A leading health policy issue for 2010-11: communicating tradeoffs in screening test decisions

One trend that stands out from 2010 is what I call screening madness. I’m referring specifically and solely to the promotion of screening tests outside the boundaries of evidence and to the emphasis only on the benefits of screening tests with concomitant downplaying or complete disregard for the harms of screening.

Why is this a health policy issue? There are several obvious reasons. If we don’t communicate balanced information on harms as well as benefits of screening tests, we’re probably never going to do so on downstream treatment choice issues. And therein is a pretty big package of the health care economy. Screening people outside the boundaries of evidence could bankrupt the nation in a heart beat.

2010 began where 2009 left off, with an important reflection on the terrible miscommunication that took place after the U.S. Preventive Services Task Force released its new breast cancer screening recommendations late in 2009. A January 2010 commentary in the Journal of the American Medical Association was entitled, “The Benefits and Harms of Mammography Screening: Understanding the Tradeoffs.” Authors Steven Woloshin and Lisa Schwartz wrote:

“..the politicalization of medical care is wrong. Promoting screening irrespective of the evidence may garner votes but will not create healthier voters. It may do the opposite. For instance, in response to the USPSTF recommendation, the US Senate passed an amendment to require insurers to provide free preventive services for women including screenings not only for breast cancer, but also for ovarian, lung, and other cancers. However, even the American Cancer Society does not recommend either ovarian or lung cancer screening because screening tests for both diseases lack evidence of benefit and can cause substantial harm.

Medical decision making about cancer screening is difficult. Some interventions help, but there are always trade-offs. It is essential to remember that the harms are just as real as the benefits.”

Journalists continue to struggle with the breast cancer screening story. When new studies were published in 2010, many stories failed to evaluate the evidence adequately.

It is my belief that the breast cancer episode of late 2009 carried over into 2010 with long-lasting effects that will remain for years.

Dr. Danielle Ofri, associate professor of medicine at New York University School of Medicine, in her “Doctor’s Voice” column on a CNN blog, wrote:

“…the cancer-screening engine rolls on, oblivious to the fact that screening is a nuanced proposition that needs to be considered differently for different groups of patients. … As much as I hate to think about it, there are likely profit motives mixed in. There are all sorts of commercial entities that stand to gain with an aggressive indiscriminate screening message. …Cancer screening is critically important in medicine. But there is a danger that the screening engine in our society is a one-track train, plowing forward, staying “on-message,” not to be bogged down with conflicting data, nuanced reasoning, or messy statistical analyses.”

Our daily review of news coverage in 2010 provided many examples of how journalism often presents an imbalanced view of screening tests.

One news organization didn’t even challenge a researcher’s claim that everyone should be screened for pancreatic cancer – after a study that examined tissue from just seven patients.

Among the problems we found
when we reviewed four competing news stories on a new colon cancer DNA screening test, were these:

• failure to include any independent perspective and using only input from conflicted individuals;
• failure to establish how very preliminary were these findings and that the kind of study that was done tends to overestimate success;
• failure to give any meaningful data-backed comparison of the new test with existing colon cancer screening tests including other blood stool tests;
• use of inflated estimates of how many people don’t get colon cancer screening now – perhaps understandable if journalists got their estimates from conflicted researchers who stand to gain in some way from promotion of these findings and this new test.

The American Cancer Society became quite aggressive in 2010 in correcting journalistic – and public – misperceptions about screening tests. In one case, Dr. Len Lichtenfeld of the ACS asked on his blog, “Does PSA Testing Really Reduce The Risk of Prostate Cancer Recurrence?” Excerpt:

“The headlines are suggesting that the study demonstrates that even though PSA tests don’t necessarily save lives, they do lead to a reduction in cancer recurrence, and therefore are valuable. I am of the opinion that no such conclusion can be drawn from this research. … This is why I emphasize so often that new studies with new thoughts have to go through a process of presentation, review, discussion and criticism. In my personal opinion, promoting this study in the press based on such a basic flaw does a disservice to the men in this country who are faced with a dilemma of trying to decide whether or not PSA screening is right for them.”

In November, after the National Lung Screening Trial results were released, David Sampson, American Cancer Society director of medical and scientific communications, wrote:

“It’s only been a few days since researchers released preliminary results of a major trial of early detection of lung cancer in heavy smokers using CT scans. At the time, the American Cancer Society and others (including the authors themselves) expressed cautious optimism, with emphasis on the cautious, saying that although enormously promising, the data was not enough to call for routine use of this screening test, even in heavy smokers. …But our greatest fear was that forces with an economic interest in the test would sidestep the scientific process and use the release of the data to start promoting CT scans. Frankly, even we are surprised how quickly that has happened.”

ACS chief medical officer Otis Brawley, in a YouTube video, discussed controversies in prostate cancer screening:

“I’m very concerned. There’s a lot of publicity out there – some of it by people who want to make money by recruiting patients – that oversimplifies this – that says that ‘prostate cancer screening clearly saves lives.’ That is a lie. We don’t know that for sure…

…We’re very concerned about a number of clinics that are offering mass screening where informed decision making – where a man gets told the truth about screening and
is allowed without pressure
to make a decision – that’s not happening. Many of these free screening things, by the way, are designed more to get patients for hospitals and clinics and doctors than they are to benefit the patients. That’s a huge ethical issue that needs to be addressed.

We’re not against prostate cancer screening. We’re against a man being duped and deceived into getting prostate cancer screening.”

I wrote about two different ad campaigns in 2010 that, although apparently well-intentioned, fueled fear-mongering about screening tests in my opinion – one by the federal government and one by the American Cancer Society Cancer Action Network. (The latter was pulled after my criticism.)

Some journalists, columnists and bloggers in 2010 took extra steps to educate readers about the tradeoffs between harms and benefits with many screening tests.

The Associated Press touched on the “overselling and overpromising” of colonoscopies.

Amidst some weak reporting on the National Lung Screening Trial, two efforts by journalists at NPR and at the New York Times were strong.

Alan Cassels, a drug policy researcher and author at the University of Victoria, British Columbia, and publisher of the Media Doctor Canada website (sibling to our HealthNewsReview.org site), wrote a column, “Screening for Alzheimer’s: What good can it do?” His conclusion:

“…the drive to ‘screen’ people for Alzheimer’s is not being seriously questioned in the medical community because most people believe strongly in the “test early, test often” paradigm. That paradigm is not working out with mammography and prostate cancer screening and the question we should be asking is “Why should we expect anything different with Alzheimer’s?”

Larry Husten wrote on his Cardiobrief blog about free abdominal aortic aneurysm screening being offered by Medtronic, K-Mart and several medical organizations. He explained that the sponsoring organizations and their members may derive a significant portion of their income from performing AAA repairs and screening. He wrote that widespread screening may not be in the public’s best interest, going on to remind readers that “any screening program and any treatment procedure has both risks and benefits.”

In a guest column in the Washington Post, nurse practitioner Veneta Masson explained why she refused to endorse routine mammography.

Psychiatrist Daniel Carlat blogged about connecting the dots between online depression self-screening tests and pharma funding.

I blogged about several important questions raised about colorectal cancer screening during 2010’s colon cancer awareness month.

I believe that the communication of information about screening tests is – itself – a key health policy issue.

The important DECISIONS study – a nationwide survey of US adults on nine common medical decisions published in 2010 – concluded that:

“Cancer screening discussions across all screening tests (breast, colorectal, prostate) apparently did not routinely meet criteria for informed decision making. Participants reported that health care providers frequently failed to discuss the cons of screening and did not routinely elicit patient preferences. Even when participants reported feeling well informed, they performed poorly in answering knowledge questions and significantly overestimated incidence and mortality risks and the predictive values of PSA tests and mammography.”

In 2011, we will continue our daily efforts to improve health care journalism by providing feedback to journalists and to the public about the messages they send and receive. We will continue to provide workshops for journalists to help them improve their ability to evaluate evidence and to evaluate the myriad claims that come their way every day about treatments, tests, products and procedures.

Even in 300 words, even on deadline, journalists can easily start to insert into their stories that in health care, more is not always better, newer is not always better, and screening tests don’t always make sense for everyone. Stories about screening tests are health policy stories – health care reform stories. Or they should be.

(Thanks to AHLAlerts – the American Health Line blog – for asking me to write about this and for posting a version of this piece on their blog.)

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Kenny Lin, MD

December 28, 2010 at 3:08 pm

Terrific summary, Gary. Kudos to you for continuing to be a voice of caution and restraint about screening tests that “work” (i.e. are USPSTF-recommended) and especially those that either don’t or about which there’s reasonable doubt of effectiveness.

Joseph P. Arpaia, MD

December 29, 2010 at 11:12 pm

I went into medicine because I wanted to help people become healthier. To my dismay what medicine seems to be becoming is the practice of convincing people that they are sick, and then administering all manner of patent medicines or procedures to relieve their iatrogenic illnesses.