Gary talks about health care media messages on Garage Logic radio show

Gary Schwitzer

December 9, 2013 at 3:22 pm

Laurence,

For one who appears to criticize many of the things that I publish, you are terribly uninformed about our work.

And I’m going to repeat some things I’ve written to you before:

• I currently have no help on this site. I can’t do everything. And I can’t respond to every comment you leave on the site. But I’m not going to post inaccuracies left by you, either. So, in the future, I may not post what I know is wrong but what I don’t have time to respond to.

• Even without any funding, and even though I’m doing this by myself, we review more health care media messages than any other such “watchdog” effort in the US and perhaps anywhere. If that’s not meeting your needs, you may wish to look elsewhere. Or start your own blog.

Now, to your comments:

First, anyone who reads my blog must have read something about the harms of screening tests. I’ve written about them dozens of times. But, to try to bring you up to speed on what you’ve evidently missed in what I and many others have written about the harms of screening, here is what the US Preventive Services Task Force says about breast cancer screening harms:

The harms resulting from screening for breast cancer include psychological harms, unnecessary imaging tests and biopsies in women without cancer, and inconvenience due to false-positive screening results. Furthermore, one must also consider the harms associated with treatment of cancer that would not become clinically apparent during a woman’s lifetime (overdiagnosis), as well as the harms of unnecessary earlier treatment of breast cancer that would have become clinically apparent but would not have shortened a woman’s life. Radiation exposure (from radiologic tests), although a minor concern, is also a consideration.

Adequate evidence suggests that the overall harms associated with mammography are moderate for every age group considered, although the main components of the harms shift over time. Although false-positive test results, overdiagnosis, and unnecessary earlier treatment are problems for all age groups, false-positive results are more common for women aged 40 to 49 years, whereas overdiagnosis is a greater concern for women in the older age groups.

There is adequate evidence that teaching breast self-examination is associated with harms that are at least small.

And here is what the USPSTF says about prostate screening harms:

Harms Related to Screening and Diagnostic Procedures

Convincing evidence demonstrates that the PSA test often produces false-positive results (approximately 80% of positive PSA test results are false-positive when cutoffs between 2.5 and 4.0 ?g/L are used). There is adequate evidence that false-positive PSA test results are associated with negative psychological effects, including persistent worry about prostate cancer. Men who have a false-positive test result are more likely to have additional testing, including 1 or more biopsies, in the following year than those who have a negative test result. Over 10 years, approximately 15% to 20% of men will have a PSA test result that triggers a biopsy, depending on the PSA threshold and testing interval used. New evidence from a randomized trial of treatment of screen-detected cancer indicates that roughly one third of men who have prostate biopsy experience pain, fever, bleeding, infection, transient urinary difficulties, or other issues requiring clinician follow-up that the men consider a “moderate or major problem”; approximately 1% require hospitalization.

The USPSTF considered the magnitude of these harms associated with screening and diagnostic procedures to be at least small.

Harms Related to Treatment of Screen-Detected Cancer

Adequate evidence shows that nearly 90% of men with PSA-detected prostate cancer in the United States have early treatment with surgery, radiation, or androgen deprivation therapy. Adequate evidence shows that up to 5 in 1000 men will die within 1 month of prostate cancer surgery and between 10 and 70 men will have serious complications but survive. Radiotherapy and surgery result in long-term adverse effects, including urinary incontinence and erectile dysfunction in at least 200 to 300 of 1000 men treated with these therapies. Radiotherapy is also associated with bowel dysfunction.
Some clinicians have used androgen deprivation therapy as primary therapy for early-stage prostate cancer, particularly in older men, although this is not a U.S. Food and Drug Administration (FDA)–approved indication and it has not been shown to improve survival in localized prostate cancer. Adequate evidence shows that androgen deprivation therapy for localized prostate cancer is associated with erectile dysfunction (in approximately 400 of 1000 men treated), as well as gynecomastia and hot flashes.

There is convincing evidence that PSA-based screening leads to substantial overdiagnosis of prostate tumors. The amount of overdiagnosis of prostate cancer is of important concern because a man with cancer that would remain asymptomatic for the remainder of his life cannot benefit from screening or treatment. There is a high propensity for physicians and patients to elect to treat most cases of screen-detected cancer, given our current inability to distinguish tumors that will remain indolent from those destined to be lethal. Thus, many men are being subjected to the harms of treatment of prostate cancer that will never become symptomatic. Even for men whose screen-detected cancer would otherwise have been later identified without screening, most experience the same outcome and are, therefore, subjected to the harms of treatment for a much longer period of time. There is convincing evidence that PSA-based screening for prostate cancer results in considerable overtreatment and its associated harms.
The USPSTF considered the magnitude of these treatment-associated harms to be at least moderate.

I really shouldn’t have to post this for you. You can look up either of these statements. They are available free and in great detail for anyone to read online. You can find evidence-based statements about the harms of many other forms of screening as well.

On the radio program you admit you listened to incompletely (“almost all”), you may have heard the part in which I cited evidence for what we’ve seen in 1,900 systematic story reviews. The media sources we reviewed when we had funding to do so (I currently have no funding and have discontinued this part of our publication) are listed at https://www.healthnewsreview.org/about-us/how-we-rate-stories/ – see “Which news organizations are reviewed.”

We can’t review all news sources. We couldn’t even do that when we had full funding. I certainly can’t do it now. So, no, we did not regularly review The New Yorker or Men’s Health or The Economist or several hundred other publications you could cite. You certainly have lots of ideas, so if you have the wherewithal, I would encourage you to start a news review website of your own that could take on the entire universe of media that you’d like to review…and in the manner you’d like to review them.

Your other comments about not distinguishing among media types are simply inaccurate. We cite specific media sources whenever we post a critique.

And you are simply wrong when you say that I “slam magazines.” You mentioned Men’s Health. Well, did you bother to see that I had written two pieces that applauded Men’s Health articles on prostate cancer?

• Men’s Health piece on proton beam for prostate cancer.

• Men’s Health feature: The $6 Million Dollar Gland

And I cited award-winning magazine pieces by Men’s Health, Vanity Fair and The New Yorker.

So your criticism is, again, inaccurate.

Look, Laurence, I always try to respond to comments that readers leave. But you leave more comments that are more inaccurate and require more of my time to respond to than any other reader of this site. Please don’t be surprised if I sometimes don’t respond to what you write. I am flying solo, running this site all by myself right now. I can’t devote this much time responding to everything you comment on.

As I’ve suggested before, why don’t you start your own blog? You could write whatever you wanted, cover the universe of media as you seem to think is easy to do with no funding and no staff, and then perhaps both of our days would be more productive.

Gary Schwitzer

December 16, 2013 at 10:31 am

Laurence,

No, the potential harm from screening test is NOT simply in the interpretation of the test. The potential harm is initiated as the test is done.

The informed decision making that must take place regarding screening tests must take place BEFORE the test. You can’t “shoot first and ask questions later.”

Once the test is done, it may kick off a cascade of events (as I have already documented) that you can’t control, including a known rate of false positives and overdiagnosis.

So once you roll up your sleeve for a PSA blood test, you can’t pull back. So the potential harm is in having the test itself. It is the act of having the test that initiates the harm.

Regarding your other request, you can find an interactive chart on our site that allows you to compare grades of competing news sources.