October 01, 2014 — Blog Post
Media Messages about Screenings and their Role in Overdiagnosis and Overtreatment
Disclaimer: the following is not an anti-screening message. It is, however, a call for improved accuracy, balance and completeness in messages about screening tests.
I’ve scrutinized media messages about screening tests for 8 years. (I’ve done it longer than that, but, for the past 8 years, I’ve given far more systematic attention as I’ve been the daily publisher of HealthNewsReview.org.)
Why does this matter? Because this is the way many people get most of their health care information.
Some journalists have excelled, explaining the trade-offs of potential benefits and potential harms – yes, harms – from screening tests. But far more often, I’ve seen news stories that promote unhelpful themes:
- Emphasizing or exaggerating potential benefits while minimizing or ignoring potential harms
- Framing screening as if it were a mandate, not a choice
- Emphasizing patient anecdotes of people who claim their life was saved by screening – something that can’t be proven
- Missing the stories of people who make rational decisions not to be screened, or the stories of people who regret making ill-informed screening decisions
It is far easier to report about screening using only the perspectives of those who promote screening – some of them with a vested interest. It is far more difficult to explain nuance, evidence, and reasons why there can be harms from a supposedly simple screening test.
Since overdiagnosis and overtreatment are themes of this year’s Health Literacy Month blog posts, let’s start right there with a list of potential harms.
The reason there are evidence-based guidelines – such as those from the U.S. Preventive Services Task Force – to guide screening decisions, is that screening outside the boundaries of the best evidence leads to overdiagnosis and overtreatment.
In a Viewpoint article in the Journal of the American Medical Association (JAMA), Drs. Steven Woolf and Russell Harris wrote, “The Harms of Screening: New Attention to An Old Concern.” Excerpts:
“Screening can produce iatrogenic complications (eg, perforation from colonoscopy), anxiety over abnormal results, and a cascade of follow-up tests and treatments. Screening can also precipitate overdiagnosis, the workup and treatment of conditions that qualify as disease but pose little threat to patients’ health. …
It is not possible to predict whether greater awareness of harms will dampen patients’ enthusiasm for dubious screening tests. More realistically, resource limitations will intervene: profligate screening practices will become increasingly unaffordable in a society struggling with spiraling health care costs. However, society’s first concern should be to confirm that screening is a net good for public health. This requires harms to be considered independently of costs. Until the reality of harms becomes more palpable to clinicians and the public, concerns about the safety of screened populations will continue to be mistaken for frugality.”
Anxiety over false positives is often downplayed in the stories journalists tell. One physician-journalist even scoffed at the notion of women having anxiety from pelvic exam screening. That suggests a possible three-way bias bursting through in the news coverage: personal and professional – both medical and journalistic bias. (This is a frequent flaw in much reporting by TV physician-journalists, but that’s a topic for another day.)
Anxiety from screening tests is real.
A paper in the Annals of Family Medicine analyzed “Long-Term Psychosocial Consequences of False-Positive Screening Mammography.” It suggested that anxiety from false alarms may last at least three years.
How news, advertising, conflicted media messages get it wrong.
While you can find many examples of incomplete, imbalanced news coverage of screening tests such as these search results from our blog, let me highlight a few prime examples.
An ABC News story on lung cancer screening used hyperbolic, promotional language. It called CT scans “simple.” There’s nothing simple about this decision. It cited a cost of a “mere $99″ – not to be matched in many locations across the US and failing to take into account the followup costs of the considerable number of false positives. It offered to help viewers find hospitals who could scan them – crossing a line from independent vetting into a resemblance of advocacy and advertising.
ABC is not alone in lung cancer imbalance. Earlier this year, we wrote: “NBC vastly exaggerates the potential benefits of lung cancer screening.”
For years, TV networks have had their personalities get screening tests on the air, reporting on themselves. Katie Couric had her famous on-air colonoscopy while at NBC. When she went to CBS, she accompanied Harry Smith as he had his colonoscopy on the air. ABC’s Bill Weir claimed his CT scan saved his life, then later retracted/corrected those claims.
During a November, 2013 TV sweeps (ratings) period, ABC’s Amy Robach was urged by colleagues to have a mammogram on the air. She was diagnosed with breast cancer. She wrote, “I can only hope my story will … inspire every woman who hears it to get a mammogram, to take a self-exam. No excuses. It is the difference between life and death.” There are several glaring misstatements in what she wrote. There are legitimate, rational reasons – please, let’s not call them excuses – why a woman would not choose to get a mammogram. And for many women a mammogram is not the difference between life and death. Dr. Peter Bach of Memorial Sloan Kettering Cancer Center, whose wife died of breast cancer, recently criticized Robach’s statements as “both wrong and hurtful.”
As evidence that the TV networks still must think it’s wonderful to promote having their personalities get screening, in that same November, 2013 sweeps period, the NBC Today show aired a special on prostate cancer screening that was wrong in so many ways, you need to see our entire critique – “NBC races the clock in a race to the bottom with anchormen & prostate cancer screening promotion .”
For two decades, the New York Daily News has promoted prostate cancer screening – “evading the evidence.”
We’ve written about:
- Troubling journalism about heart screening of student athletes
- What women need to know about US News & World Report’s “16 Health Screenings All Women Need”
- Too much uneven, imbalanced reporting of colon cancer screening studies
- Prevention magazine editor promotes ovarian cancer screening despite lack of evidence
But perhaps the worst episode – one from which I don’t think the public dialogue has recovered – was news coverage of the US Preventive Services Task Force’s mammography recommendations in 2009. Maggie Mahar wrote a good summary, “Truth Squad – Medical Reporting on Mammograms.”
I could list many other examples. But by now you should have the picture: men and women, children and adults, hearts, colons, breasts, ovaries, prostates, lungs – you name the target organ or demographic group – you’ll find that many journalists deliver unhelpful, imbalanced stories about screening.
Media promotions by medical centers muddy the picture even more. Examples:
- Shuffle off to Buffalo for another questionable prostate screening promotion
- Free Throat, Head, Neck Cancer Screenings Promoted Without Full Info
- News story shines light on hospitals promoting questionable screenings
- Public Citizen has written to 20 hospitals in eight states urging them to “sever their relationships with a screening company because the company’s heavily promoted, community-wide cardiovascular health screening programs are unethical and are much more likely to do harm than good.
“The ethics of highly-advertised campaigns by commercial screening companies – often in partnership with hospitals, churches or drug stories – were addressed in the Annals of Internal Medicine. There’s a website devoted solely to the issues surrounding private, commercial screening tests.
And then when people do schedule a visit with their doctors, those doctors may not discuss the harms of screening tests – presenting an imbalanced picture.
So, with that combined impact of news, advertising, business interests, and less than optimal discussions in the clinical setting, we should not be surprised when we learn from a JAMA paper that:
“A substantial proportion of the US population with limited life expectancy received prostate, breast, cervical, and colorectal cancer screening that is unlikely to provide net benefit. These results suggest that overscreening is common in both men and women, which not only increases health care expenditure but can lead to net patient harm.”
What kind of messages would improve this picture?
News stories or blog posts such as:
- “Can Cancer Ever Be Ignored?” in the New York Times magazine.
- “Why One Doctor Says ‘No’ to Many Screening Tests,” by US News & World Report.
- “Will We ‘Just Say No’ to Screening Tests?” on the Prepared Patient ® Blog.
- “Some Medical Tests, Procedures Do More Harm Than Good,” on Newsweek.com. This article profiled two learned physicians – a man and a woman – who decline PSA testing, annual electrocardiograms and mammography, respectively.
Websites such as:
- TheNNT.com – which stands for the number to treat. That’s the statistical method to determine how many people need to be treated – or screened – in order for one person to benefit. You can see the analyses for mammography, for the PSA test for prostate cancer, and for CT scanning for lung cancer.
- The Harding Center for Risk Literacy, and its fact boxes on mammography, prostate cancer screening, and pap test screening.
More evidence-based, shared decision making discussions about screening:
- Lack of Shared Decision Making in Cancer Screening Discussions – American Journal of Preventive Medicine.
What’s at stake
If we don’t improve the public dialogue about screening tests, we probably can’t adequately address overdiagnosis.
And if we don’t improve the public dialogue about screening tests, we probably have no chance of improving the public dialogue about downstream treatment issues. So we’ll lose the overtreatment battle as well.
And, as much as I dislike military metaphors in health care, I feel like we are, indeed, in a pitched battle for the hearts and minds of Americans on screening tests. Calls for balanced, evidence-based discussions are often subject of derision.
Media messages have often framed evidence-based discussions as rationing – not rational.
Vested interests have charged that those who try to introduce balance into the screening discussion are guilty of “killing men” and “throwing women under the bus.”
There are harms in failing to recognize the harms inherent in any screening decision.
Media messages can help people understand that there are tradeoffs involved in any screening test decision. There is something you may gain but there’s also something you may lose.
Anyone communicating about screening – doctors, researchers, journalists, industry, medical centers – should reflect on whether their own biases enter into their messages about screening.
The stakes are high: avoidable ignorance, avoidable harm, and avoidable health care.