Medscape video series on colorectal cancer in young adults: Does it fear-monger?

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Michael Joyce produces multimedia at and tweets as @mlmjoyce

Screenshot from Medscape’s “Not on Anyone’s Radar: Colorectal Cancer in Young Adults”

It’s a video series that mostly features one doctor, from one cancer center, that seems to want to make one thing clear about colorectal cancer (CRC) in young people:

  • “there’s a rising tide of young people … (in their) 20’s, 30’s .. with colon cancer”
  • “since the mid 1990’s there’s been a sharp increase in colorectal cancer in young adults”
  • “colorectal cancer has begun to stalk healthy men and women in their 30’s and 40’s” (bold is my emphasis)

The doctor featured in the series — John Marshall, MD, Director of the Ruesch Center for the Cure of Gastrointestinal Cancers at Georgetown University — makes this point in the video:

“Just yesterday (I saw) 30 patients (with CRC), probably half of them now under the age of 50”

“But that’s the perspective and selection bias of a cancer specialist who sees the worst of the worst,” says Rich Hoffman, MD, MPH, Director of General Internal Medicine at the University of Iowa. He adds that the absolute risk of colorectal cancer is still very small —only a few cases per 100,000 for people in their 20s, slightly more for those in their 30s.

“So to report that jump as a ’51 percent increase’ – as this video does – can become disease-mongering, because colorectal cancer in the young is just not a huge public health problem.

What’s missing from this video is the alternative world view of those of us in primary care, as well as speculating how much of this increased incidence simply reflects more cancer being picked up by the appropriate screening of people under 50 who have family histories of colorectal cancer or other worrisome risk factors.”

This important context is not included in the video or its associated website.

Choosing emotional impact over information?

To my eyes and ears this video feels emotionally manipulative. The soundtrack is melodramatic to say the least. A sense of urgency is conveyed that CRC in the young is neglected and burgeoning. This is driven home by the heart-wrenching stories of two people in their 30’s with metastatic CRC who we learn — in the very last frame of the video — die of their cancers.

But are we given the absolute numbers of young people who develop CRC? No. Do we learn about the signs, symptoms, or risk factors doctors take into account when evaluating young people for CRC? No. A primer on the basics of screening for colorectal cancer? No. 

If your focus is revealing a “disturbing trend” with “devastating consequences,” why wouldn’t you provide your audience with the information they need to better understand it? Without that information I could easily see some viewers assuming the video is arguing for moving the recommended screening age for CRC much younger. I asked Dr. Marshall if that was the intent:

“Not at all. It’s the opposite of that. I think our current screening techniques — which are quite coarse and need to get better — would not serve this population well. I do not think fecal occult blood tests or colonoscopy should be implemented as routine screening in the under 50 crowd.”

In the video we get a passing allusion to what are called “the usual suspects” of obesity, sugar and inactivity playing some sort of role in colorectal cancer. What that role is, isn’t made clear.  There’s speculation that maybe the explanation for why we’re seeing more CRC in young people has something to do with the changing microbiome of our guts. Do we get an explanation or researcher’s take on this? No.

What little information is presented comes in the form of this rather misleading graphic:

The left side of this graphic is correct in showing that the vast majority of colorectal cancers occur in people over the age of 50.

But the right side, correctly showing the decreasing incidence of CRC in older adults (aqua) and the increasing incidence of CRC in those under age 50 (orange), seems contradictory in implying that the true incidence of CRC in young people has surpassed that in the elderly. This may bolster the main argument of the video, but it’s grossly misleading. If drawn to scale the two blue lines would be far, far above the orange lines.

Again — according to a study by the American Cancer Society just five months ago —  the absolute risk numbers for millennials are quite low:

  • absolute risk of colon cancer for individuals born in 1990 is 5 per 1,000,000 people  (up from 3 per 1,000,00 for those born in 1950)
  • absolute risk of colorectal (colon + rectal area) for individuals born in 1990 is 4 per 1,000,000 people (up from 1 per 1,000,00 for those born in 1950)

I shared my concern with Dr. Marshall that I felt the narrative, graphics, and overall portrayal of colorectal cancer in the young was at the least, misleading, and at times alarmist. His reply:

“It’s not meant to be the ‘sky is falling’ or it’s an epidemic. It’s an observation of a pattern, a new phenomenon. Not to scare everybody or create terror in young people.”

But in response I ask: “Don’t you think the video is a bit sensationalistic?” His response: “I will not comment on that.”

How to balance information and intrigue

As a producer I understand the challenge of balancing information and intrigue. This video series clearly favors the latter and — I would argue — to a fault, at the expense of neglecting valuable context, and with potential consequences; not the least of which is fear-mongering.

How could this have been avoided?

  • Don’t give just relative numbers that favor your message. Give absolute numbers as context (and reality check)
  • Words matter. Does an absolute risk going up by 2 or 3 cases per one million people really qualify as a “sharp increase” or “rising tide”? And should a well-respected medical website anthropomorphize cancer and claim it has begun “to stalk healthy men and women”? This boils down to: are you choosing your words for impact or accuracy?
  • Why predominantly one source? From one cancer center? A variety of perspectives and opinions would have strengthened the video considerably.
  • If you think too much information might overwhelm your audience or compromise your narrative flow, then move that information to the website associated with the video. That’s also a great place to provide links to industry-independent opinions.

The Medscape mission is “to improve patient care with comprehensive clinical information and resources.” The topic of colorectal cancer in young adults is a worthy topic.

The inclusion of absolute risk data, less melodramatic language, a wider breadth of opinions, and links to more resources would have strengthened this video series considerably.

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