This is an amended version to reduce file size to allow it to fit on SlideShare. My main theme was news coverage of screening tests that emphasized only benefits while denying/ignoring/minimizing evidence of potential harms.

1. Cheerleading, shibboleths and
uncertainty
Gary Schwitzer
Publisher
HealthNewsReview.org

2. Cheerleading
“The press, on its own, if it chooses, can make the
transition from cheerleaders of science to
independent observers. The journalistic
trumpeting of medical cures, even though
accompanied by sober cautions against
optimism, deserves to be severely throttled back
in recognition of an unfortunate reality: though
news is sold around the clock, major advances in
medicine come along infrequently.”
-- Daniel Greenberg: Science, Money, and Politics, 2001

3. Shibboleths
It’s Hebrew for a password that identifies one as a
member of a cult/sect. Also refers to a
longstanding belief associated with a particular
group, especially one with little current meaning
or truth.
Dr. Barry Kramer, NCI Director of Div. of Cancer
Prevention, uses it in reference to screening tests.
Director of the
In some medical & journalism circles, a common
shibboleth is the almost cult-like advocacy for
screening tests and the search for weapons of
mass destruction inside all of us. News about
screening tests will be my main theme in this talk.

4. Uncertainty
There’s a problem with news stories that convey false
certainty where it does not exist.

5. Our criteria: Does the story explain…
• What’s the total cost?
• How often do benefits occur?
• How often do harms occur?
• How strong is the evidence?
• Is the condition exaggerated?
• Is this really a new approach?
• Is it available?
• Are there alternative choices?
• Who’s promoting this?
• Do they have a financial conflict of interest?

6. Report card – after 6 years and 1,700+
stories reviewed
~70% of stories fail to:
✔ Discuss costs
✔ Quantify potential benefits
✔ Quantify potential harms
✔ Evaluate the quality of the evidence

7. Kid-in-candy-store picture of U.S. health care
 Everything is terrific
 Nothing is risky
 No price tags

8. We see a lot of cheerleading for new
drugs, for new technologies, for local
health care industry
The high-speed train of expensive
technologies has left the station before
enough evidentiary questions are
answered.
 Robotic surgical systems
 Proton beam radiation facilities
 Intensity-modulated radiation therapy facilities

9. Then, when questions of evidence are raised…
• Denial kicks in and such concerns are
easily labeled as:
–Rationing
–Anti-industry
–Anti-progress
–Socialism
• Have we forgotten Vioxx? Or autologous bone
marrow transplants for metastatic breast cancer?”
• We seem conditioned to exaggerate benefits and
deny/ignore/minimize harms

10. Worst, most biased coverage I’ve seen in 35 years

11. Dana Milbank, Wa Post “Send Task Force to the Death Panel”
Elisabeth Hasselbeck on “The View” called it “gender genocide.”
Elizabeth Cohen, CNN: "This task force is the only big group
that is saying this.”
Dr. Manny, Fox News: “Mammograms should be done because
they save lives. Period.”
ABC’s Dr. Tim Johnson: “I recommend sticking with the
current guidelines.”
CBS’ Dr. Jennifer Ashton: "I am not telling women to deviate
from their screening practices."
AP quoted one breast CA advocacy group opposing the
recommendations but didn't quote two much larger
national advocacy groups supporting the
recommendations.

12. Worst, most biased coverage I’ve seen in 35 years
What the Task Force actually wrote:
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.”

13. The editors of the Annals of
Internal Medicine referred to a
“media cacophony”:
“Confusion, politics, conflicted
experts, anecdote, and emotion
ruled front pages, airwaves, the
Internet, and dinner-table
conversations”

14. Editorial cartoons in leading newspapers
drilled home common themes: (examples
deleted on SlideShare)
• The task force was all about cutting
costs (false)
• Task force members were stupid non-
expert bureaucrats (false)
• Cartoons of women’s cemetery scenes
emphasized only benefits of screening while
minimizing harms of false positives,
overdiagnosis, number needed to screen

15. The ONLY editorial cartoon mentioning evidence –
Rock River Times, Rockford, IL

16. Veteran science journalist John
Crewdson wrote in The Atlantic:
"The current controversy over
the task force's report owes
much to the media's confusing
coverage, some of which has
been misinformed, including by
TV doctors who ought to know
better.”

17. "Are you comfortable with what you're saying? You're a
nurse. What you're saying is that some lives are not worth it -
that's why we're changing these recommendations. That's an
incredibly frightening thing to hear from someone like
yourself. Is that what you're saying?"

18. A viewer who is a breast cancer
survivor wrote to me:
"She was basically made to defend a
position that Dr. Gupta asserted as
fact. It was a pretty crappy tactic.
… I hope physicians-that-are-also-
journalists start realizing that by
(ab)using their positions of trust as
doctors to lend credibility to hit-and-
run stories, they cheapen both
medicine and journalism."

19. Crusading advocacy on CBS News
“Well, we’ve had a conclusion for many, many years at
Susan G. Komen, almost a generation. Screening saves
lives. The 5-year survival rates for breast cancer
diagnosed early is 98 percent…and this is largely due to
screening and early diagnosis.”

20. Fox News website, March 3, 2010
Headline: “Cancer Society Casts Doubt
on Value of Prostate Cancer Test.”
Excerpt: "Dr. David Samadi, a Fox
News contributor and chief of
Robotics and Minimally Invasive
Surgery at Mount Sinai School of
Medicine in NY, 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.”

21. Leaders of ZERO: The Project to End Prostate Cancer
When the US Preventive Services Task Force recommended
against routine screening of men with the PSA blood test, CEO
Skip Lockwood said the UPSTF’s advice “condemns tens of
thousands of men to die this year and every year going forward…”
COO Jamie Bearse wrote about the chief medical officer of the
American Cancer Society:
“Otis Brawley has killed more men by giving them an excuse to
not be tested.”

22. Brawley & Len Lichtenfeld of
ACS have gone on
offensive, even posting a
YouTube video in which
Brawley said:
“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…
… Many of these free screenings 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."

23. Duped & Deceived?
Tim Glynn, lawyer, age 47
when doctor “decided I’d
have a PSA test without
consulting me.”
“Men should be aware of the
Profiled in Shannon Brownlee’s
truly terrible consequences. NYT Sunday mag piece,
As a screening tool, you could “Can Cancer Ever Be Ignored?”
do as well by throwing dice on
a table.”

25. Prizes for Prostates

26. In 2010 after the National Lung Screening
Trial results were released, the ACS posted
on its blog:
"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."

27. Amidst generally weak
journalism, NPR stood out:
Interviewed Dr. Peter Bach of
Sloan-Kettering:
“Bach says the risk that this test
will give a false positive result is
about 100 times higher than the
chance that it will keep someone
from dying of lung cancer.”
And Dartmouth’s Bill Black:
“How long do we screen these people for? How often do we
screen them? How exactly do we interpret all the findings?
There's tons of questions that have to be answered.”

28. Evidence that consumers are skeptical about
evidence-based health care. Carman et al.
Health Affairs 2010
“Clearly, consumers will revolt if evidence-
based efforts are perceived as rationing or as a
way to deny them needed treatment. Policy
makers, employers, health plans, providers, and
researchers will thus need to translate
evidence-based health care into accessible
concepts and concrete activities that support
and motivate consumers. A necessary condition
for effective communication, after all, is to start
where your audience is—even if that is not
where you hoped or expected it to be.”

29. Next few
slides courtesy
Woloshin &
Schwartz of
Dartmouth

30. Imagine academy awards for
exaggeration .....
…and the winner is:
Survival Statistics & screening
2 ways to improve survival
without changing mortality
*lead time bias
*overdiagnosis
“Most misused statistic”

31. Screening facts: Screening mammograms for breast cancer
Screening is a tradeoff: it helps some women but harms others.
Why is screening a decision?
The harms are as real as the benefit.
How should I decide? Most major medical organizations suggest women consider
screening in their forties or fifties. Compare the benefits and
harms in the table below to decide whether getting a
mammogram is right for you.
What happens to 1,000 women who are screened every year or two for 10
years? Women Women Women
40-49 50-59 60-69
Benefits of screening
Reduced 10 year chance of dying from breast cancer
No screening 3.5 5.3 8.3
Screening 3.0 4.6 5.6
Avoided a death because of screening 0.5 0.7 2.7
Harms of screening
False alarm Experience at least one false alarm 50-200 50-200 50-200
that requires a biopsy
Overdiagnosis Experience the diagnosis and
treatment of breast cancer that would not have
caused harm if never found. 1-5 1-7 5-27

32. To treat your facts with
imagination is one thing; to
imagine your facts is another.
John Burroughs (1837-1921)

33. Journalists could help people understand
and deal with the clash between:
• Science  Intuition
• Evidence  Emotion
• Data  Anecdote
• Recommendations for  Decision-making by an
entire population individual
• What we can prove  What we believe, wish, or hope
• Grasping uncertainty and  Promoting false certainty,
helping people apply shibboleths and non-evidence-
critical thinking to based, cheerleading advocacy
decision-making issues

34. Thank you.
gary@healthnewsreview.org