer screening for younger women." So this is not "rogue" and not "surprising" to anyone who has made any attempt to follow the issue.

Why did he choose to give only Nancy Brinker's side of the story? His own paper reported this praise for the USPSTF recommendations:

"It's about time," said Fran Visco, president of the National Breast Cancer Coalition, a Washington-based patient advocacy group. "Women deserve the truth -- and the truth is the evidence says this is not always helpful and can be harmful."

But it's really sick when a columnist suggests that task force members be sent to Gitmo and that they be sent "to the Death Panel for a humane end."

If he thought this was humorous, it wasn't. If he thought his column clarified anything, it didn't. Confusion and rhetoric will reign as long as we continue to get one-sided, vacuous, inaccurate columns like this. If, indeed, anyone is reading it.

Paul Scott has an opinion piece in the Rochester Post-Bulletin in which he criticizes what he calls the Mayo Clinic's "vague and surprisingly unprepared" response to the US Preventive Services Task Force's mammography recommendations.

"Taking unspecified issue with "the modeling data used in the analysis," it stated "a substantial number of women who receive biopsies because of a screening mammogram are found to have cancer." Mayo's Dr. Sandhya Pruthi added "there are many stories about younger women who have found cancer early as a result of screening."

I'm not sure why she made mention of stories. Dr. Pruthi is surely a talented clinician, but in supporting mammograms for women in their 40s here she is citing anecdotes, not data. It would have been better for her to acknowledge that when it comes to population-wide recommendations about screening and illness, medicine always eventually draws a line in the sand somewhere. People invariably will fall on either side of that line wrongly, but if we don't draw a line somewhere, you have to screen everybody for everything, and screening sets in motion the potential for new harms."

It seems that anyone who opposes the USPSTF recommendations trots out personal anecdotes to bolster their argument. Scott countered and concluded with an anecdote of his own:

"I would like nothing more than for our society to prevent the incidence of breast cancer. It took the life of my mom, who identified a tumor on her own at 37, was treated surgically at Mayo in the mid 1970s, and who then lived another 26 years. But my mom believed in science, and in trusting science, and in this case, the science says what it says. I hope that Mayo can do the same, even when doing so runs against that which is popular."

The first online comment posted in response to Scott's opinion piece stated that "there isn't one single oncologist on the US Preventive Services Task Force." I've heard that curious argument before. Evidence is evidence - regardless of whether you're a primary care doc, an oncologist, an epidemiologist, an ob-gyn or a breast surgeon. Evidence-based medicine should be guided by the best evidence, not by the personal experiences or preferences of any specialty group.

For a long time, I've urged health care journalists to refer to the recommendations of the US Preventive Services Task Force and to educate readers/viewers about how the group operates.

Perhaps one of the reasons the task force's recommendations this week caught so many people by surprise is that journalism hasn't done a good enough job of:

• explaining the uncertainties that still exist and always have existed about mammography
• explaining the work of the USPSTF

Gina Kolata of the NYT offers somewhat of a backgrounder/explainer today.

All of their work - how they do it - what they base their recommendations on -who they are - is available online - and has been.

Since they're an independent group of experts from across the country, they have no PR machine like the American Cancer Society does. So it's easy for the ACS to rule the airwaves and the columns when they disagree with something the USPSTF states.

But I think journalists have failed badly in explaining this work. And the harm done to evidence-based medicine this week may be lasting.

In the stories reported by major news organizations all across the US, there have been countless quotes that make wild, unsubstantiated charges about the motivation behind the US Preventive Services Task Force's breast screening recommendations.

A quote in a New York Times story yesterday:

"Why all of a sudden this change?" said Karen Sun, 41, who was loading her groceries into her car here in Los Angeles. "It feels out of nowhere."

As the Washington Post led with in their story, this has been a decades-long debate. What we have seen in the past 3 days is akin to what happened with the uproar 12 years ago after a NIH Consensus Conference on this issue made a concluding statement that many women - and their politicians - disagreed with.

In an ugly clash between science and politics, confusion reigned.

And now it's happening again.

From the LA Times:

Some Republicans jumped on the report as the kind of government intervention in medical decisions that Obama's healthcare plan would bring.

"This is really the first step toward that business of rationing care based on cost," said Rep. Phil Gingrey (R-Ga.), a physician.

Where is the evidence for that? That is fear-mongering rhetoric.

In the Washington Post:

"We can't allow the insurance industry to continue to drive health-care decisions," said Rep. Debbie Wasserman Schultz (D-Fla.), who said earlier this year that she had undergone treatment for breast cancer.

Wasserman-Schultz, whose legislation promoting breast cancer education in young women was widely criticized by evidence-based experts, should be forced to produce evidence for her claim as well.

And on ABC last night, a physician was allowed to say - unchallenged - that mammograms pick up early cancers when they need less treatment. If anecdotes are going to rule the day, then that physician should have to counter the anecdotes I've heard from women whose early DCIS or ductal carcinoma in situ - often called "pre-malignant" or "pre-cancerous" - was picked up by mammograms. And the range of treatment options then thrown at them - as aggressive as prophylatic bilateral mastectomy - left the DCIS-diagnosed to wish that they had actually received a diagnosis of invasive cancer because the choices were easier and more clear cut. These are real stories I heard from real women. The story - the discussion - isn't complete without taking into account the experiences of women like that.

I watched all three TV networks' lead stories from last night's newscasts - all three on the US Preventive Services Task Force's new breast cancer screening recommendations. Lots of talk about "anger, confusion, concern, fear, outright revolt, disturbing, shocking" reactions from women and doctors all across the country.

First, I'll note a reasonably well-balanced job by CBS' Dr. Jon LaPook and by NBC's Dr. Nancy Snyderman. LaPook included a woman who had experienced a false positive mammogram. Snyderman talked about data versus personal anecdotes.

But ABC's Dr. Timothy Johnson gave a personal recommendation - perhaps only because he was asked to by anchor Charles Gibson - and recommended "sticking with the current guidelines." He said he understood concerns about costs and quality. But that misses the underpinning of much of the USPSTF's recommendation and rationale. It implies that the USPSTF considered costs, which they have repeatedly reiterated they did not. He never addressed false positives and the harms thereof. So his summary was misleading and incomplete.

And CBS again allowed Dr. Jennifer Ashton to give her own personal medical opinion, saying "I am not telling (women) to deviate from their screening practices."

I have a lot of problems with the networks giving airtime to the opinions of their physician-correspondents. Do they ask political reporters about their voting habits? Do they ask economics reporters what their investments are? Do they ask the White House correspondent if they personally like the President or support his stances?

I don't personally care what Timothy Johnson or Jennifer Ashton recommend - and I don't think there's any reason for anyone in the viewing audience to care. In this venue, they are supposed to be journalists. Not recommenders. Not opinion-promoters.

Instead of promoting their celebrity docs, the networks should use that precious air time to educate people on the evidence behind the USPSTF recommendations.

All three networks - and many other news organizations - are treating this issue as if it's new. There never has been certainty about mammography recommendations for women in their 40s. And it was just 12 years ago that an NIH Consensus Conference on this issue resulted in a great uproar - what one editorialist described as "what took place seemed more akin to the Queen's order in Alice's Adventures in Wonderland: "Off with her head!" Thus began the latest round in the debate over recommendations for breast-cancer screening."

Journalism has to take responsibility for conveying far too much certainty about screening issues. And at times like this, when evidence-based bodies speak up, journalists - and the public they serve - act as if their worlds have been shaken. But, in fact, their world on this issue never was cast in concrete. Anyone who spends anytime following this issue would know that.

In the face of the confusion, journalists can fuel the flames by interviewing endless women about their personal anecdotes. Or they can explain, give context, history, guide readers and viewers through the confusion.

As I predicted yesterday, there has been nary a story on the US Preventive Services Task Force's new statement that the evidence isn't in yet on nine ways to look for signs of coronary heart disease in people without symptoms.

Journalists - many of whom sang the praises of at least two of those methods (the CRP test and coronary artery calcium CT scans) - either aren't aware or don't care about cautious, evidence-based recommendations from the USPSTF.

The only stories I've seen were by the Wall Street Journal health blog and by MedPage Today which did a
story and a blog posting.

On the MedPageToday blog, Peggy Peck wrote:

This is a setback for CRP believers, a group whose numbers swelled significantly when Paul Ridker reported last November that giving "healthy" adults who had hs-CRP of 2.0 mg/L or higher a potent statin for less than 2 years reduced "the rate of MI stroke, arterial revascularization, or cardiovascular death was 44% (P<0.00001)."

Those findings came from the JUPITER trial and when they were announced there were lots of pundits predicting that hs-CRP would become everyone's favorite test and that maybe it really was time to consider putting statins in the water.

Since last November churning out additional analyses from JUPITER has become something of a cottage industry and some weeks it is difficult to pick up a heart journal or attend a cardiology meeting without being confronted with yet another JUPITER result.

In my opinion it had gotten out-of-hand, so about a month ago I started telling every PR person so sent me the latest breathless JUPITER press release that "I am done with JUPITER."

But here I am, once again, strumming the JUPITER tune. There's no escaping it.

Well, there may no escaping it for journalists like Peck.

But almost every other journalist and news organization - so far - has found such news very easy to escape.

It seems to me that when previously highly-promoted approaches are judged to be not ready for prime time by an independent panel with no axe to grind, that's news.

We salute the Philadelphia Inquirer and reporter Stacey Burling for a terrific piece, "Debate surrounds new prostate cancer treatment."

It got a rare five-star (top score) rating on HealthNewsReview.org. Excerpts of the review:

This was an excellent, provocative exploration of some of the critical issues involving the tension between treatment options, payment responsibility, patient choice, and evidence on risks and benefits. There are a great number of uncertainties about prostate cancer itself, whether active treatment is called for and if so, which is the most appropriate choice for individual patients. Combining this with financial interests of those providing treatment adds another layer of difficulty in making good individual choices.

High marks for a terrific enterprise piece that helps readers understand an important health policy and health care reform topic.

One standout quote from a physician in the story:

"There's a lot of politics involved in this. There's a lot of self-interest. There's a lot of greed."

With all of those aging prostates on Capitol Hill, one wonders how much money Washington, DC urologists make off of legislators' walnut-sized glands.

Here are two examples of the kind of public discussion through journalism that we need more often - and both focus on prostates.

David Leonhardt discusses prostate cancer as a litmus test for health care reform. Why prostate cancer? He explains:

Some doctors swear by one treatment, others by another. But no one really knows which is best. Rigorous research has been scant. Above all, no serious study has found that the high-technology treatments do better at keeping men healthy and alive. Most die of something else before prostate cancer becomes a problem.

"No therapy has been shown superior to another," an analysis by the RAND Corporation found. Dr. Michael Rawlins, the chairman of a British medical research institute, told me, "We're not sure how good any of these treatments are." When I asked Dr. Daniella Perlroth of Stanford University, who has studied the data, what she would recommend to a family member, she paused. Then she said, "Watchful waiting."

But if the treatments have roughly similar benefits, they have very different prices. Watchful waiting costs just a few thousand dollars, in follow-up doctor visits and tests. Surgery to remove the prostate gland costs about $23,000. A targeted form of radiation, known as I.M.R.T., runs $50,000. Proton radiation therapy often exceeds $100,000.

And in our current fee-for-service medical system -- in which doctors and hospitals are paid for how much care they provide, rather than how well they care for their patients -- you can probably guess which treatments are becoming more popular: the ones that cost a lot of money.

Use of I.M.R.T. rose tenfold from 2002 to 2006, according to unpublished RAND data. A new proton treatment center will open Wednesday in Oklahoma City, and others are being planned in Chicago, South Florida and elsewhere. The country is paying at least several billion more dollars for prostate treatment than is medically justified -- and the bill is rising rapidly.

You may never see this bill, but you're paying it. It has raised your health insurance premiums and left your employer with less money to give you a decent raise. The cost of prostate cancer care is one small reason that some companies have stopped offering health insurance. It is also one reason that medical costs are on a pace to make the federal government insolvent.

Meantime on MinnPost.com, Susan Perry writes about more doubts about prostate cancer screening:

On Father's Day last month, Sen. John Kerry, D-Mass., and radio shock jock Don Imus co-authored an op-ed for the Boston Globe in which they argued that men needed to be sure they received regular preventive screening check-ups for prostate cancer. Both men are prostate cancer survivors.

"Screening for prostate cancer is the only option," they wrote.

But therein lies a big, big problem -- and yet another medical controversy. Just a few days after that op-ed ran, a review article in the medical journal CA: A Cancer Journal for Clinicians reported that the PSA blood test, routinely used to screen for prostate cancer, saves few lives, wastes money and often leads to risky and unnecessary treatments.

An editorial that accompanied the review noted that not a single well-designed clinical trial has yet to show that PSA screening reduces the death risk from prostate cancer.

However, if you don't want to be discouraged about engaging the public in a discussion of the role of evidence in health care refom, don't read the comments attached to either piece.

I think I got Susan Perry of MinnPost.com turned on to the controversy surrounding the bill co-sponsored by Sen. Amy Klobuchar and Rep. Debbie Wasserman-Schultz

Regardless of how she got inspired, Perry is now all over the story, adding a new posting today. She adds the fact that noted breast cancer author Dr. Susan Love opposes the legislation, adding her name to a long list of critics. Excerpt from the new posting:

One of the most contentious issues of the bill is its emphasis on breast self-exams for women under 40, despite research from large randomized trials that have shown such exams have no effect on either detecting breast cancer or influencing survival rates in women of any age.

And Christine Norton of the Minnesota Breast Cancer Coalition says in the new article:

"It's upsetting to me that the preponderance of evidence was not persuasive to stop the introduction of this legislation that would call for $45 million over a five-year period," says Norton. "I understand that that amount is 'decimal dust,' but to a taxpayer, it's significant, especially at this time when we're supposed to be focusing on health-care reform."

The Wall Street Journal added to the discussion about cost-effectiveness of cancer drugs reflecting on a commentary in the Journal of the National Cancer Institute estimating that "it would cost $440 billion to extend life by one year for the 550,000 Americans who die annually of cancer."

Important topic. I'm glad the WSJ addressed it.

But one line bothered me. It read:

"Some countries, like the United Kingdom, agree to pay for expensive drugs only if they meet a certain threshold of efficacy, but no such rationing exists in the U.S."

A news story that comes right out and labels a demand for proof of efficacy as rationing?

A semantics purist may say that the term applies in this discussion - like restricting or rationing consumption of meat or electricity during war.

But given that any newsroom must realize how the term is used as a heavy-handed piece of rhetoric by those who oppose evidence-based medicine and who oppose health care reform that calls for such evidence, this seems like editorializing.

Good story - but that one word in that one sentence left a bad taste for me. Semantics, word choice and framing matter if you care about public understanding of complex health policy issues.

Despite my red marks on that one section, read the rest of the article (if it's still available online), which was important enough to be on page one of at least the D section of the printed WSJ, not way back on D4.

"This is so ridiculous, it may not be worth blogging on," Marilyn Mann wrote to me.

I thrive on the ridiculous.

Whenever and wherever I see something this absurd, this non-evidence-based, this unhelpful and potentially harmful to health care consumers, I'm going to comment.

The columnist, a certified personal trainer, says she adapted her column from the July/August issue of Men's Health magazine.

She advises men to think about getting

• Cardiac CT angiography

• Bone density scan - She writes: "Uh, oh, fellows. Did you think osteoporosis was just for women? Nope."

• VO2 Max Test. She writes: "For this one, you get on a treadmill or stationary bike and pump up your cardiovascular volume to maximum effort while wearing a mask that measures your every breath.

The VO2 Max Test is the master cardiovascular test that will let you know what you're made of. It's the most accurate measure of your cardiovascular and overall health."

You won't find one evidence-based recommendation that supports any of those recommendations.

This kind of junk journalism feeds the "test, test, test" mentality that fuels the worried well and drives up health care costs.

I hope Philly Daily News readers either didn't read this column or didn't pay any attention to it. But for those that did, now you know the rest of the story.

Bad week on network TV.

Stories on...

• a male contraceptive

• robotic surgery

• a new MRI device

* and a new skin cancer detection device

all failed to discuss costs, to quantify benefits and harms, or to give independent perspectives.

Viewers of these programs got one-sided, incomplete, imbalanced portrayals of health care treatments, tests, products and procedures.

I will give the NBC Today Show some credit for trying to address the issue of too much cancer screening and the overtreatment that results.

Matt Lauer acknowledged that the segment would counter much of what the program had told viewers over the past 10 years or so. What he didn't say is that the questions about cancer screening are NOT new and that the Today Show had actually misinformed viewers in many of their earlier messages.

But despite the good effort, today's program was given too little time, was too loosely organized, and probably left viewers horribly confused.

Thank goodness they had one of the best evidence-based minds on the set to address the topic - Dartmouth's Dr. Gil Welch.

Lauer half-promised there would be more segments in the future on this topic. I hope they live up to that.