Dr. Val Jones' Get Better Health site wrapped up our entire thread of posts on the American Cancer Society Cancer Action Network ad campaign - from our original criticism through to Newsweek joining the analysis and on to ACS CAN pulling the ad.

On the Retraction Watch blog:

"Kudos to Schwitzer for having an impact and reminding the ACS that data must drive our health care decisions and spending.The episode is a good reminder that blogs can have an impact."

Lots of Twitter action on the topic.

Mary Carmichael of Newsweek wrote:

"Wow! ACS shows real class. Kudos all round."

Journalist Bill Heisel (a reviewer on HealthNewsReview.org) wrote:

"Stunning example of pen > sword."

Physician-writer Ben Goldacre of the UK tweeted:

"Overstated cancer screening ad gets pulled after excellent blog post by @garyschwitzer."

Of course, there are also many online comments left by readers - after each of our blog entries on this topic, on the Newsweek site's blog post, and on MedPageToday.com, which is also re-posting our work. Not all of the comments agree with our stance - although most do. Regardless, we need to have a better public discussion about what's incomplete and unhelpful about vague messages like the "Screening is Seeing" campaign conveyed. I know that some parties within the American Cancer Society agree with me and I would look forward to working with them in trying to improve these messages in the future.

But, as Mary Carmichael pointed out, ACS - or its arm of ACS CAN - took the right first step by pulling the ad.

Now let's take a deep breath and try it again.

A national spokesperson for the ACS CAN office confirmed late today that the "Screening is Seeing" ad that I criticized on this blog yesterday has now been pulled.

The spokesperson said, "It would be unfortunate if, in trying to raise awareness about this critical issue, a brief, powerful message in the ad became the story rather than the issue itself."

It has become clear to me within the last 24 hours that the ad was not universally embraced within the American Cancer Society and that there was significant agreement with the stance I took in criticizing the ad.

More to come on this as it becomes available.

Since I posted a note earlier this week about Larry Husten's fine journalism on Cardiobrief.org regarding the SHAPE (Society for Heart Attack Prevention and Eradication) cardiovascular screening guidelines, I'm now posting a link to his followup story. Excerpt:

"Earlier this week we reported that SHAPE was preparing to update its controversial guidelines. It now appears that the guidelines are only the public facade of a larger program designed to encourage the growth of, and take a larger share of, the business of cardiovascular screening. Although conflict-of-interest concerns have previously swirled around SHAPE, new evidence suggests that the non-profit organization has aligned itself with a commercial venture, and presumably stands to benefit from the success of these projects."

If you're interested (as I think you will and should be), please go the link above to read Larry's full story.

Today on this site we've reviewed three stories that made claims about a new Alzheimer's Disease test. Each was far less than what it could have been. Here are the reviews, for your convenience:

• New York Times story review
• WebMD story review
• Reuters story review.

Also today I blogged about my concerns over a new American Cancer Society ad campaign, "Screening is Seeing."

It strikes me that there's a common theme between what was missing in the Alzheimer's test stories and what bothered me about the ACS screening ad.

One of our story reviewers, journalist Andrew Holtz, wrote to me after reviewing the three Alzheimer's stories:

"One general comment is the responsibility of journalists to word stories in a way that avoids lazy assumptions that "it's better to know." Not only do the results of this study document how many false positives this test would produce if used in isolation. Identifying someone as having (or likely to develop) an untreatable condition is likely to create great mischief while providing a benefit in only very specific circumstances."

Granted, the Cancer Society ad wasn't about untreatable conditions. But it did promote the broad, vague "it's better to know" concept, drumming that into consumers minds once again.

Holtz writes about "providing a benefit in only very specific circumstances." Messages about screening also need to be specific - for specific audiences for whom the evidence is clear. Otherwise the messages may encourage screening in populations for whom the uncertainties mount, and for whom the potential harms may start to stack up with the potential benefits.

Sometimes you just need to step back, connect the dots, and see the firehose of "screen, screen, screen...test, test, test" messages that deluge the American public. And realize there has to be a better way.

Addendum 4:20 pm Central time 8/11: Mary Carmichael of Newsweek built on my criticism of the ACS ad campaign and improved on it by creating a mock counter-ad. Get the message, ACS?

A well-intentioned ad campaign run by the American Cancer Society is too vague, and, therefore, may leave impressions that are imbalanced, incomplete and unsubstantiated - the kind of common tactic seen in many drug company ads.

That's my opinion based on my analysis of the ad and based on my reading of the text.

A Cancer Society news release states:

The American Cancer Society Cancer Action Network (ACS CAN) is launching a new print and online advertising campaign in congressional districts across the country this week, urging lawmakers to fully fund a lifesaving cancer prevention, early detection and diagnostic program that is celebrating 20 years of screening low income, uninsured, and medically underserved women for breast and cervical cancer. The ads also send the message that when it comes to increasing your odds of surviving cancer, access to evidence-based early detection tools is critical.

The ads reference the Centers for Disease Control and Prevention's (CDC) National Breast and Cervical Cancer Early Detection Program (NBCCEDP), which has a track record of reducing deaths from breast and cervical cancer. The program has provided more than 9 million screening exams to more than 3 million women and diagnosed more than 40,000 cases of breast cancer and more than 2,000 cases of cervical cancer since it launched in 1990. But with limited funding, the program is able to serve fewer than 1 in 5 eligible women.

The accomplishments of the CDC NBCCEDP are noteworthy. So this blog entry is no knock on that program.

It's a criticism of the ad.

There is no specific mention of the specific goals of the CDC NBCCEDP. The ad doesn't state what the news release states that this is promoting "20 years of screening low income, uninsured, and medically underserved women for breast and cervical cancer."

Instead, the ad promotes unspecified screening - all screening, one could infer. "We can't fight cancer if we can't see it....When it comes to cancer, screening is seeing...It's time to take the blindfolds off and stop cancer before it starts." Catchy phrases from an ad agency or from someone creative at the Cancer Society. But are we talking about prostate cancer screening? Lung cancer CT scan screening? Ovarian cancer screening? Show me where it does NOT say that. And show me where it DOES say this was about breast & pap smear screening for medically underserved women?

But this is a fund raising and political message: "current funding isn't enough...tell your members of Congress (to) increase funding..."

And when you're raising funds, a little vague fear-mongering can't hurt, right?

Wrong.

One other piece of copy from the ad demands scrutiny: "60% of cancer deaths could be prevented." The implication is that's all from screening because screening is the only prevention method mentioned in the ad. Nothing about stop smoking or other lifestyle changes. If the ad meant to imply that 60% of cancer deaths could be prevented just from screening, it should provide the evidence for that. If the ad did not mean to imply that, but was just misleadingly vague, then I call for the ACS to pull this ad. In either case, I think they have a problem.

That unsubstantiated 60% figure is especially ironic since the ACS news release includes this line: "Access to evidence-based prevention is just one component of the fight to defeat cancer." We needed a little more clear evidence here - evidence that would show that screening is just one part of prevention.

Earlier this summer I criticized a federal agency's vague screening promotion ads. I'll end this note in a fashion similar to the way I ended that note:

I know that the folks at the American Cancer Society (or their ad agency) had their hearts in the right place with this campaign. But their heads have to do a better job of learning how to communicate about screening. Or else they'll be guilty of the same disease-mongering techniques that are so prevalent in so many other messages in general circulation these days. The worried well are constantly whipped into a frenzy over the supposed weapons of mass destruction inside all of us. As a physician-colleague reminded me: "All screening tests cause harm; some may do good as well."

You'd never know it from the ACS ad. But then again, it's "only" a fundraising ad, right?

We do a lot of colonoscopies in this country, looking for colon cancer. And that's a good thing.

But do people realize that 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)? It's an inexpensive (about $20) at-home test kit that often seems to get lost in the enthusiasm for in-office higher-tech procedures like standard colonoscopy - or its new sibling, virtual colonoscopy.

This week, a study in Health Affairs reminds us about the relative benefits of FOBT. And it's about time. Kaiser Permanente in California thinks highly enough about FOBT that it mails test kits to subscribers to use at home. From a public health perspective - trying to reach as many people as possible with a cost-effective approach - it sure seems to make sense.

Katie Hobson writes about this study on the Wall Street Journal health blog and includes links to the Health Affairs study and to a MedPageToday.com story, "Virtual Colonoscopy Misses Mark on Cost." See Katie's story and visit those links if you're interested in learning more.

Meantime, one message for journalists is to include a discussion of FOBT whenever discussing colon cancer screening. It seems incomplete and imbalanced not to do so.

And a possible message for consumers (although we don't give medical advice on this blog), ask your physician about FOBT whenever other colon cancer screening methods (e.g., colonoscopy, flexible sigmoidoscopy) are brought up.

Why NOT talk about the evidence for (or against) FOBT?

I've spoken and written about the imbalance in the news coverage about the U.S. Preventive Service Task Force's new guidelines on mammography last November.

If stories and communications are going to use anecdotes, then for every anecdote about a woman who claims her life was saved by a mammogram in her 40s (something that can't be proven), there should be a countering anecdote with a woman who had a mammogram in her 40s and got a diagnosis of DCIS or ductal carcinoma in situ.

Well the New York Times nailed that story this week, under the headline, "Prone to Error: Earliest Steps to Find Cancer."

I'll only offer the link and will post only this one excerpt:

"Diagnosing D.C.I.S. "is a 30-year history of confusion, differences of opinion and under- and overtreatment."

Everyone should read this story in its entirety.

It covers what was missing too often in the discussion about mammography screening last November. There are tradeoffs of harms and benefits. There is a need for fully informed shared decision-making in the face of this diagnosis. This story makes that clear. Much of our public discussion has not.

The winding stream of science.

Last week the journal Pediatrics published a study promoting universal cholesterol screening for kids. This week's Pediatrics publishes a study with a quite different perspective.

Reuters Health reports:

Very high cholesterol levels in kids may decline over time even without intervention, researchers from the U.S. Centers for Disease Control and Prevention (CDC) have found.

The findings add to an ongoing debate over the importance of high cholesterol in children, and whether cholesterol-lowering drugs are appropriate when changes in diet and physical activity don't cut it.

Such drugs, including statins, are used in adults to reduce the risk of heart disease, a major killer in Western countries. But it isn't clear if they also work for kids.

The new study, published in the journal Pediatrics, shows that after a few years, some youngsters with high cholesterol would no longer be considered for drug treatment according to guidelines.

While this isn't an argument to abandon drug therapy altogether, doctors shouldn't jump the gun when treating kids for cholesterol, the researchers caution.

"Both in kids and in adults there is quite a bit of variability over time," David S. Freedman of the CDC told Reuters Health. "People with very, very high cholesterol are likely to be those that are having a bad cholesterol day."

My thanks go out to reviewers of the three stories on kids and cholesterol screening this week. Here are links to all three stories. It's not easy comparing three stories like this. And after it was over, two of the reviewers had more to say than what may have come across in the reviews.

Reviewer Andrew Holtz, a journalist with MDiTV.com, wrote to me afterwards:

"If an editor decides to report the story, then the news organization should boldly and clearly tell readers that the real question is what to do when the test result is a matter of debate among experts. After all, how much difference does it make whether cholesterol screening of children is catching 2/3 or almost all kids with elevated cholesterol, when we don't know whether treating these children offers them a health benefit? Unfortunately two out of three of these stories just highlighted the process argument about how to increase the yield of the screening program without addressing the basic question about how to respond to test results.

I don't give much credit to the stories for pointing out that lifestyle changes are suggested before resorting to drug treatment. Why would you need a cholesterol test in order to advise better diet and more physical activity for kids? My understanding of the research on adults is that cholesterol test results have a very weak effect on changing behavior. And again... everyone should be helped to have a healthier lifestyle regardless of cholesterol levels, so the tests really only have value if there is a medical intervention that is likely to provide a health benefit...which, as only the Reuters story points out, there simply isn't the evidence to support.

If I were assigned this story, my question to the researchers and others would be: West Virginia has had universal cholesterol screening of children for a number of years. Is there any evidence that the expanded testing has had an effect on the health of the children? If not - and given that there are studies indicating that there may not be a clear benefit to treating children with cholesterol-lowering drugs - how do these doctors justify the leap to their conclusion that universal testing would be beneficial?"

And Dr. Michael Pignone of the University of North Carolina wrote:

"I don't think some editors know to ask these questions because they don't know that the underlying paradigm (early is always better; more information is always better) is not always true.

As another example worth pursuing, look at Gardiner Harris' reporting on Avandia in the NYT this week. He has done some great investigative work, but it keeps being directed to whether Avandia may cause more heart attacks than Actos, another drug from the same (TZD) class. What is missed in these stories is that ALL drugs in this class cause fluid retention that leads to heart failure (or heart failure-like) syndromes and that the risk of that adverse effect is quite a bit larger, not controversial, and is enough reason to not use these expensive drugs when cheaper and better alternatives (certainly metformin, maybe others) are available."

This gives you a glimpse of how seriously our reviewers take the job of reviewing news stories. I welcome their additional thoughts, and yours, if you care to comment.

Headlines every day in the New York Daily News are luring men in as part of a mass prostate cancer screening campaign which the American Cancer Society not only does not endorse - its chief medical officer recommends against. Yet the paper brags that it is beginning its second decade of this non-evidence-based campaign. Sample headlines:

• Doctors urge New York men to take advantage of free, city-wide PSA testing

• What you don't know can kill you. Get a FREE prostate cancer test. It can save your life

• Bring dad in for FREE prostate cancer test across the city on Father's Day

and

• Don't skip the PSA test! My prostate cancer is treatable because simple test caught it early (written by a Daily News staffer).

Meantime, as I wrote one year ago when the Daily News promoted this campaign:

Either the paper doesn't realize or doesn't care that:

* The American Cancer Society does not support routine testing for prostate cancer at this time and specifically recommends AGAINST such mass screenings.

* The US Preventive Services Task Force and the American Academy of Family Physicians state that "Current evidence is insufficient to assess the balance of benefits and harms of screening for prostate cancer in men younger than age 75 years."

* No major group - except urologists - recommends starting screening as early as this newspaper does - starting at age 40. And that urology group's thinking is the source of major controversy.

That's a huge public responsibility for a newspaper to take on - especially when it conflicts with medical evidence.

Before being screened, what did the newspaper inform men about the tradeoff of harms and benefits? On the American Cancer Society website, its president, Dr. Otis Brawley says:

"There are some proven harms associated with screening. Screening, for example, leads to unnecessary treatment in some men who are diagnosed with localized disease.

It is difficult to comprehend, but there are prostate cancers that are confined to the prostate and never destined to metastasize (spread to other parts of the body). Screening diagnoses a large number of men who would never be bothered by the disease. In one clinical trial, more than 12% of average risk men were diagnosed through screening over 7 years. This group of men is estimated to have a lifetime risk of death of less than 4%. This study suggests that 2 out every 3 men in this study did not need to be diagnosed nor treated. While this study suggests that the proportion of men in the overall population who are diagnosed with cancers that do not need therapy is as high as 67% of men with localized disease, others estimate it to be as low as 30%. We have very poor ways of predicting who needs treatment because their prostate cancer might kill them, and who does not need therapy because their tumor is of no threat to them."

It's not just a simple blood test, as it is so often promoted. That's why Dr. Brawley says:

"Many health care provider organizations and many well-meaning community groups encourage prostate cancer screening and offer mass screening at health fairs and other activities. The American Cancer Society is concerned that so many do not understand that the benefits of screening are still undetermined. The ACS recommends against such mass screening activities because one cannot be assured that the patient has the opportunity to hear a balanced explanation of screening in an environment in which he can feel comfortable to ask questions and make an informed decision."

Even more to the point of the newspaper's promotion and advertising of this mass screening, Brawley wrote in an editorial in the Journal of the National Cancer Institute:

"I heard a radio commercial that brings perspective to the issue. A local celebrity was promoting prostate cancer awareness. He said, "Prostate cancer is 100% curable when caught early." He encouraged all men to get screened and announced that a van was touring the area offering screening in supermarket parking lots. This was a community service project sponsored by the radio station, the supermarket chain, and a radiation oncology practice.

A commercial like this plays to our fears and prejudices. ...

Prostate cancer screening has resulted in substantial overdiagnosis and in unnecessary treatment. It may have saved relatively few lives. ... The benefits of prostate cancer screening are still open to question. This means that informed or shared decision making should be done using the data now available before screening is performed. Some of the confusion of prostate cancer screening can be avoided if we all clearly label what we know, as what we know; what we do not know, as what we do not know; and what we believe, as what we believe. Of course, one must not confuse what is believed with what is known to do this."

First, let me emphasize that I believe that the US Agency for Healthcare Research and Quality (AHRQ) was well-intentioned with its new "just in time for Father's Day" ad campaign, described by the Wall Street Journal's Laura Landro, who reports:

"A darkly humorous ad campaign being launched this week aims to tackle the serious issue of an aging generation of men in denial of their health risks.

In one TV spot, a family is gathered in their new house with the real-estate broker, who predicts they will have many happy years there. "Except for you," she says to the dad, "because you'll be gone three years from now...struck down by the same disease that got your father."

In a parting shot the broker adds: "Sadly, it could have been detected early with a simple test....but you didn't have it."

Now I know that viewers are directed to an AHRQ website where only evidence-based recommendations will be made - say, for example, for blood pressure screening. So you won't see wholesale endorsement of prostate cancer screening because of the uncertainties surrounding the benefits vs. harms of that test in a general population.

But the ads don't say that.

They leave the vague impression of being "struck down by the same disease that got your father." And "Sadly, it could have been detected early with a simple test."

Readers of this blog - and of anything with any substance to it concerning screening tests - know that there's almost no such thing as "a simple screening test."

As a physician-colleague reminded me: "All screening tests cause harm; some may do good as well."

Here's another TV ad in the campaign:

I know that AHRQ and the Ad Council had their hearts in the right place with this campaign. But their heads have to do a better job of learning how to communicate about screening. Or else they'll be guilty of the same disease-mongering techniques that are so prevalent in so many other messages in general circulation these days. The worried well are constantly whipped into a frenzy over the supposed weapons of mass destruction inside all of us.

Maybe feds' ad campaigns should go for a little less dark humor and a few more plain facts.

This is all so ironic because the AHRQ recommendations are based on the same US Preventive Services Task Force recommendations that so many Americans seem so uninformed about - including the breast cancer screening recommendations published last November that led some misguided observers to say that the task force didn't care about some women's lives.

The feds didn't communicate those recommendations very well and the new ad campaign almost swings the pendulum too far in the other direction.

That's my opinion.

Re-write or re-do, AHRQ?

Reuters reports on a study in the current Archives of Internal Medicine that shows that:

"...after the U.S. Congress had mandated Medicare coverage of a digital tool to help detect breast cancer, health providers were quick to pick it up even though it hadn't showed clear-cut benefits for the women.

The technology, known as computer-aided detection, costs more than $100,000 to install, according to the researchers...

"It illustrates a bigger problem that exists in our society, where the rails are really greased to get new technologies into practice before we are sure that they are safe," Dr. Joshua J. Fenton, who led the study, told Reuters Health.

"There is no evidence that the use of computer-aided detection reduces breast cancer mortality," he added.

A commentary by Dr. Karla Kerlikowski in the same journal calls for "evidence of benefits outweighing harms before implementing new technologies." Excerpt:

Why do new technologies get disseminated so quickly when evidence is incomplete and/or conflicting? One explanation is that the focus of evaluating new diagnostic tests is on providing evidence to support improved or at least equal benefit of the technology with much less attention to the potential harms of new technologies prior to dissemination. In other words, the benefit of the new technology compared with existing technologies is examined but not necessarily whether the potential benefit of the new technology outweighs the harms of the test. In addition, the designs of comparative studies are often maximized to measure the added benefit of the test to detect disease compared with standard tests rather than assessing effectiveness in community practice on important clinical outcomes. Lastly, there are several forces that may encourage the rapid adoption of new technologies, including investigators with professional interests, technology companies with financial investments, lobbyists with vested interests, and a public convinced that new advanced technology is always better.
...
Health care providers and individuals cannot presume that newer technologies are better than existing ones without actual data to that effect. Health care providers should not adopt new technologies without first demanding scientific evidence beyond that required for FDA approval. They need to ask how strong and consistent is the evidence for new technologies and whether the evidence shows an important clinical benefit, whether there are important harms, and whether the benefits outweigh the harms. To be responsible advocates for high-quality medical care, our enthusiasm for new technologies should not replace strong, consistent evidence that the benefits of the new technology outweigh the harms in a clinically important way.

Finally, in another commentary in the journal, this one by Dr. George Sawaya on the attempt to reduce harms of cervical cancer screening "by setting appropriate lower and upper age limits for screening and avoiding too-frequent testing among average- and low-risk individuals," harms are another key focus:

To move forward, clinicians and patients must first be more cognizant of screening harms in all its forms, and studies must be designed to measure not only the likelihood of benefit with various screening strategies but also the likelihood of harm. Second, comprehensive and integrative methods must be identified and used to determine an appropriate balance between benefits and harms that seems reasonable to a variety of stakeholders. Finally, the rationale behind screening guidelines designed to maximize benefits and minimize harms must be clearly communicated to everyone.

While the "less is more" argument may never be convincing to many stakeholders in cancer screening, its rationale should resonate with many clinicians steeped in the tradition of doing no harm.

Here we go again.

The big annual conference of the American Society of Clinical Oncology meeting is still weeks away. But last week ASCO held a news briefing in which it selected six out of more than 4,000 abstracts posted online in advance of the meeting.

6 out of 40,000.

Predictably, journalists started reporting on those posted abstracts and especially on the ones highlighted in the briefing, even though:

• they haven't been peer reviewed

• it's difficult to get informed second opinions from other experts when the full data haven't been presented, much less published
• the abstract may reflect unfiltered optimism for an unvetted claim.

One ASCO headline was entitled, "Promising New Ovarian Cancer Screening Strategy" building on the CA-125 blood test.

The Houston Chronicle (whose story was reviewed by us) at least injected one note of caution from the American Cancer Society's Dr. Len Lichtenfeld, who said, "More research and refining needs to be done before it should be implemented. I can remember when doctors all rushed to adopt the Prostate Specific Antigen test, and we still don't know how to use it."

And on his own blog, Dr. Len wrote:

"Before we get too excited, let's take a step back and realize that we still have a long way to go before we have an effective screening test for the early detection of ovarian cancer in women at average risk. More studies need to be done, and in fact the authors of the current report stress that they plan to move forward with those studies, including examining other tumor markers to see if they help improve the results of the current program.

We have a tendency in this country to hear news about "new science" and believe that it provides all of the answers. We tend to discount the limitations of our science and knowledge, especially when it comes to making a devastating cancer curable. Such has been the case with prostate cancer over the past 20+ years, where it has taken us that long to find out that the PSA test--although it may prevent deaths from prostate cancer--may not be as perfect as we once thought.

Let's not make the same mistake with ovarian cancer. Is there reason to be encouraged? Absolutely. But there is still a long road to travel before we validate the concept that CA-125 is in fact the answer to our prayers for the early detection of this devastating disease."

That didn't stop Bloomberg news from posting a story under this headline: "Blood Test for Early Ovarian Cancer May Be Recommended for All."

And there was a lot of other hyperbole in other stories by other news organizations.

Once again, some journalists seem to fall in love with screening stories - evidence be damned.

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.

Gil Welch and Bill Black of Dartmouth address cancer overdiagnosis in a new review article in the Journal of the National Cancer Institute. Excerpt from the abstract:

"We estimated the magnitude of overdiagnosis from randomized trials: about 25% of mammographically detected breast cancers, 50% of chest x-ray and/or sputum-detected lung cancers, and 60% of prostate-specific antigen-detected prostate cancers. We also review data from observational studies and population-based cancer statistics suggesting overdiagnosis in computed tomography-detected lung cancer, neuroblastoma, thyroid cancer, melanoma, and kidney cancer. To address the problem, patients must be adequately informed of the nature and the magnitude of the trade-off involved with early cancer detection."

Before we close out colon cancer awareness month, I want to draw attention to another important paper in the journal Gastroenterology, "Understanding differences in the guidelines for colorectal cancer screening," by Thomas Imperiale and David Ransohoff. (subscription required, published online March 16 ahead of print).

The authors start with the broad message that guideline-setting in general is of such concern that the Institute of Medicine has formed a committee "to develop standards (that) ensure that clinical practice guidelines are unbiased, scientifically valid and trustworthy." They remind readers that:

"The problem of varying quality is highlighted by the fact that there are nearly 300 guidelines-making organizations that have created over 2300 guidelines in a process described as "essentially unregulated."

But their focus was on colorectal cancer screening guidelines, and specifically different updates issued by two major guidelines organizations in 2008:

• The "multi-society" guidelines issued jointly by subspecialists in cancer prevention, gastroenterology and radiology.

• The US Preventive Services Task Force.

The authors focus on the first group's "preference for tests that image the colon" - especially colonoscopy.

The authors say that the USPSTF, on the other hand, "considered several strategies to be similar in terms of years of life saved and reduction in colorectal-specific mortality," including colonoscopy and less expensive blood stool tests. The USPSTF stated no preference among methods. But the USPSTF did not share the multi-society group's endorsement of newer virtual colonoscopy and fecal DNA testing.

These are significant differences, according to the authors:

"The current differences in CRC screening guidelines raise practical questions not only about what doctors and patients should do in the face of disagreement, but also about the larger process by which guidelines are made and how "trustworthy" they may be.
...
Further, the potential for conflict of interest is real when subspecialists support or recommend procedures from which they derive income is real; that conflict should be acknowledged and managed rigorously. Conflict may be not only financial; it may also be intellectual, when professional enthusiasm causes one to favor what one has learned to do and knows best."

I encourage journalists to find and read the full Imperiale/Ransohoff paper.

Gastroenterology. 2010 Mar 16. [Epub ahead of print] Understanding differences in the guidelines for colorectal cancer screening.

Imperiale TF, Ransohoff DF.

Division of Gastroenterology and Hepatology, Department of Medicine,
Indiana University School of Medicine, Indianapolis, IN; Regenstrief
Institute, Inc., Indianapolis, IN.

PMID: 20302867 [PubMed - as supplied by publisher]

And I encourage them to be aware of the Institute of Medicine's review of guideline setting. Many "awareness month" campaigns are far too simplistic and incomplete and may, indeed, mislead consumers in the certainty they seem to convey. This is far from a certain field at this point in time.

Here are some recent posts raising important questions about what we know and don't know about colon cancer screening:

http://www.healthnewsreview.org/blog/2010/03/kaiser-takes-blood-stool-test-kit-campaign-to-youtube.html

http://www.healthnewsreview.org/blog/2010/03/colon-cancer-awareness-month-often-means-claims-but-no-evidence.html

http://www.healthnewsreview.org/blog/2010/03/memo-to-harry-smith-cbs-news-re-colonoscopy-crusading.html

http://www.healthnewsreview.org/blog/2010/03/journal-editor-troubled-by-obamas-ct-scan-for-coronary-calcium-virtual-colonoscopy.html

http://www.healthnewsreview.org/blog/2010/02/the-overselling-and-overpromising-of-colonoscopies.html

http://www.healthnewsreview.org/blog/2010/02/what-reporters-missed-at-the-nih-colon-ca-screening-state-of-the-science-conference.html

There's been surprisingly little coverage of an analysis by the Nordic Cochrane group in this week's BMJ that concludes:

"We were unable to find an effect of the Danish screening programme on breast cancer mortality. The reductions in breast cancer mortality we observed in screening regions were similar or less than those in non-screened areas and in age groups too young to benefit from screening, and are more likely explained by changes in risk factors and improved treatment than by screening mammography."

Of the stories I could find, Andre Picard of The Globe and Mail had one of the better reports, including a quote from one of the researchers:

"We have to start asking unpleasant questions about mammography screening."

Dr. T.R. Levin, a gastroenterologist at Kaiser Permanente Medical Center in Walnut, Creek, California, has a YouTube video on Kaiser's widespread use of blood stool test kits for colon cancer screening. Click here to see the video.

Reporters all over the country had been sent an announcement about a revolutionary colon cancer blood test.

Well, Katie Hobson of US News & World Report checked it out and reports that the claims are long on hype but short on proof.

Yet, she writes, "a company press release issued on December 14 begins by stating that 'embarrassing and sometimes uncomfortable colonoscopies may soon be a thing of the past.' "

This is how it goes in health care marketing these days: feed the worried well with the promise of more screening tests that are easier to do.

Meantime, Sharon Begley of Newsweek sends her kudos to us for our recent posts on colonoscopy questions. Thanks, Sharon. Just doing our job.

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 done your 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?

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.

Here's another problem with the practice of TV networks using physician "contributors" to comment on health care news. They may have a clear conflict of interest that is not addressed.

When the American Cancer Society released its updated guidelines on prostate cancer screening today, Fox News reported:

"Dr. David Samadi, a Fox News contributor and chief of Robotics and Minimally Invasive Surgery at Mount Sinai School of Medicine in New York City, said he thinks the new guidelines could cause unnecessary deaths.

"In my practice, we find men in their 30s and 40s that are at high-risk and develop prostate cancer," Samadi said.

"Knowing your PSA is power, it is educational; you follow it all the time. You can find a silent prostate cancer that will not affect you, and there is a possibility to over-diagnose, but that's a risk the patient needs to take. You could also find cancer that could lead to death."

The number of prostate cancer deaths continues to decline because of regular screening, Samadi added.

"I really recommend (the age) of 40 as a baseline age," Samadi said."

Doesn't Fox see that he has a blatant conflict of interest on this topic as one who runs a robotic surgery center? There are countless ways to counter these short quotes from Dr. Samadi, but I'm not going to run through them here. Read the Cancer Society report and you'll find all of them there - in dispassionate, non-conflicted, evidence-based depth.

Look at how Katie Hobson of US News & World Report included an expert urologist's input, and one with a much more open-minded and balanced perspective.

"... the gist of all this is a firm end to the notion, still held by some clinicians, that screening for prostate cancer is "the same as colorectal cancer screening or cholesterol screening," says Durado Brooks, director of prostate and colorectal cancers for the ACS and coauthor of the report.

"There has to be a conversation," says John Davis, assistant professor in the department of urology at the M. D. Anderson Cancer Center in Houston. "And these guidelines give some very nice bulleted points and Web links you could build into an information sheet and give to patients."

The American Cancer Society has just released updated guidelines on prostate cancer screening.

Because of the uncertainties of benefits vs. harms of such screening, the ACS puts a new emphasis on shared decision-making and on the use of patient decision aids to help men.

Excerpts from ACS statements released today:

"As it has since 1997, the American Cancer Society advises against a general recommendation for men to undergo screening, instead saying testing should only occur when a man is provided the opportunity to learn about the limitations and potential benefits of screening and treatment.

...The guidelines now outline the uncertainties regarding the balance of benefits and harms associated with screening. They clearly state that every man should be told of the uncertainties, risks and potential benefits of screening, and that no man should be tested without receiving this information."

On the problems with big community screening events:

"The American Cancer Society discourages participation in community-based prostate cancer screening programs unless those can adequately provide for an informed decision-making process and appropriate follow-up. For men who have limited or no access to other sources of care, community-based screening programs may provide the only opportunity to make an informed decision about testing. Men who are contemplating screening through these programs should first receive high-quality objective informed decision-making, either through interaction with trained personnel, or through the use of validated, high-quality decision aids, appropriate to the target population. Since virtually all men age 65 years and older have health insurance through Medicare, they should be discouraged from participating in community-based screening programs, and should be referred to a primary care provider."

The Foundation for Informed Medical Decision Making (disclosure: they support this HealthNewsReview.org project) posted a video clip with its president, Dr. Michael Barry, reinforcing the shared decision-making message.

For now, the Foundation's shared decision-making program on prostate cancer screening can be seen online. Check it out.