Friday, April 03, 2015

“Your Best Chance For Beating Cancer.”

Those who are concerned about the mixup of science and marketing at America's hospitals will appreciate this comment from Tazia Stagg over at, following a post about Emperor of Maladies:

I’m board-certified in Public Health and General Preventive Medicine. The university I went to for college and medical school has a public radio station and an NCI-designated cancer hospital on its campus. The mission of the hospital is “to contribute to the prevention and cure of cancer.” Its current marketing tagline is “Your Best Chance For Beating Cancer.”

Six weeks ago, I emailed the hospital’s CEO (copied the founder and the marketing director) to ask why he thought it was okay to use the inaccurate slogan. The marketing director replied with “I would love the opportunity to talk with you about this,” and instructed me to call him.

Then I found billboards around my neighborhood advertising a health fair–presented by the cancer hospital–to be held on campus for poor minorities (my neighbors). Five weeks ago, I emailed the marketing director to attempt to prevent the inappropriate testing announced on the event website. Instead of answering, he replied with, “I am more than happy to answer any questions that you have.” and “I am happy to speak with you about this.”

I decided to intervene on the event, which appears to have been designed and organized by the marketing department of the cancer hospital. In one of the prostate cancer screening workshops, I requested a microphone during the Q&A session. I asked the non-clinician who had delivered the inadequate presentation in English to tell us about his qualifications and conflicts of interest. (He hilariously answered, “I work at [cancer center] and I have no conflicts of interest.”) Then I pointed out that screening experts recommend against prostate cancer screening, and asked the non-clinician to tell us about the likelihood that a man who accepted these tests would experience benefit or harm (because this hadn’t been included in the non-clinician’s presentation). This, too, was foreign to him.

(At the conclusion of the workshop, as the poor men were rushing out of the auditorium to claim their tickets to free net-harmful tests, he approached me privately, asked me if I had questions for him, didn’t answer my questions, and recommended that I “never do that again.” He also instructed me to “Be careful.”)

This past weekend, I attended a town hall meeting (Ken Burns documentary screening, radio program taping/panel discussion, public Q&A session) at the hospital. A non-clinician on the panel twice recommended prostate cancer screening.

I wasn’t selected to ask a question, so I later emailed my question to the hospital CEO (copied the founder, others, of course not the marketing director): “I attended this morning’s promotional event and would like to understand the following. Considering the position of the word “prevention” in [cancer hospital's] mission statement: Is there now, or has there ever been, a preventive medicine specialist among [cancer hospital's] leadership or on its staff? If not, why not?"

The marketing director sent a reply. Guess what he wrote!


nonlocal MD said...

These sorts of confrontations are necessary although not sufficient. However, we in medicine are now coping with the aftermath of decades of pounding into people (both doctors and patients) that early cancer detection is critical and they need to screen. Just as with quality and safety issues, it is hard to convert the ignorant, especially when you are doing a 180 as with screening. Witness the apparent recent Twitter battle between Mark Cuban and Charles Ornstein.
Yes, I believe there are those who are capitalizing on this ignorance to make money. But, I do think a large proportion of even the provider community is still ignorant itself.

Barry Carol said...

For many years, an annual PSA test was included as a routine part of my corporate physical which my employer paid for in full. I continued to get it after I retired until I became aware that the USPSTF doesn’t recommend it because it isn’t cost-effective. When I told my primary care doctor that I didn’t want the test last year, he resisted but I said, don’t worry. Just note in my chart that the patient declined the test. I told him that I’m in my late 60’s, I’ve never sued anyone in my life and, besides, I believe in personal responsibility. His response: “You’re one of the few.” Fortunately for me, the years of PSA tests never resulted in any additional follow-up testing. However, my experience suggests that defensive medicine driven by fear of lawsuits, especially in litigious states and cities, trumps hard evidence about cost-effectiveness. That’s why I think we need safe harbor protection from failure to diagnose lawsuits for doctors who follow evidence based guidelines and protocols where they exist.

I watched all three episodes of “Emperor of All Maladies” and was impressed by both how far the science of cancer has advanced and how far it still has to go. While I understand that discovering cancer at an earlier stage makes it more treatable, I wish I had a better understanding about the ultimate effect on mortality. Five year survival rates can look impressive when the cancer is discovered early but what’s the ultimate effect on the patient’s life expectancy?

I was also struck by how hard doctors try to deliver bad news as gently and humanely as possible. I understand that a lot of patients, especially the younger ones and their families, just aren’t prepared to hear an unvarnished, honest prognosis if the news isn’t good. That’s why the use of terms like “I am worried” or “the test results weren’t what we hoped for” at least still leave room for some hope.

Peter Yang, MD said...

There is certainly much controversy about the recommendations regarding prostate cancer screening & there are conflicts of interest that exist for people advocating screening, but I disagree with the confrontational style. Furthermore, one could fairly argue that saying "screening experts recommend against prostate cancer screening" is incorrect since most professional societies besides USPSTF recommend a shared decision-making approach: (JAMA: Screening for prostate cancer with the prostate-specific antigen test: a review of current evidence.)

Dr. Daniel Merenstein and his residency program were sued and lost for not screening someone for prostate cancer (JAMA 2004: A piece of my mind. Winners and losers.), even though the patient didn't want it at the time of the visit and it was properly documented in the note. A key part of the plaintiff's argument was that the care was different from the standard of care in the community.

"On June 30, 7 days after the trial started, I was exonerated. My residency was found liable for $1 million.

The plaintiff’s lawyer was convincing. The jury sent a message to the residency that they didn’t believe in evidence based medicine. They also sent a message that they didn’t believe in the national guidelines and they didn’t trust the shared decision-making model. The plaintiff’s lawyer won."

nonlocal MD said...

Yes, but Dr. Yang the article which you cite came from 2004. Thinking on this issue and the entire issue of evidence-based medicine has evolved significantly since then. One could almost argue that someone who is automatically screened and suffers harm without having prostate cancer could now sue for the screening.......

Peter Yang MD said...

nonlocal MD, the article about the lost lawsuit was from 2004, but the first link I provided is a review article about prostate cancer screening guidelines from the March 19, 2014 JAMA.

In that article, table 1 lists that USPSTF recommends against prostate cancer screening. On the other hand, these following organizations recommend that screening be considered for certain patient populations with shared decision-making: American Urological Association (2013); American Society of Clinical Oncology (2012); American Cancer Society (2010); American College of Physicians (2013); Canadian Urologic Society (2011).

There is certainly an argument which can be made against screening, but quite bluntly, it was inaccurate for Tazia Stagg to say "screening experts recommend against prostate cancer screening," and it's concerning how certain this person was of that conviction.

nonlocal MD said...

Peter , I think you are certainly right about blanket statements. I believe that's why Paul, in a post a few months ago, made the far more accurate statement that routine screening in an unselected population of normal males is not recommended (don't hold me to that wording; it's from memory). The nuances of subgroups, etc. are often lost although I think Paul's characterization was probably what Dr. Stagg meant but did not say.

I am left with the cynical thought that it will make plaintiffs' lawyers a bit hard up for citing violations of standard of care any more. But honestly, that's what shared decision making is supposed to be about anyway - making individual, not standard, decisions.

Anonymous said...

What I said was exactly what I meant to say.

Anonymous said...

Try to substantiate the statement:
saying screening experts recommend against prostate cancer screening" is incorrect.

Anonymous said...

No, you're wrong; it wasn't inaccurate.

Who do YOU think are screening experts?

Anonymous said...

Even the AUA, which exists to promote and preserve the interests of urologists (who are not screening experts) recommends against screening in a health fair setting.

Describe your understanding of shared decision making.
Please tell us about your qualifications and conflicts of interest for discussing prostate cancer screening.

Anonymous said...


Thank you for appreciating and sharing this story.

The desktop view doesn't allow replies to comments; and my replies that I entered from a mobile browser appear (when viewed from a desktop) as comments 7 thru 10, instead of replies to 6, 3, 5, and 5. It's difficult to follow the conversation, and Dr. Yang's complaints look like they went unrefuted. Can you change the theme to one that allows/displays conversation threads in both versions?

Paul Levy said...

I don't see a setting change that allows that. Perhaps you can advise on how to do it.

Anonymous said...

I'm not very familiar with Blogger, but after looking into this, my new best guess is to try this:

On your dashboard, click Settings | Posts and comments. Then for Comment Location, select Embedded. Then Save Settings.

Paul Levy said...

Nope, sorry, that doesn't do it. I don't think the format you hope for is offered.

Anonymous said...

Thank you for trying.

If that didn't work, maybe there is a glitch in the template code. You might be able to get help from Google by using the report a problem feature.