Only so much to say about this story.

It's about Senator David Vitter of Louisana.

He says that an FDA advisory committee's vote to revoke the approval of Roche-Genentech's Avastin for treating breast cancer is "essentially government rationing." The WSJ reports:

New studies presented to the panel showed more side effects among women being treated with Avastin and no overall survival benefit, though they did show women taking the drug had an extra month to 2.9 months of progression-free survival. Advisory panels do not discuss monetary costs of the drugs they consider.

"I shudder at the thought of a government panel assigning a value to a day of a person's life," Vitter said in a statement. "It is sickening to think that care would be withheld from a patient simply because their life is not deemed valuable enough." In a letter to the FDA cancer division leader, Richard Pazdur, Vitter said the committee's vote appeared to be based on cost effectiveness, not safety issues.

"I am not suggesting that Avastin is a perfect drug, but it has a proven record of effective treatment for some patients when used along with chemotherapy," he wrote.

This is the same Senator who, as the WSJ reminds us, "slammed the new U.S. Preventive Services Task Force mammogram guidelines that said yearly tests shouldn't be automatic for most women under 50. In May he asked the HHS to take the recommendations off the agency's website."

Summary:

• Scientists find no overall survival benefit and considerable side effects.

• Senator says the drug has proven track record of effective treatment and calls rejection "sickening...rationing."

Questions:

• Who knows better?

• Whose advice to trust?

(There, I've blogged about it without injecting my own opinion. Just the facts and some pertinent questions. Talk amongst yourselves. I'm verklempt.)

On the Forbes blog this week:

"Dendreon shares are down today on the heels of news that the Centers for Medicare and Medicaid Services (CMS) will undergo a lengthy review of whether or not Provenge "is reasonable and necessary under sections 1862(a)(1)(A) and/or 1862(a)(1)(E) of the Social Security Act" and should be reimbursed by Medicare.

Most analysts believe that Medicare will ultimately agree to pay for Provenge, because it's FDA-approved, and it was shown to extend survival by 4 months in clinical trials."

Meantime the UK's Telegraph reports:

Kidney cancer patients denied drug that can extend their lives

Kidney cancer patients will not be allowed a new drug that could extend their lives by up to three months because it is too expensive, the NHS drug rationing body has said.

Four months added survival for one drug - and questions are raised about why the U.S. is even reviewing the drug.

Three months added survival for another drug - and the British National Institute for health and Clinical Excellence says the drug does not offer enough benefit to patients to justify the cost.

I wish we'd see more comparisons like this in American journalism. Both headlines - both stories - were right out there for anyone to see this week. The irony was unavoidable.

The worst-kept secret in journalism circles recently was that the New York Times was planning an article critical of the Dartmouth Atlas. That article was published online last night.

Among the main points in the article:

• "The mistaken belief that the Dartmouth research proves that cheaper care is better care is widespread."

• "the atlas's hospital rankings do not take into account care that prolongs or improves lives."

• "Even Dartmouth's claims about which hospitals and regions are cheapest may be suspect."

• "failing to make basic data adjustments undermines the geographic variations the atlas purports to show."

The Times has also published the correspondence it had with the Dartmouth team about methodology questions.

The Dartmouth team challenges each of these criticisms in a pdf statement online. The team says the Times made at least five factual errors and several misrepresentations. They write: "What is truly unfortunate is that the Times missed an opportunity to help educate the American public about what our research actually shows -- or about the breadth of agreement about what our findings mean for health care reform."

Oddly, the Times called the Atlas researchers "a once obscure research group at Dartmouth College." I guess if you consider "once obscure" as 20 years ago you might be right. Putting that phrase in the opening sentence opened the discussion on a questionable note.

The Times is correct in stating that "The debate about the Dartmouth work is important."

But as Merrill Goozner wrote on his blog today,

"...as is often the case in journalism, the attempt to reduce complex realities into a single-factor analysis that can be summarized in a headline or a single "why this story is important" paragraph can leave a mistaken impression. Regional variation in Medicare spending is one indicator of gross overutilization. Something is happening when a hospital in McAllen, Texas does twice as many knee implants per Medicare beneficiary as a hospital in Rochester, Minnesota.

But that by itself tells us nothing about why that overutilization occurs. Greedy doctors or hospitals working in a fee-for-service system are part of the problem. Cost shifting due to high levels of uninsurance and illness severity also may account for some or even much of those differences. And, as the Times report points out, quality differentials have to be taken into account.

The pushback by Dartmouth defenders has already begun. Columbia University professor Andrew Gelman on his blog suggests the reporters need a lesson in statistics. My complaint with today's story comes from an entirely different angle. Higher quality care lowers costs, it doesn't raise costs."

Thoughtful people should read a lot about the criticism and the countering comments from Dartmouth. This is not something that can be absorbed in a headline, in a nut graf, or in a quickie talk show segment.

Disclosure: I worked at Dartmouth throughout the 90s, right down the hall from many of these Atlas researchers. I consider many of them my friends. My work is currently supported by the Foundation for Informed Medical Decision Making, one of whose co-founders was Dr. Jack Wennberg of Dartmouth, whose work was the basis for the Atlas project.

US Senator David Vitter (R-LA) wrote to HHS Secretary Kathleen Sebelius last week requesting that she have the Agency for Healthcare Research and Quality remove from its website last Fall's breast cancer screening recommendations from the US Preventive Services Task Force. Vitter writes:

"The recommendations were ill-conceived from the start - developed via a process without transparency, without input from those with experience and expertise in the field, and without due regard for the thousands of lives that could be impacted by the recommendation. They represent a step backward in our fight against a horrible disease and the taxpayers' dollar must not be spent in further promotion of them."

He could not be more wrong.

Vitter is a politician, not an evidence-based medical researcher, but he should know that the USPSTF process is perhaps the most transparent of any organization that publishes recommendations or guidelines. In fact, on the very website Vitter wants taken down, are html and pdf files of the complete recommendation, a supporting article, an evidence update article, an evidence synthesis and a clinical summary.

Government should be so transparent. USPSTF is widely praised for how completely it documents how it arrives at the recommendations it makes.

Strike one, Senator.

He says the recommendations were made "without input from those with experience and expertise in the field." Has he checked the qualifications of the USPSTF members? Is he making the ridiculous claim that only an oncologist or a radiologist can judge evidence?

Strike two, Senator.

He claims that the recommendations were made "without due regard for the thousands of lives that could be impacted by the recommendation." Is that why the punch line of the published recommendations reads: "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."? Where is the lack of regard for the individual in that statement?

Strike three, Senator.

As he heads back to the dugout to dream up more rhetoric, he may want to stop over at the meeting of the National Breast Cancer Coalition which meets in DC this weekend. That smart bunch of evidence-based breast cancer advocates doesn't agree with him at all. On their website they state:

NBCC continues to conclude that there is no statistically significant evidence that screening women age 40-49 years reduces mortality, and no strong evidence that it does so in women over 50 years.

Women need honest information regarding the value of all medical interventions. Public health resources need to be used with certainty to improve the public's health. The reality is that screening has not been effective. While the incidence of ductal carcinoma in situ and localized invasive breast cancer increased substantially as a result of screening programs, the incidence of regional or distant stage disease declined only slightly. There may be several reasons for this, but primarily it is because screening increases the detection of non-threatening cancers, while missing the most aggressive cancers.

NBCC continues to affirm the position we have taken for over a decade. Women should make a personal decision about whether to undergo screening mammography after weighing the risks and benefits.

But maybe Senator Vitter thinks these women don't know anything about breast cancer, either.

The AP reports that a group opposing the current health care reform legislation has "outraged" Pennsylvania Democratic Rep. Kathy Dahlkemper, who recently lost both parents to cancer.

The ad reflects on the US Preventive Services Task Force's breast cancer screening recommendations from last November. Among the distortions in the ad are its claims that the "government panel that didn't include cancer specialists says women shouldn't get mammograms until age 50. ... If government takes over health care, recommendations like these could become the law for all kind of diseases."

That isn't what the task force said. And the big government takeover theme is classic rhetorical fear-mongering.

More from the AP:

"Dahlkemper called for the ad to be pulled. But its sponsor, Americans for Prosperity, has refused.
...
"In the past month, I've lost both my parents to cancer," she said in a statement. "It's truly disgraceful for outside groups to then attack me for not being tough enough on cancer."
...
The nonpartisan group Factcheck.org denounced the ad for its "sheer number of falsehoods." Politifact, another independent group, gave the ad its lowest rating for truthfulness and accuracy: "Pants on Fire."

AP reports that Dahlkemper was targeted in an ad campaign that is being echoed throughout 18 Democratic districts.

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."

Australian journalist Melissa Sweet writes in the BMJ this week (subscription req'd for full access) about "Science, politics, and headlines in the home birth war," regarding a recent study published in the Medical Journal of Australia

She raises questions about journal editorial practices, journal news release practices, and news coverage that relies on those news releases. (Disclosure: she interviewed me for the BMJ article.) Excerpt:

"Last month the Medical Journal of Australia published a study on outcomes of home birth that generated many media stories sounding the alarm about the safety of such births.

Many stories focused on the study's findings that babies were seven times more likely to die during labour in a planned home birth and in particular were 27 times more likely to die from asphyxiation."

Some also did mention the finding that there was no significant difference in the overall perinatal mortality rate between planned home births and those planned for hospital delivery.

These were also all findings highlighted in the media release accompanying the journal, which made no mention of uncertainty surrounding the relative risk estimates. The confidence interval for both was wide: 1.53 to 35.87 for intrapartum deaths and 8.02 to 88.83 for deaths from intrapartum asphyxia.

Other questions she raises:

• the journal news release didn't mention the numbers of deaths involved or the absolute risks.

• "Nor did it mention the authors' caveats that 'small numbers with large confidence intervals limit interpretation of these data" and that 'in the 16 year study period there were only three perinatal deaths for which one can reasonably assume that a different choice of care provider, location of birth, or timing of transfer to hospital might have made a difference to the outcome.' "

• the news release quotes an obstetrician who is president of the Australian Medical Association and who wrote the accompanying editorial. The association, Sweet reminds readers, "which owns the Medical Journal of Australia, opposes home births and has been at loggerheads with nurisng and midwifery organizations over propoed reforms of maternity services in Australia."

• One homebirth advocate said that most of the journalists who interviewed her "said they had not read or even sourced the study."

Sweet has also written about this in more detail on the Croakey health blog.

If you're interested, here are links to related materials:

• The study on homebirth outcomes.

• The journal news release.

• Other posts on the Croakey blog about this issue.

Why is this worth the attention? Because it's a case where research - and how it's published and intepreted - could affect public health policy. It happens all the time. We just don't often see it broken down as well as Sweet did in this case.

The Center for Public Integrity has posted a searchable database of what they say are the 1,750 companies and organizations that have hired 4,525 lobbyists to influence health care reform legislation. The Center states:

"Despite the recession, 2009 was a boom year for influence peddling overall with business and advocacy groups shelling out $3.47 billion for lobbyists to represent them on all kinds of issues, according to the nonprofit group Center for Responsive Politics.

Much of that money went to fight the health reform battle, according to Center for Public Integrity data. Businesses and organizations that lobbied on health reform spent more than $1.2 billion on their overall lobby efforts. The exact amount they spent on health reform is difficult to quantify because most health care lobbyists also worked on other issues, and lobby disclosure rules do not require businesses to report how much they paid on each issue.

From an industry perspective, it was money well spent. A close look at the health reform bills that passed the House and Senate show lobbyists were apparently effective at blocking provisions like a robust government-run insurance program, and blunting the effect of cost-cutting measures on health care companies."

The health spendings projection article in Health Affairs contains this one historic note:

In 2009 the health share of gross domestic product (GDP) is expected to have increased 1.1 percentage points to 17.3 percent--the largest single-year increase since 1960.

A Los Angeles Times story gets to the heart of the matter:

"There is growing concern that as much as a third of the medical care delivered in this country does not help patients.

"Are we getting value for the dollar? That is the question," said Len Nichols, health policy director at the centrist New America Foundation. "If you believe that so much medical care is unnecessary, as I do, then it is criminal that we are spending so much."

Yet there is gridlock on federal health care reform legislation. Indeed, for all the rhetoric and fear-mongering about "government taking over health care," the latest data shows we're already there.

The Wall Street Journal reports and provides this graphic:

"For the first time, government programs next year will account for more than half of all U.S. health-care spending, federal actuaries predict, as the weak economy sends more people into Medicaid and slows growth of private insurance."

One of the reasons we review news stories about "new stuff" in health care is that we believe news stories may drive up undue demand for unproven, perhaps unsafe, and costly new technologies without giving a balanced picture of the tradeoffs between harms and benefits, without evaluating the quality of evidence behind the new ideas, without looking at conflicts of interest in those promoting the new ideas, etc.

At last check, 70% of the nearly 1,000 stories we've reviewed fail to adequately discuss costs, or quantify harms or benefits. A kid-in-the-candy-store view of US health care.

We believe these are health care reform stories - even though they often aren't presented that way. Just look at what we've written about just in the past week and you see the daily drumbeat of news stories and ads that fill our heads with visions of sugar plums in health care.

• CT and MRI scans

• Robotic surgery

• A weeklong network TV series taking you inside the O.R. for technological wonders

• Misleading drug ads

17.3% of the GDP and rising.

A team of reporters from KHN delivers this thoughtful piece. Excerpts:

"There's nothing in (the proposals) the average person could understand about why your costs would be lower," says Robert Blendon, professor of health policy at Harvard's School of Public Health. "They don't even have good illustrations about how it would be cheaper. They did not find a way to save money for people with job-based insurance." ...

Many of the taxes have been dropped or scaled back. Others have been designed to pressure the health care system to operate more efficiently. But the laundry list of levies has fueled concerns that Americans, struggling with the severest economic slump in decades, would have to pony up more for the tax man.

"The final bill will not have all those taxes in it," says Blendon, "but people hear about the tax on insurers, the tax on pharmaceuticals, the income tax - and they can't segregate it in their minds." Opposition to taxes was a key part of (newly-elected Massachusetts Senator Scott ) Brown's campaign.

"People don't like taxes," says Leslie Norwalk, who was acting director of the Centers for Medicare and Medicaid during the administration of President George W. Bush. "The electorate is trying to decide what it thinks about this health care stuff, sees the economy is in trouble and a lot of discussion about taxes, but isn't all that unhappy about their own healthcare. Weighing those two things can be difficult."

Alicia Mundy of the Wall Street Journal reports: "The final health-care bill is likely to require coverage for more mammograms than the new guidelines recommend after women's groups, doctors and imaging-equipment makers stepped up pressure on lawmakers -- one of many threads of the bill negotiated behind the scenes."

Great piece of local health policy journalism by the Dallas Morning News. Excerpts:

"There's a lot of money to be made in owning imaging machines," said Dr. Richard Strax, president of the Texas Radiological Society. "You can buy a relatively inexpensive second- or third-hand MRI machine for a few hundred thousand dollars and make millions on it."

"Today we can't even tell you how many MRI machines are in Texas, who owns them, what condition they're in and what quality of scans they're turning out," Ron Luke, health policy chairman of the Texas Association of Business, told state lawmakers this year. "That doesn't sound like we're very bright, does it?"

For three sessions, radiologists and doctors have fought in the Texas Legislature over the issue of self-referral. This year's legislation, backed by radiologists and business lobbyists, would have required licensing and accreditation of imaging machines, along with a year-long state study of the extent of self-referral by physicians. But it failed.

Proponents of the legislation say opponents are driven by financial motives. Imaging has become a "lifeline" for many doctors, said Dr. Cynthia Sherry, past president of the Texas Radiological Society.

"It's all about the money, OK? Those very doctors opposed to this are the ones participating in it," Sherry said.

An 1,800-word story on a vital health policy topic. Wow, do we need more like this. Ten gallon hats off to the Dallas Morning News.

"Smoking Memo - or Bad Journalism" - that's the title of Maggie Mahar's blog post on the alleged Obama-PhRMA deal. Excerpt:

Yesterday, it seemed that the Huffington Post's Ryan Grim had a scoop. He reported that Huffington has obtained a memo that "confirms" that the White House and the pharmaceutical lobby secretly made a deal--the deal that I wrote about a few days ago in a post titled "What Was Billy Tauzin Thinking?" According to the memo, the White House supposedly pledged to oppose any Congressional efforts to let Medicare negotiate for discounts on drugs, or to import drugs from Canada.

The memo in question turns out to be typed--and unsigned. How does the reporter know that it is authentic? "A knowledgeable health care lobbyist" told him so. According to the lobbyist the memo "was prepared by a person directly involved in the negotiations [and it] lists exactly what the White House gave up, and what it got in return.

Wait a minute. As PhRMA senior vice president Ken Johnson points out later in the story: "Anyone could have written it. Unless it comes from our board of directors, it's not worth the paper it's written on. . . ."

And who is the "knowledgeable lobbyist" who gave the memo to Huffington? His name is not disclosed.

What we have then, is a story based on what one unnamed source says--and a typed memo that probably is untraceable.

She goes on to quote me about whether this is acceptable journalism.

"Smoking Memo - or Bad Journalism" - that's the title of Maggie Mahar's blog post on the alleged Obama-PhRMA deal. Excerpt:

Yesterday, it seemed that the Huffington Post's Ryan Grim had a scoop. He reported that Huffington has obtained a memo that "confirms" that the White House and the pharmaceutical lobby secretly made a deal--the deal that I wrote about a few days ago in a post titled "What Was Billy Tauzin Thinking?" According to the memo, the White House supposedly pledged to oppose any Congressional efforts to let Medicare negotiate for discounts on drugs, or to import drugs from Canada.

The memo in question turns out to be typed--and unsigned. How does the reporter know that it is authentic? "A knowledgeable health care lobbyist" told him so. According to the lobbyist the memo "was prepared by a person directly involved in the negotiations [and it] lists exactly what the White House gave up, and what it got in return.

Wait a minute. As PhRMA senior vice president Ken Johnson points out later in the story: "Anyone could have written it. Unless it comes from our board of directors, it's not worth the paper it's written on. . . ."

And who is the "knowledgeable lobbyist" who gave the memo to Huffington? His name is not disclosed.

What we have then, is a story based on what one unnamed source says--and a typed memo that probably is untraceable.

She goes on to quote me about whether this is acceptable journalism.

Journalist Maggie Mahar blogs:

"I fear that the way the media has been reporting on reform has played a significant role in shaping the public's perception of both the president and what some like to call "ObamaCare," personalizing the issue, as if reform were merely the president's favorite hobby-horse.

Begin with coverage of health care reform. In recent weeks, Media Matters has done an excellent job of tracking how "the media continues to spread conservative misinformation on health care reform." Here are just a few examples:

 "Despite clear progress, media declare health care reform nearing "life support"

 "On health care reform, networks highlight perceived setbacks far more than progress" July 22

 "Politico ignores contradictions in calls by "moderates" for lower costs, limits on public plan" July 20

 "CBS' Smith advanced falsehood that Dems are taxing small businesses to fund health bill" July 19

 "NY Times ignores House health bill's exemption protecting small businesses"

 "Wash. Post column cites inapplicable CBO assessment to claim public plan option has 'huge cost, minor benefit'" July 07

 "CNN.com joins Republican fear-mongering about Canadian-style health care" July 07

And here I'm not even including the over-the-top distortions of the truth that have become regular fare on Fox News, and in the pages of some decidedly conservative newspapers."

There's much more on her blog.

NPR explores an issue many others haven't, reporting that in "three critical months, PhRMA and its member companies spent $40 million lobbying Congress. That's more than $3 million each week."

I am a one-man band. A mom-and-pop blogger minus the mom. Yet I've written four times since March 26 on the misguided EARLY Act supported by Senator Amy Klobuchar of Minnesota and Congresswoman Debbie Wasserman-Schultz of Florida.

• March 26

• June 19

• July 2

• July 13

Finally, this week, the Star Tribune, the biggest news organization in Minnesota, caught up with the story.

Where has the Strib been on this story? Among the smaller Minnesota news organizations that have already reported on the controversy are MinnPost.com and KMSP-TV. Yes, a TV station did a better job - sooner - than the state's biggest newspaper did.

(I will be pleased to run a correction if the Star Tribune reported on this earlier and I missed it. After all, I am merely a one-man band. A mom-and-pop blogger minus the mom.)

Here's proof that local TV news can do a meaty job on a meaningful health policy issue. At a time when more local TV news becomes light, fluffy, "news you can use" that you really can't use, this effort is a refreshing and important use of airtime.

Jeff Baillon of Fox-9 TV news in Minneapolis-St. Paul put together a piece on US Senator Amy Klobuchar's (D-Minn.) support for "The EARLY Act," which Baillon reports, "would spend $9 million a year over five years on an educational campaign that would, among other things, encourage women as young as 15 years old to perform regular breast self exams in the hopes of catching the disease early."

But rather than go with the flow of what appears to be a noble cause, Baillon reported that there's no scientific evidence that screening young women in their teens and 20s does any good, and that it could actually do some harm.

MinnPost.com has also recently reported on the controversy surrounding the legislation.

I am not aware that the "big 3" of Minnesota news organizations - the Star Tribune, the Pioneer Press, or Minnesota Public Radio - have even touched the controversy. I will happily issue a correction if I simply missed anything they have done on the matter.

I know that two of the interviews Baillon used in this piece were captured when he attended a journalist workshop hosted by the National Institutes of Health last month. He paid his own way there. But he wanted to learn more about how to scrutinize claims in health care. This piece is good evidence of what he's learned. (Disclosure: Baillon was a student in my graduate health journalism seminar in Fall 2008. He got an A.)

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.

Longtime Poynter Institute ethics guru Bob Steele - now a professor at DePauw University - published a column, "Dr. Sanjay Gupta Covers Obama's Health Care Policies with Competing Loyalties." Excerpts:

"My heightened concern focuses on the erosion of Gupta's journalistic independence given his two-plus months of discussions with the Obama administration about becoming surgeon general. ...

Gupta's withdrawal from consideration deserved scrutiny it did not receive on CNN Thursday night. Larry King had a buddy-buddy chat with Gupta that elicited little insight. But King's show is more entertainment than journalism.

However, on "Anderson Cooper 360," which is a news program, Cooper said how happy he was Gupta was going to stay at CNN and lobbed a few simple questions his way. There was no serious attempt to probe why Gupta had stayed in contention for over two months only to withdraw now. No effort to report on what his pulling out might mean to an Obama administration that has lost a number of appointees. No references to concerns about Gupta voiced by some politicians. ...

It was ironic that CNN used a breaking news label for the interview, imparting the event with that sense of importance, then treated Gupta's interviews like soft news. ...

It sure appears to me that CNN and Gupta are on a collision course filled with competing values and competing loyalties, one that could affect future coverage. In his wrap-up of the interview, Cooper teased Gupta's upcoming coverage of the administration. ...

For a couple of months we've had Sanjay Gupta in the running to be one of Obama's trusted allies. As surgeon general he would have had a key voice in the President's health care policy. While Gupta was, in essence, interviewing for the surgeon general's position, he was likely interviewing the President as well, not as a reporter but as a potential team player. He was bound to learn some insider information.

That's where the ethical challenges surface. To whom does Dr. Gupta owe loyalty? Can he serve the public with comprehensive reporting uninfluenced by his White House connections? Can he fairly report on an administration he almost joined? Can he fairly report on critics of Obama's health care plans?"

While I was on vacation last week, many web surfers found my name when searching for articles on Sanjay Gupta's work after the announcement that he was being considered for the Surgeon General position.

Because of a failure in search engine functioning, some surfers weren't able to find what they were searching for and asked me to provide an index. Here's some of what I've written:

• on non-evidence-based screening test advice for men

• on an "unquestioning - almost cheerleading - approach to health news"

• about a journal article that pointed out his involvement in a doctor's office waiting room video program that "overtly offers sponsors, including drug companies, the chance to boost sales of their products."

• about the political newsletter CounterPunch and the Chicago Tribune asking readers:"Do you trust CNN's Dr. Sanjay Gupta?"

• about Trudy Lieberman's article describing ineptitude by CNN and Gupta in coverage of health policy news.

• about Gupta vs. Michael Moore regarding "Sicko"

• about the waste of air time speculating over the cause of death of Anna Nicole Smith.

• about a one-sided view of the controversy over mammography for women in their 40s.

• about a Pfizer ad for Pfizer's sponsorhip of the "Paging Dr. Gupta" program.

• about some laughable, some dangerous coverage on Gupta's "Housecall" program

• about bad judgment employed in his live TV news coverage of Raelian cloning news conference.

Two of his stories were reviewed on HealthNewsReview.org:

• about disease-mongering of wrinkles on CNN

• a review of his CBS story about a treatment for addiction to painkillers that got one of our lowest scores.

One of the smartest pieces I saw was by Sandy Szwarc on her Junkfood Science blog.

My summary:

1. What does the President want from a Surgeon General? Is it just PR & glitz? Then let's stop the charade and abandon the position. Like ending the Pony Express - a once good idea whose usefulness is past.

2. What does the American public need from a Surgeon General? I suggest "Nothing."

3. The prevention & wellness messages that Gupta so often promoted on CNN can go too far - pushing screening tests outside the boundaries of evidence and ignoring that such screening may cause more harm than good. If that is the message that he would promote as Surgeon General, I would consider that a non-evidence-based abuse of the bully pulpit. And a huge mistake by the Obama administration. See Gilbert Welch's pre-election essay in the NYT on the overpromotion of screening/prevention by both Obama and McCain.

4. The industry conflict of interest questions that have arisen are cause for concern. Usually where there's smoke, there's fire.

5. On the air at CNN he too often acted as a doctor not as a journalist. That's because he really wasn't a journalist. He wasn't trained as one - CNN threw him into that situation. There are countless more pre-eminent doctors and countless better health communicators than Sanjay Gupta. So what's his qualification?

6. Presumably Surgeon General Gupta would work closely with new HHS secretary Tom Daschle. Several passages from Daschle's book, "Critical: What We Can Do About the Health Care Crisis," raise questions in my mind about the Gupta appointment. Daschle wrote about "using evidence-based guidelines and cutting down on inappropriate care" as effective ways to control rising health-care costs. But Gupta's reporting, as noted in the entries above, often didn't reflect a great appreciation for evidence-based health care. Daschle also wrote, "It is relatively easy to misinform the public and stoke fears, no matter how strong the desire for reform." Promoting screening outside the boundaries of evidence is fear-mongering. These are potentially troublesome disconnects for an Obama health care team.

The Chicago Tribune, in the middle of a good story with a catchy headline - "The United States of Anxiety: Worried Sick Over Our Health Care" - includes some vital messages:

"Polls show voters worry a lot about health care and how much they spend on it. Presidential candidates John McCain and Barack Obama have responded by peddling plans they claim will help more Americans attain and afford care.

But neither candidate has focused publicly on treating the real problem: why American medical care costs too much and isn't as good as it should be.

We waste money on tests and visits to specialists that don't make us better. We spend big to add a few weeks or months to the inevitable end of a dying patient's life. We use expensive technology at any cost, even when it exceeds our needs, and we fail to encourage simple, proactive steps that would keep us healthier and save us money. We often don't know which treatments work the best, so we err on the side of too much care, for too much cost, with sometimes damaging consequences.

As a result, Americans pay significantly more for medical care than anyone else in the industrialized world. Every year, we spend a bigger chunk of our family budget on doctor bills, hospital stays and prescription drugs. Yet we trail several other nations in health-care quality, access and efficiency.

Most Americans have long assumed that more is better when it comes to their health: more doctors, more tests, more hospital time. But a decade of comprehensive studies suggests that all those visits and tests and hospital stays are often a waste of money—and sometimes a drag on our well-being."

Trudy Lieberman writes:

The Rocky Mountain News’s coverage of John McCain’s campaign stop in Denver last week raises an important issue for reporters, especially those covering the election: Do you let a candidate’s remarks stand unchallenged even if they are wrong or misleading?

McCain had come to town to talk mostly about health care, the paper reported, noting that the topic took up a large part of his hour-long speech. The News offered all too typical coverage of such talks, however—bits and pieces on a lot of topics, with quotes here and there. We do learn that on health care, McCain urged states to take a leadership role in reform, and that he pumped his tax credit aimed at helping Americans buy health insurance. In the next graph, the paper said that McCain’s rationale for the tax credits “is that making major reforms and using government to work through the problem will affect the quality of coverage for Americans—which he called the best in the world.��?

The best health care in the world? McCain has asserted that before and so have other politicians. No doubt we will hear it again. But the evidence says otherwise.

Read the whole piece and see some of her reminders about Clinton's and Obama's less-than-true campaign comments.

On this blog I have been remiss not to weigh in on the recent and ongoing debate over children's health insurance and the SCHIP or State Children's Health Insurance Program.

Not surprisingly, some of the wittiest commentary has come from Jon Stewart and Stephen Colbert. Their segments within the past week should not be missed.

Stewart's coverage on the Daily Show includes a biting commentary from John Oliver.

On the Colbert Report, the host said:

"If we really care for our kids, we should deny them health insurance now to immunize them against expecting it as adults. If we don’t, when they grow up, who knows what other unrealistic things they’re going to expect? You know, if we fund Head Start now, later, they’ll expect education. If we fund school lunches now, later, they’ll expect food."

Who spent more time exploring the issues and looking at the debate: Comedy Central? Or ABC, CBS, NBC, CNN, MSNBC, Fox?

Johns Hopkins University president William Brody, in a speech at the National Press Club on Friday, said journalists are not asking presidential candidates the right questions about health care reform.

“If you’re only reporting cost and coverage issues, you‘re missing a big part of the story,� Brody said.

Brody said that almost no one -- candidates or reporters -- is addressing equally essential elements of the health care puzzle: the quality and consistency of care; the complexity of medical practice today; and the role of chronic disease, the treatment of which threatens to monopolize health care resources. These “three C’s� of health care -- consistency, complexity and chronic disease -- need to be front and center in any reform efforts, Brody said.

“The fact is, cost and coverage solutions alone will not solve our problems,� Brody said. “We can’t provide health insurance for all unless we control the spiraling costs of health care. But we won’t control costs until we deal with these other issues.�

Brody said he will help get the right questions on the table by participating in a planned series of televised conversations with presidential candidates. Brody said that Johns Hopkins is working with the nationally distributed Retirement Living TV network and the National Coalition on Health Care to produce and air Presidential Spotlight on Healthcare ’08: Which Way Forward? during the primary season. In half-hour discussions, Brody will provide the presidential candidates a platform to explain their health care proposals in terms that address all age groups of Americans.

Brody urged reporters and voters to question presidential candidates closely on how they propose to bring rationality and order to what he described as the industrialized world’s most inefficient medical system.

“At The Johns Hopkins Hospital, we have to bill more than 700 different payers/insurers, such as HMOs, PPOs, Medicare and Medicaid,� he said. “Each one has its own set of rules regarding what services are covered, the level of reimbursement, and what kind of documentation and pre-approval is required. Nationally, this kind of inefficiency costs patients billions of dollars every year.�

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.�

Merrill Goozner suggests that the FDA announcement late last Friday afternoon, issuing an official warning against giving cancer patients erythropoietin drugs (Epogen, Procrit, Aranesp) for anemia, was timed to minimize bad news or embarrassment. Goozner writes:

"What struck me most about yesterday's announcement was its timing. It has long been a hallmark of White House public relations staff that the best time to release bad news was late on Friday afternoons. That way, the least number of people will hear about it through traditional news media sources. It's too late to make the Friday evening newscasts; and the print stories usually wind up inside the Saturday papers, which are the least read of the week. (The New York Times story, at least, got mentioned on the front page.)

This late Friday afternoon release shows as much as anything how the culture of the agency has been transformed in recent years from industry watchdog to industry lapdog."

I watched the 6 o’clock TV news on the 3 leading Twin Cities TV stations last night and I give them all an F on covering the President’s visit to the area.

Were issues covered? No.

He met with a health care panel and signed an executive order to make more health care cost and quality information available to consumers.

But the TV newscasts had more silly discussion about traffic jams caused by the Presidential motorcade and Air Force One than there was attention to issues. One station even offered live cut-ins of the president waving as he got back on the plane and then again as Air Force One began to roll on the runway. Wow, that's good and important TV.

Come on! This is the 14th largest broadcast market in the country. And this is the best we can get on substance? On issues?

If this was just a political fundraising trip, why not call it that? If there was no substance to the alleged policy announcements, why not report that?

What value was there in the President’s ideas and in the executive order? Where was the reporting? Was the biggest issue the traffic jam caused by his visit?

I think not, not given rising health care costs, problems of the uninsured, calls for universal national health insurance, questions about integrity in science at the federal level, etc., etc. etc.

Shame on the local media.

(AP Photo)