Seminar presentation at Preventing Overdiagnosis 2015 conference in Washington DC 9/1/15 by Gary Schwitzer, Publisher, HealthNewsReview.org & Adjunct Associate Professor, University of Minnesota School of Public Health

1. Role of the media in preventing
or promoting overdiagnosis
Gary Schwitzer
Adjunct Associate Professor
University of Minnesota School of Public Health
and Publisher

3. Outline of this session
• Background on HealthNewsReview.org
• Painting a big picture – mosaic of examples of
media messages promoting overdiagnosis –
and a few messages that try to prevent it
• Discussion: Your ideas about how to address
the media tsunami

5. • ABL =
• accidental bowel leakage. Ad for new Butterfly Body Liners that
fit discreetly between the buttocks.
• BBS =
• bashful bladder syndrome – or paruresis – or bashful kidneys,
mental cloggery, stage fright, pee fright, urophobia, pee-shyness,
slow dribbles, creeping pee-pee, public piss syndrome, shy
bladder syndrome. And, yes, antidepressants are sometimes
prescribed
• ED =
• erectile dysfunction or impotence. That was the easy one.
• EIB =
• exercise-induced bronchospasm.
• ES caused by SWD or OSA =
• excessive sleepiness caused by shift work disorder or obstructive
sleep apnea. Ads for Nuvigil for ES - a federally-controlled
substance in prescription drug form

6. • GAD =
• generalized anxiety disorder. Yep, antidepressants.
• HSDD =
• hypoactive sexual desire disorder or not in the
mood tonight. Yep, antidepressants again.
• PE =
• premature ejaculation
• PMDD =
• premenstrual dysphoric disorder
• SAD =
• social anxiety disorder. Yep, antidepressants again.

7. • 9.5 years
• >2055 story reviews
• >50 news release reviews
• >2150 blog posts
• The only systematic review and feedback mechanism for
health care media messengers in the U.S.
• Modeled after a pioneering Australian effort – now shelved
• We receive funding from the Laura & John Arnold Foundation

8. We review health care media messages:
• Journalism – that sometimes
looks more like advertising
• Advertising
• Public relations
• Marketing
• Journal policies

9. • 14 MDs
• 6 PhDs
• 13 journalists/science writers
• 5 communication scholars and/or
academic public information officers
• 4 public health grad students
• 3 women with breast cancer (one w/PhD,
two with Master’s degrees)
Every story* is
analyzed by 3
reviewers, each
applying the same
10 criteria
As of April 1, we’re also reviewing health care news
releases

10. • HealthNewsReview.org reviews news stories
that include claims about interventions:
treatments, tests, products, procedures
• We regularly check:
Boston Globe
Los Angeles Times
New York Times
Philadelphia Inquirer
USA Today
Wall Street Journal
Washington Post
Associated Press
Bloomberg News
Websites of ABC, CBS, CNN,
Fox, NBC
NPR health & science page
HealthDay
Reuters Health
Vox.com
Slate.com
FiveThirtyEight.com
BuzzFeed.com
Websites of TIME, Newsweek,
U.S. News & World Report

11. Our criteria: Does the story …
• Discuss the total cost?
• Discuss how often benefits occur?
• Discuss how often harms occur?
• Evaluate the quality of the evidence?
• Discuss alternative choices?
• Avoid disease-mongering?
• Establish the novelty of the approach?
• Establish the availability of the approach?
• Include an independent perspective?
• Explore conflict of interest in sources?
69% 
66% 
64% 
61% 
56% 
Percent
unsatisfactory
after 2,055
story reviews

12. Most common flaw:
Conveying certainty
that doesn’t exist
• Exaggerating effect size – relative not absolute data
• Using causal language to describe observational studies
• Idolatry of the surrogate: Failing to explain limitations of
surrogate markers/endpoints
• Tyranny of the anecdote: telling success stories but rarely
profiling dropouts, dissatisfied, those who choose conservative
route or lifestyle change instead of treatment
• Single source stories with no independent perspective
• Failing to independently analyze quality of evidence

13. Ignore
or
Minimize
Potential Harms
This is
avoidable
ignorance

14. Although the harm isn’t intentional,
it is very real
• Whips “worried well” into a frenzy, making people
anxious about things that will never bother them
• Raises false expectations about health care system
• Promotes undue demand for unproven technologies
which may do more harm than good
• Distracts from the important health care delivery
and health care policy issues that deserve attention
This is avoidable harm.

15. Infoxication • Information intoxication
• Like trying to get a drink from a
firehose
• Like a giant tsunami washing over
the American public every day
• Health care marketing messages
• DTC drug ad disease mongering
• News & Talk shows
• Journals competing for public attention
• Medical center/industry news releases
• Editorial cartoons
• Patient advocacy groups
• Social media messages

16. Drivers of overdiagnosis
Technological changes detecting ever smaller “abnormalities”
Commercial and professional vested interests
Conflicted panels producing expanded disease definitions and writing
guidelines
Legal incentives that punish underdiagnosis but not overdiagnosis
Health system incentives favouring more tests and treatments
Cultural beliefs that more is better; faith in early detection unmodified
by its risks
BMJ. 2012 May 28;344:e3502. doi: 10.1136/bmj.e3502.
Preventing overdiagnosis: how to stop harming the healthy.
Moynihan R, Doust J, Henry D.

17. Media messages promoting overdiagnosis
in women’s health issues
• Menopause
– Cognitive decline
– Vaginal atrophy (“End the
Silent Suffering” ads)
– CNN: “A new study shows
beyond a doubt that
menopause, not the natural
aging process, is responsible for
a sharp increase in cholesterol
levels.” So when did menopause
stop being part of natural
aging?
• Female sexual dysfunction
– including news about An
extra 0.7 "satisfying sexual
events" per month
• Female orgasmic disorder
• Breast cancer screening confusion
• Celebrity breast CA news: Dr. Holly
Phillips, CBS NY – after Christina
Applegate diagnosis/surgery: “What’s
most important is to screen, so as long as
you get in for screening, I’m happy….
generally, we start home breast exam at
age 20. I suggest every month, at the
same time of the month, examine your
breasts at home and get into your doctor
for a breast exam at least every three
years, earlier if you can.”
• Breast reduction surgery – NY Daily
News let plastic surgeon get away
w/saying: “The pain that women with
large breasts can have has been
compared to when someone gets
metastasized cancer of the spine.”

18. more Women’s health issues
• Aging : NYT twice in a week
– ”Never Too Old for
Plastic Surgery”
– and ”Fighting Cleavage
Wrinkles”
• Plastic surgery “fix” for
resting bitch face
• Overactive bladder ads
• Thyroid – “Start having
hormone levels screened
when you’re 35” – Women’s
Health magazine
• Osteopenia:
– Washington Post blogger:
“Glee” was pretty darned
great last night, eh? I was so
wowed by Gwyneth
Paltrow’s singing and also
with her dancing. Paltrow’s
dance performances were
particularly impressive to
me in light of her recent
diagnosis of osteopenia, a
thinning of the bones that
can lead to osteoporosis.”

19. Preniva parody on SNL
• http://www.nbc.com/saturday-night-
live/video/preniva/n12827
• http://www.healthnewsreview.org/2010/06/s
nl-tops-sally-fields-boniva-ads-with-preniva-
parody/

20. “See how
beautiful 60 can
look? See how
invisible
osteoporosis
can be?”

21. In 2009 after the USPSTF
mammography recommendations,
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.”

22. Battle for hearts and minds of women…and of journalists
…on mammography & many other issues

23. Impact on journalists may have been seen
in one recent week in imbalanced news
• Many stories about NEJM paper about
International Agency for Research on Cancer
breast CA screening recommendations –
stories that often read “Breast screening
reduces risk of death by 40%”
• Almost no mainstream news media stories
about JAMA Surgery paper suggesting surgery
overdone for “low-grade” DCIS

24. “Mingle & Mammogram” parties
Stories describe
pampering,
appetizers,
chocolate, sparking
cider or wine,
flowers, swag bags,
massages, foot
reflexology, and
cuticle paraffin
treatments.

25. Perfect smile, perfect skin, perfect hair
That’s what the CBS
Early Show promotes.
So if you have fine
lines, wrinkles, eye
dark circles, acne, age
spots – CBS tells you
that “All can be easily
treated to enhance
your overall look in the
new year, prevent signs
of aging for the long-
term, and increase
your self-esteem.”

27. Among the questionable advisories from the Post:
•Telling men in their 30s to sign up for complete physicals”
•Telling men in their 40s to get complete physical every 2 yrs
Telling men in their 40s to start skin cancer screening.
20s, 30s, 40s, 50s…”
Tips for Men in 30s, 40s, 50s
• EKG in 30s
• “Men should visit their doctors annually”
• Men in 50s “should be aware they they
need prostate cancer screening”

28. National Cancer Institute:
• about 8% of men will develop cancer of the prostate between
their 50th and 70th birthdays.
• And the lifetime risk of dying from prostate cancer, according to
the American Cancer Society, is more like 1 in 36.
This is what such campaigns tend to do – use the scariest numbers
to “heighten awareness.”

29. We wrote:
Such promotions might help more men if they
spent more time discussing the poor quality of
shared decision-making that takes place around
prostate cancer issues. The DECISIONS survey
found that “most prostate cancer screening
decisions did not meet criteria for shared
decision making because subjects did not
receive balanced discussions of decision
consequences, had limited knowledge, and were
not routinely asked for their preferences.”

30. 2010: AHRQ/HHS “Just in time for
Father’s Day ad campaign”

32. Philadelphia Inquirer unquestioning story

33. NBC’s race to the bottom with
prostate cancer screening promotion

34. Prizes for Prostates

36. Men’s health issues
In 2010, The German drug giant Bayer settled complaints by
three states that it had deceptively used the fear of prostate
cancer to sell One A Day vitamins without proof the pills could
prevent prostate cancer. Illinois’ Attorney General decried Bayer
for trying to increase One A Day sales by “deceptively leveraging
fear of prostate cancer and relied on a promotional campaign
called “Strike Out Prostate Cancer” that enlisted Major League
Baseball as a promotional partner. That effort included
billboards, print and broadcast ads, and testimonials from
baseball players.”

37. Low T ads ran during the NBA playoffs

43. Know Your Numbers media campaigns

45. We provide you with the opportunity to appreciate and better
understand the inner intricacies of parts of your body such as your
spine, your joints or your pelvis through an MRI scan.
Are you puzzled by why you have been having sinus pain, back pain
or knee pain? Are you tired of ongoing treatments that waste your
time and money? Are you curious about what is really happening
inside you? An MRI-based health screening can help get you on the
right path to appropriate treatment and a healthier life.

46. $299 Laser Toenail Fungus Treatment
$50 MRI scan for headache prevention screening
$35 for one Colon HydroTherapy Session

47. Cold”
Makers of Zicam
trademarked the
term “Pre-cold”

49. “hope to persuade state legislators to mandate the heart
exams for all students entering middle school in Texas.”

50. Gupta was shown being wheeled into a CT scanner to
undergo a coronary artery calcium scan. The statement was
made – unchallenged - “Unless you do the imaging and
advanced testing, you are really playing Russian roulette with
your life.”

51. "I'm not generally a big fan of direct-to-consumer TV
ads," says Dr. Mark Buchfuhrer. "However, for this
particular disorder, I think they've done a great
service by spending most of the time identifying the
problem."
But in the process, Glaxo also identified a market
and began introducing Americans to a problem
many people didn't realize they had, or had never
mentioned to their physicians.

52. K-Mart blue light special – free aneurysm screening at
900 K-mart pharmacies, sponsored by Medtronic and
3 vascular surgery professional groups

55. Reuters special report on esophageal cancer :
Cancer screening feeds overdiagnosis debate

56. Television news “teases”
Teases – those TV news set-up lines that tell you what’s “still to come”
after the next commercial – are soimportant that a popular TV news
industry website posted a “How To Tease Health Stories” tip. It’s worth
nothing that the column was entitled “Marketing Matters.”
“When teasing these medical breakthrough stories, remember that the
story is about the results of the study, not the technical specifics of the
research. If the story is about a breakthrough in birth defects, show
healthy kids playing, not researchers. If the story is about a
breakthrough in bone density, show people playing tennis or walking
with a cane. Don’t focus on the dull clinical study, focus on the how this
breakthrough may affect real life. Analyze the research story and look
for its potential benefits down the road. The story isn’t about
cholesterol levels, it’s about fewer heart attacks and living longer. The
story isn’t about prenatal blood allergies, it’s about happy families with
smiling healthy children.”

57. No acknowledgement that just 2 months earlier Victor
Montori of the Mayo Clinic and John Yudkin of University
College London wrote in The BMJ, “The epidemic of pre-
diabetes: the medicine and the politics.”
Harms from overdiagnosis—A label of pre-diabetes bring problems
with self image, insurance, and employment as well as the burdens
and costs of healthcare and drug side effects
A diagnosis of pre-diabetes does not mean that you will develop
diabetes. In fact, of 100 people like you, fewer than 50 are likely to
develop diabetes in the next 10 years
USA Today:
“Pre-diabetes rates fuel national health crisis.”

58. How could this happen?
The USA Today story uses an American Diabetes
Association spokesman as a key source. He is
quoted saying:
“We’ve proven (pre-diabetes) is an intervention
time,” said Matthew Petersen, the association’s
managing director of medical information and
professional engagement. “It’s a call to action.”

59. Fear - DCIS
Online comment:
“I am one of thousands of women who have been HARMED with OVER
diagnosis and OVER treatment of DCIS thanks to a mammogram.
Thankfully I took the time to investigate this problem and got an
expert 2nd pathology opinion and said NO to mastectomy, radiation
therapy and tamoxifen….all were being pushed heavily… after a core
needle biopsy and 3 lumpectomies (which did not get clean
margins)……all of these procedures are very invasive and the
emotional toll is even worse. Then come all the bills…very
stressful…and the docs just want to prescribe Xanax! Nobody really
understands what the harms truly mean…unless you live through it.
We must find a better solution than mammograms as they find too
many NON cancers and miss too many aggressive cancers.”
“Breast Cancer Screening: Let Evidence Trump Fear”
– Health Affairs blog by Shannon Brownlee (Lown),
Lisa Simpson (Academy Health)

60. Dr. Richard Lehman –
BMJ journal review blog
• On precision medicine:
“the immense information load threatens to
overwhelm every person—be they healthy, ill,
medical, or technical—with data that leads to
nothing but more data-seeking and more anxiety.
…The latest way to make the luckiest humans in
history anxious during their short stay on Earth.”
Confusion -
Anxiety

61. JOSH BILLINGS (PEN NAME OF HUMORIST
HENRY WHEELER SHAW, 1818 – 1885)
“The trouble with
people is not that they
don't know, but that
they know so much that
ain't so. …
I honestly believe it is
better to know nothing
than to know what ain’t
so.”
Confusion -
Anxiety

64. In order to drown out the cacophony
and not add to it…we need humor

65. The editors of the Annals of
Internal …not even in the urinal ---
“Confusion, politics, conflicted
experts, anecdote, and emotion ruled
front pages, airwaves, the Internet,
and dinner-table conversations.”
We are flooded and there’s no escape….

66. Dr. Willet Whitmore
Sloan Kettering urology chair >30 years
“Is cure possible in those for
whom it is necessary?
And is cure necessary in those for
whom it is possible?”

67. “The current state of prostate cancer may not be
good medicine but it sure is good business.”
“There are more people making a living from
prostate cancer than there are dying from it.”
“The patient may not be dead but he wishes he
was.”

68. More Whitmore wit
“Tell me what you want to hear and I’ll refer you
to someone who will recommend it.”
“When results are good, we tend to say, ‘That’s
a good treatment.’ When treatment fails, we
shake our head and say, ‘That’s a bad cancer.’ “
“Let’s try to replace heated opinion with cold
facts.”

69. Discussion
gary@healthnewsreview.org
Twitter: @HealthNewsRevu
Or
@GarySchwitzer