Breast Cancer and the Press

I spoke Sunday morning before the National Breast Cancer Coalition's annual advocacy conference in Washington, DC. Here's a truncated version of my remarks:

A few years ago, the Journal of the National Cancer Institute published a study about the role of the press in spreading misinformation about breast cancer. The authors surveyed all the articles that appeared in popular magazines over a year's time. They found that fully 84 percent of the women portrayed in the articles were younger than 50, and nearly half were under 40. Yet just 16 percent of breast cancer cases occur among women under 50, and just 3.6 percent under 40.

There's a reason why writers and editors run such coverage.

Young, attractive women with breast cancer and preferably small children at home make a much more compelling story. But, as the study pointed out, they create an entirely unrealistic fear in many women's minds about their actual risks for contracting and dying of breast cancer.

When it comes to breast cancer, misleading coverage in the rule, not the exception. Here's a lead from a recent news story in the New York Times. "Two important studies being published today challenge conventional thoughts about treating and avoiding breast cancer."

The first study and the one covered more extensively in the article suggested taking estrogen-blocking drugs might obviate the need for chemotherapy in breast cancers that feed off estrogen. But as one read deeper and deeper into the article, the reader learned that doctors don't have an effective way of determining which tumors feed off estrogen. Even the doctor who conducted the study told the reporter that chemotherapy was still needed for all cancers above a certain size. "Period. End of story," he said.

So how does this challenge conventional thoughts about treating breast cancer, which was the lead?

Which brings me to hormone therapy wars. Can it really be just six years ago that Lauren Hutton was on the cover of Parade Magazine offering the beauty tips of the stars. Her number one beauty secret was estrogen-based hormone therapy. There had already been stories in the medical literature warning that the powerful drugs might increase the risk of heart attacks and strokes in healthy women, but the landmark Women's Health Initiative, which proved that connection, was still two years away. What might have tipped off that reporter or Parade's editors that this wasn't the best idea in the world -- encouraging women to take estrogen? If they knew Ms. Hutton was a paid spokesperson for Wyeth-Ayerst, the drug's maker, perhaps they might have foregone that cover. But either they didn't ask, or decided not to tell their readers.

Indeed, as recently as January of this year, the Times carried a story about women still on hormone replacement therapy. The gist of the story was that researchers are exploring the theory that early initiation of hormone replacement therapy -- at the average age of menopause of 51 rather than the average of 64 for women in the Women's Health Initiative -- might in fact be cardioprotective. They quoted one Mary Jane Minkin, a professor at Yale Medical School. "Personally, in my heart of hearts, I think there is a benefit," she said. "However, I'm politically incorrect if I say that." Two paragraphs later, readers were informed she was a paid speaker for "companies that make the estrogen products she prescribes."

I first learned about the hype and hope associated with breast cancer research stories when writing my book, "The $800 Million Pill." I read Michael Waldholz's "Curing Cancer" and Robert Bozell's "Her-2." The former covers the story of Mary Claire King's discovery of the genes linked to some breast cancers. The latter told the story of the discovery of Herceptin, the targeted drug that attacks a specific mutation. What both books, just like the extensive coverage of Herceptin over the years, only briefly mentioned was the fact that only 15 to 20 percent of breast tumors occur in women who carry such genes or have that mutation.

So far, I've emphasized the misleading nature of much coverage about breast cancer issues. But what doesn't get covered. In March of this year, the British Medical Journal ran an important analysis of one of the more comprehensive tests of mammography on breast cancer incidence. It showed that routine mammography probably increases the incidence rate by about 10 percent more than is actually the case -- in other words, at least 10 percent of the cancers found by mammograms do not really exist or were benign lumps that would never have turned into a virulent cancer. This story received not one mention in the U.S. that I could find, even though it was extensively covered by the European press.

What should reporters do to improve their coverage of this important issue?

First, they must pay more attention to the conflicts of interest of the physicians who have conducted the studies they're reporting on. A 2000 study by Ray Moynihan and colleagues that appeared in the Journal of the American Medical Association found that just one-third of ties between doctors and drug companies got reported in the press when those doctors' studies were quoted. Today, I suspect the percentage is a bit higher. The organization I work for, The Center for Science in the Public Interest, has lobbied news organizations to improve their policies. Last year, the New York Times adopted a policy of routinely reporting such conflicts. But that policy is sometimes honored in the breach and many other organizations still have not followed suit. They should.

Second, disclosure doesn't go far enough. When reporters report on a study funded by a drug company, they have an obligation to probe the data with a healthy skepticism. Too often, preliminary results presented at a scientific meeting that will never appear in a peer-reviewed medical journal gets splashed across the front pages of leading newspapers. Women need more critical coverage than that.

Another important point is presenting the real risks women face and the real benefits women might receive from a therapeutic alternative. Yes, there were 40,000 deaths from breast cancer last year, making it the second leading cause of cancer death among women after lung cancer. But half those deaths occured in women who were in 69 years of age older. It reminds me of the old joke: "Look at me, I'm 85, never smoked, never drank, and I'm lying in bed, dying of nothing." To the extent cancer is a disease of aging, reporters and the public need to disaggregate the data and present the real risks women face.

The government's long-standing war on cancer, and the anti-cancer establishment it created, is partially to blame for this. The National Cancer Institute routinely talks about women's one in eight risk of getting breast cancer in their lifetimes. That's a pretty scary number. But in women under age 40, the odds are only 1 in 229; even for women ages 60 to 69, the risk is 1 in 26. The 1 in 8 chance of getting breast cancer is first and foremost an artifact of aging, not a growing epidemic.

Finally, it is incumbent on reporters to cover the risks as well as benefits that come from a particular therapy. Last May, a report at the American Society of Clinical Oncology meeting that received widespread coverage showed that taking statins lowered the risk of breast cancer. "Half as likely" said every lead. Sounds pretty dramatic. But elsewhere in the story, it was reported that only 12 percent of the 40,000 women in the study were taking statins; and only 1.4 percent of the group contracted cancer (it was a multi-year study). You had to do a lot of finagling with the numbers to discover that it would require putting 700 women on statins for five years to eliminate just one case of diagnosed cancer -- a case, by the way, that had a one in five chance of being fatal.

At the same time, the story never mentioned the liver problems or muscle-wasting problems associated with prolonged statin use. Indeed, simply by checking the FDA label, a reporter could discover that Lipitor, the most widely prescribed statin, has a 1 in 500 chance of causing liver problems at the lowest doses, and a 1 in 50 chance at the highest doses of causing liver problems. Are we encouraging women to substitute one disease for another when we mindlessly report the findings of the latest industry-funded study?

Finally, it is time for reporters to begin inserting cost-benefit analysis into their coverage. Yes, cost-benefit analysis has gotten a bad name, largely because insurance companies used it as justification for arbitrarily cutting off their HMO patients from needed coverage in the 1990s. But with the Baby Boom entering their high cost years, figuring out what new products Medicare should pay for is going to become a huge social issue.

Let's use the previous example: Patented statins cost about $1,000 a year. Given that 700 women would need to take these drugs for five years to eliminate one case of cancer, which probably wouldn't be fatal if treated, the cost of that preventive measure would be $3.5 million. Is that worth it? Or more importantly, could that $3.5 million be spent in other ways that might prevent far more cancer cases -- like intensive screening in communities where the women are most at risk, like in the black community, which has a far higher breast cancer mortality rate than the white community?

Breast cancer is a serious problem, as are the more than 200 other forms of cancer. And advocacy groups like yours have played an important role in raising many of the questions I am raising this morning. But you have to figure out a way to make your criticisms (and mine) the main point of the story, rather than the one-paragraph caveat buried deep on the jump page.

Thank you.

Posted by gooznews at May 1, 2006 09:00 AM