"Vague, fact-free, emotionally charged statements are the language of public relations, not scientific discourse.”
Dr. Adriane Fugh-Berma, Georgetown University Medical Center, and Alicia M. Bell, member of the board of directors of the National Women's Health Network.
News reports on the mammography controversy reached a pitch of high hysteria last week, the baseline syncopated with the language of hate and fear.
Minnesota journalism professor Gary Scwitzer tracked the dismal progress (“descent” might be the better word), of the debate over the US Preventive Services Task Force (USPSTF) recommendations regarding mammography on his blog, Health News Review. There, he points to the fear-mongering and rampant exaggeration that has distorted media coverage. For example, “On ABC’s daytime talk show, ‘The View,’ co-host Elisabeth Hasselbeck made the stunning claim that the recommendations [represent] ‘gender genocide.’”
But it is not only women who have resorted to the language of “attack TV.” Last week, Washington Post columnist Dana Milbank crossed the border that separates advocacy journalism from simple bad taste when he suggested that: “Many oncologists, no doubt, would like to send [Preventive Services Task Force chairman] Ned Calonge and his colleagues off to Gitmo, where they could live out their years happily denying one another cancer screenings.”
Milbank ended his column with what he may have viewed as a flourish, recommending that, given the fury of the national reaction to the Task Force’s update, perhaps Congress should “take pity on the panelists and send the task force to the Death Panel for a humane end.”
“If he thought this was humorous, it wasn’t,” observed Schwitzer, who many view as the dean of health care journalism.
Why Is the Media Response So Heated?
No question, “breast cancer” is a charged phrase. In an instant, the two words conflate the beginning of life, when a baby feeds at its mother’s breast, and the end that so many Americans fear, “the Big C.” Sex and death packed into one phrase—little wonder that the words can unleash such strong emotions.
Compare the recent brouhaha over mammography to the media’s coverage of other USPSTF updates. In February, when the Task Force issued a recommendation saying that there is too little evidence regarding the risks and benefits of full-body screening for skin cancer to recommend the procedure, the statement barely caused a ripple in the mainstream press. In August of 2008, when the Task Force announced that “Current evidence is insufficient to assess the balance of benefits and harms of screening for prostate cancer,” the USPSTF update drew some fire, but nothing like the current uproar.
Breast cancer remains a special case. Both women and men find the thought of a woman losing a breast extremely disturbing. To many, the breast symbolizes beauty, femininity, sexuality and motherhood. It’s not surprising that the public responded to the suggestion that mammograms may not offer much protection for women in their forties with confusion and fear.
What is surprising—and shocking–is the media’s overwrought reaction. In an e-mail, Schwitzer describes it as marking “a low point for journalism and for our public discussion of screening, science and evidence.” The USPSTF released its update just as the battle over health care reform had reached a crescendo of anger, fear and recrimination, and those who oppose reform seized on the Task Force statement to insist that “reform” will mean “rationing.” Others simply saw an opportunity to sell newspapers, preying on the public’s fear of cancer and its anxiety about health care reform in double-decker headlines. Rather than explaining the science, they exploited the politics. Meanwhile, gloomy liberals took the news as proof that Americans just aren’t ready for evidence-based medicine.
The Media Doesn’t Just Report the News, It Helps Shape It
Let me suggest that bad cases make bad law. And the media hasn’t just been reporting the news, it has been pouring fuel on fire, shaping the public reaction. I don’t think that headlines like “More Death Recommendations From the Government Task Force” accurately reflect how the vast majority of patients would respond if their doctors had an opportunity to calmly explain what medical evidence shows about the advantages and disadvantages of a great many tests and treatments. This includes talking about the risks as well as the benefits of preventive care.
Health care reformers want to make those discussions possible by beginning to compensate primary care doctors for the time they need to talk to-–and listen to—patients. Medicare already has announced it wants to raise fees for primary care doctors by 4% next year, and reform legislation would raise reimbursements by another 5% to 10% in 2013, while providing additional bonuses for primary care doctors who create a medical home or join an accountable care organization. Over the next three years, I expect to see more hikes in Medicare reimbursements for primary care. A public plan would incorporate Medicare’s reforms and private insurers will follow suit.
Americans may not respond well to fear-mongering headlines, but if our doctors have the time to begin to talk to us about the risks and benefits that comparative effectiveness research reveals, I believe that many patients will listen. In the meantime, it would help if journalists reported facts, not fiction.
Truth vs. Fact
Schwitzer suggests that the media coverage merits a Truth Squad investigation. I agree.
No doubt many HealthBeat readers recognize that over-the-top reporting distorted the truth. Nevertheless, I’m afraid that the press has succeeded in sowing seeds of confusion and doubt. For instance, after all of the charges and counter-charges, how many HealthBeat readers know exactly what the Task Force said?
Below, my effort to clarify what is true and what isn’t regarding
- the Task Force’s recommendation;
- the potential harms and benefits of mammograms;
- the science behind the guidelines
- and what the controversy means (and doesn’t mean) for health care reform.
False Claim: The USPSF tells women under 50 that they shouldn’t have mammograms
Washington Post, columnist Howard Kurtz helped muddy the waters by describing the USPSTF’s recommendation as “advice that women in their 40s no longer seek breast cancer screening.”
Kurtz summed up as the Tasks Force’s counsel as: “don't-worry-be-happy-till-you're-50.”
Truth: The Task Force did NOT recommend that forty-something women skip mammograms.
Here is what it actually said:
"USPSTF recommends against routine screening mammography in women aged 40 to 49 years. 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." The Task Froce went on to recommend biennial screening for women 50 to 74.
"So, what does this mean if you are a woman in your 40s?” asked Diana Petitti, MD, MPH, Vice Chair, USPSTF. “You should talk to your doctor and make an informed decision about whether a mammography is right for you based on your family history, general health, and personal values.”
The key word in the Task Force’s recommendation is “routine.” The panel is saying that women in their forties should not automatically have mammograms. They should talk to their doctor, and together, make a decision, taking Context into account. Context includes family history. If your sister and mother both have been diagnosed with breast cancer this will, of course, affect your decision. You’re a “high-risk” patient.
False Claim: “Thousands of Women Will Die . . .”
On AlterNET, linguist George Lakoff “frames” the issue with a headline that screams: “47,000 Women Could Die As a Result of the New Mammogram Guidelines.”
Unfortunately, a combination of bad arithmetic (which assumes that the 80,000 females in America under the age of 40 are all equally at risk of dying of breast cancer), and a failure to recognize the difference between “cost-benefit analysis” (which focus on costs) and “comparative effectiveness research” (which considers risks and benefits for patients, regardless of cost) turns Lakoff’s essay into mush.
Truth: “Mammograms reduce the chances of dying by a fraction of a percent”
As proof, Schwitzer offers hard numbers, reprinting a table created by Dr. Steve Woloshin, of the Veterans Affairs Outcomes Group, which shows that over a ten-year period, a woman age 40 to 49 has a 0.28% chance of dying of breast cancer if she goes for regular mammograms, and a 0.33% chance of dying of breast cancer if she doesn’t. These are “the numbers that get lost in the rhetoric,” says Schwitzer.
But, thanks to a forty-year campaign to instill “breast cancer awareness” in the minds of American women, most remain convinced that that breast cancer represents a real and imminent danger. They believe that they must be on red alert.
Schwitzer quotes USA Today: “Forty percent of women estimate that a 40-year-old's chance of developing breast cancer over the next decade is 20% to 50%. The real risk is 1.4%, according to the National Cancer Institute." Schwitzer’s comment: “Is it any wonder that women say they'll ignore the USPSTF recommendations when they over-estimate their own risk by such a huge degree!”
False Claim: Mammograms Cut Your Risk of Death by Breast Cancer by 15% to 20%
No doubt you’ve seen these numbers in the news. Time.com’s Kate Pickert is angry at the thought that so many lives are being dismissed. “Women are incensed that some faraway task force has decided a 15% risk reduction – i.e. actual lives saved – is not enough to warrant mass screening.”
Truth: Risk is 0.5% for 130,000 Women over 40 who Have Mammograms, 0.4% for A Group That Does Not
The truth is that reducing risk by 15% or 20% represents the “relative benefit” not the “absolute benefit” of mammography.
In The Atlantic, John Crewdson explains the difference: “For example, the relative survival benefit of 20 percent among women ages 40-74 who had mammograms in the Swedish trials translates to 511 women dead of breast cancer out of 130,000 who were screened for 15 years—a death rate of 0.4 percent.”
Among the comparison group of 117,000 Swedish women who did not have mammograms, the breast cancer death count was 585 women, or 0.5 percent. True, that’s a 20 percent relative benefit in favor of mammography. ” In other words, 0.4 percent is 20% smaller than 0.5% .“ But,” as Crewdson notes, “0.4 and 0.5 are very tiny numbers.”
Crewdson also quotes Dr. Donald Berry, head of biostatistics at the M.D. Anderson Cancer center in Houston, who calculates that a decade of mammograms for a woman in her 40s increases her lifespan by an average of 5 days. “The estimated average of 5 days of life lost if a woman in her early forties delays mammography for 10 years is similar to that for riding a bicycle for 15 hours without a helmet,” Berry says, “or of gaining two ounces of body weight (and keeping them on)."
The Atlantic piece illustrates how the press can use its power to educate rather than to stir up fears—if that is what it chooses to do.
False Claim: “Cost benefit analysis can kill”
Commentators like Kate Pickert are outraged in part because they have been told that the USPSTF made its recommendation with an eye to saving health care dollars, putting money ahead of lives. Lakoff reinforces that assumption in the opening line of his AlterNet Post: “Cost benefit analysis can kill.”
Truth: USPSTF Was Not Doing Cost-Benefit Analysis
In that first sentence, Lakoff offers up his first piece of misinformation. The USPSTF is not charged with comparing the benefits of a treatment to the cost—its mission is to compare benefits to risks. As Task Force chair, Dr. Diana Petitti explained on NPR: “The US Preventive Services Task Force reviewed the evidence without regard to cost, without regard to insurance, without regard to coverage.”
It is important to realize that the Task Force is not a committee of bean-counting bureaucrats. It is “an independent panel of private sector experts in prevention and
primary care, set up in 1984 by a physician then serving in the Reagan administration. The idea was to fund a group that could operate outside of government to review ongoing research and data in an effort to determine how well certain strategies to combat disease actually worked.” (Thanks to the Amherst Bulletin’s Suzanne Wilson.)
Over at Huffington Post, obstetrician and gynecologist Dr. Peter Klatsky elaborates: The USPSTF is “composed of physicians and scientists whose only motivation is to improve the health and wellness of women nationwide. Being invited onto the USPSTF is a huge honor. These are our best and brightest. They strive to determine what is best for our patients, our community, and our loved ones.”
In Part 2 of this post, I will respond to claims that: the Task Force pulled these numbers “out of the air and out of the blue;” the only “harm” associated with mammograms is “anxiety;” cancer survivors and doctors all “denounce the new recommendations;” and under reform, “the government will use comparative effectiveness research to ration care.”