Unhealthy Advocacy: Journalists and Health Screening Tests
Journalists and news organizations sometimes seem to abandon
their usual healthy journalistic skepticism when it comes to coverage of
certain health screening tests. While
the journalistic intent here may be benign, the practice may produce more harm
I lead a team that monitors U.S. health news coverage each
day for a Web project, Health News Review,
that evaluates and grades health news stories.
In the course of that work, I've seen surprisingly strong evidence of
bias in favor of screening tests. Some
stories, even by reputable journalists, ignore the recommendations of the U.S. Preventive Services Task
Force, probably the most important, unbiased, balanced source on such
questions. And the American College of
Physicians' recently released guideline
on mammography for women in their 40s doesn't seem to be getting the attention it deserves, either.
What gets left out of these stories is the important concept
that both benefits and harms can come
from screening tests. You can screen
many people and find a few problem cases.
But in the process, there are always false-positive test results that
suggest people have a problem when they really don't. That leads to anxiety, more testing (some of
which carries its own risks) and more expense.
Also, with today's more sensitive screening tests, some forms of "pseudo-disease" may be found -- early hints of possible problems without clear
evidence about whether they will go on to create real trouble or not. That can mean many more people are
inappropriately labeled with "disease" and treated. (An excellent source on these issues is the book "Should I Be
Tested For Cancer? Maybe Not and Here's
Why" by Dartmouth College's Dr. Gil Welch.)
Some specific examples:
The U.S. Preventive Services Task Force concludes "that the evidence is insufficient to recommend for or against routine
screening for prostate cancer using prostate specific antigen (PSA) testing or
digital rectal examination."
OK, but what's wrong with what journalists often call "a
simple screening test"? The Task Force tells men that prostate "screening may
result in harm if it leads to treatments that have side effects without improving
outcomes from prostate cancer, especially for cancers that have a lower chance
of progressing. Erectile dysfunction, urinary incontinence and bowel
dysfunction are well-recognized and relatively common adverse effects of
treatment with surgery, radiation or androgen ablation."
So explaining the pros and cons, the harms and benefits, is
a big deal. But you wouldn't know that
from some reporting on the issue.
During the week of April 23, the Chicago Sun-Times sponsored free prostate
cancer screenings in the Chicago area. A Sun-Times
news release states: "Men ages 40 and older are urged by health officials to
take advantage of the screenings," which include a PSA blood test and a digital
rectal exam. Which health officials? Not the ones on the Task Force.
But the Sun-Times
didn't stop by sending out news releases. It ran a story about its own
The story stated, under the heading "GET TESTED," "Men ages
40 and older can stop by one of the mobile clinics for the free, private prostate
cancer testing and physical exam."
ignored important evidence and took an aggressive advocacy stance in promoting
prostate screening to men in their 40s.
Readers responding might find a few cancers but could also expose
themselves to unnecessary harms.
publisher John Cruikshank did not respond to my e-mail request for an
March 28, on NBC's "Today," chief medical editor Dr. Nancy
Snyderman told men, "You turn 50, you just have to
have a rectal exam to feel that prostate. And you get a prostate-specific
antigen, a PSA test."
In February 2006, on CNN's "American Morning," medical
correspondent Dr. Sanjay Gupta hosted guest Dr. Christopher Kelly of New York University's
School of Medicine. Kelly said that men in their 50s "should also be aware
that they need prostate cancer screening."
Drs. Snyderman, Gupta and Kelly all omitted the fact that
this advice conflicts with the Task Force's recommendations. If you're scoring at home,
that's TV physicians 3, best evidence
Breast cancer screening:
mammography in the 40s
On April 12, CNN's Elizabeth Cohen
offered an entire litany of screening-test recommendations for women -- much of
it unsupported by the best medical evidence. Perhaps the most glaring was this: "At 40 ... women need to start having
mammograms every year."
The story never mentioned that just nine days earlier, the
American College of Physicians (ACP) released a new
clinical practice guideline on screening mammography for women 40 to 49
years of age. That guideline did not say that women at age 40 need to have
annual mammograms. The ACP reminds women
of the harms that much reporting omits: false-positive and false-negative
results, exposure to radiation, discomfort and anxiety.
On April 8, CNN's "House Call with
Dr. Sanjay Gupta" responded to the ACP news, but he did so by hosting only a
guest who opposed the ACP guidelines. No
one representing ACP appeared on the program. The guest was an oncologist who
said he didn't accept the College of Physicians' reasoning, writing the group
off as "an organization of internists" -- not cancer specialists or surgeons.
Why did Gupta give airtime only to one side of this scientific debate? Gupta's
guest said, "We still need to figure out why they (ACP) made this
recommendation." Why not ask them on the air?
I wanted to ask CNN editorial
director Richard Griffiths, but he did not respond to my e-mail request for an
The weekend of April 14 to 15, Georgia
Public Radio aired a special report, "Breast Cancer in the African American
Community." It included the statement, "Typically every woman should start
having mammograms at age 40." The GPR Web site said, "The American Cancer
Society recommends that every woman over 40 have a regular screening
mammogram." There was no mention of the ACP's new clinical practice
Lung cancer screening
In November 2006, NBC's Mike
Taibbi, a lifelong smoker, reacted to a study in The New England Journal of
Medicine by Dr. Claudia Henschke. The study touted the benefits of lung-CT scan screening of smokers. Taibbi went to
Henschke's hospital, had his lungs scanned and then personally endorsed the
scans on the air. When, in March 2007,
another study in The Journal of the American Medical Association countered the
evidence in the Henschke-NEJM study, Taibbi and NBC offered no equally weighted
Web site, a team of reviewers analyzed coverage of the Henschke study by eight
different news organizations.
- Six of eight failed to discuss adequately the
potential harms of such screening, which can include radiation exposure,
needless anxiety after receiving a potentially false positive result and
significant medical complications associated with biopsies.
- Four of eight stories failed to discuss the
costs of such screening, which were discussed in the journal article upon which
the stories were based. Estimates range from $200 to $1,000 per scan.
- Five of eight stories relied on a single source
(the authors of the published study) and/or failed to present balanced,
Additional examples of coverage with pro-screening bias are
available at our Web site, HealthNewsReview.org.
Why is this
"The pro-screening bias comes down to being able to promote
a piece," says Maria Simbra, M.D. She's
a medical reporter for KDKA-TV in Pittsburgh and a member of the Association of
Health Care Journalists' (AHCJ) board of directors."TV news loves to be
able to tell viewers to do something. It's more promotable than saying, 'Well, maybe you should just hold off until we understand more.' Furthermore,
emotion plays well on TV -- perhaps better than medical evidence."
And evidence, Simbra says, takes a long time to
explain. So television news may have an
inherent bias in favor of screening. "How do you show the human side of not getting screened?" she asks.
Simbra's fellow AHJC board member Phil Galewitz is a medical
reporter for The Palm Beach (Fla.) Post. He says, "It's difficult for reporters to
focus stories about people getting screened unnecessarily when many aren't
getting screened at all.
"I would guess few health reporters are even aware of the U.
S. Preventive Services Task Force guidelines and the same probably goes for the
American College of Physicians. That's a
shame because they often have the most updated and reliable standards."
Another AHCJ board member, freelance health
journalist Andrew Holtz in Portland, Ore., says the quick and easy approach is
not to question screening.
"When experts confirm what journalists want to hear, that
is, that a screening test saves lives, (journalists) often stop looking for
more information or other sources. And because too many reporters and editors
lack training in critical thinking on medical or science topics, they fail to
challenge expert sources. And in the news business, the pressure to offer 'news
you can use' warps editorial decisions. When your cover-story assignment is to
write about the 'Top Five Ways to Prevent Cancer,' what do you do with all those
pesky facts about the limitations or even potential harms of screening tests?"
Holtz also commented on the number of instances in which physicians on TV were
pro-screening advocates: "It strikes me
that relying on physicians, especially those with active practices, to cover
medicine and health is a bit like asking a defense contractor to cover foreign
affairs. Don't be surprised when their reports reflect an affinity for
recommending new weapons systems as the preferred way to deal with potential
Clearly, some journalists are guided by their own personal
experience. In the April 5 issue of Editor & Publisher magazine,
Philadelphia Inquirer editor Bill Marimow said that he was returning to work after
treatment for prostate cancer and that he would be "a zealot ... proselytizing to everyone to have an annual
physical. ... I am going to be lobbying like
hell on a one-to-one basis." That kind
of proselytizing outside the newsroom is his prerogative. If it affects editorial decision-making,
falling outside the boundaries of the best medical evidence, it would be a
Many remember Katie Couric's
promotion of colon cancer screening after her husband's death -- including her
on-the-air colonoscopy. She used her national platform as a journalist to
promote screening in a demographic group (under age 50, healthy women like her) -- a practice the evidence does not support.
No one questions her commitment to consciousness-raising about a disease
both deadly and preventable. I do
question her commitment to critical journalism values in crusading for colon
The Society of Professional Journalists' code of
ethics states that journalists should "distinguish
between advocacy and news reporting. Analysis and commentary should be labeled
and not misrepresent fact or context." By shining a light on these
practices, we can show journalists how far from ethical norms they have strayed
in the coverage of these important health topics. We hope journalists will see the harm they
may be causing. And we hope to promote a
new wave of evidence-based health reporting.