Reporting on unnecessary cancer screenings

Published on
October 7, 2011

I just posted the story that I wrote for The Center for Public Integrity, which focuses on how much money Medicare spends on unnecessary cancer screenings.

It was a fascinating reporting journey and one that you may be able to partially replicate, as the debate heats up about the necessity of prostate cancer screening tests. The U.S. Preventive Services Task Force, an independent panel of medical experts, just proposed downgrading its prostate screening recommendation, so no men would be advised to get routine PSA blood tests. This may well create a firestorm in upcoming weeks.

When the task force declared in 1997 that women in their 40s did not need mammograms, members -- leading scientists in their field -- were accused of condemning American women to death. When the task force made a similar recommendation a few years ago, it did not fare much better. As I reported my story, I heard a number of people completely dismiss anything the task force had to say, pointing to this controversial breast cancer recommendation.

So much for evidence-based recommendations. If the evidence doesn't agree with what people feel, these recommendations can be an incredibly hard sell. But the controversy makes for compelling -- and important -- public health stories.

I began my story almost a year ago, when the Center for Public Integrity asked me if I'd like to write an article for its ongoing series about unnecessary Medicare spending. The Center and The Wall Street Journal had banded together to get data from CMS, giving both organizations an opportunity to explore Medicare spending like never before.

I started the project by interviewing academics and other public health experts, asking what they thought Medicare was spending money on that was not medically necessasry. While I considered a wide variety of possible angles, I was intrigued by preventive screenings. H. Gilbert Welch, a Dartmouth medical school professor, had just come out with his fascinating book, Overdiagnosed: Making People Sick in Pursuit of Health. Welch believes that overdiagnosis, the process of detecting medical abnormalities that will never harm patients' health, is "the biggest problem posed by modern medicine."

I discovered the U.S. Preventive Services Task Force had recently started recommending upper age limits on some screening tests -- in part, because some cancers grow too slowly to actually harm elderly people's health. There's no point in screening -- or treating -- a 90-year-old for a slow-growing cancer, experts say, because that 90-year-old can't possibly live long enough to be harmed by the malignancy.

Welch wasn't the only talking about this issue. Lots of doctors were concerned -- not just because of money wasted, but because people were being harmed by the tests. Some patients wound up suffering side effects from screenings -- or more invasive follow-up tests. And there were also unforeseen consequences of continued screenings. One elderly woman, who dutifully walked through a snowstorm to get an annual mammogram she didn't need, wound up slipping on the ice and breaking her hip.

My colleague, Elizabeth Lucas, began running all kinds of computer analyses of the Medicare data. We found that there were an extraordinary number of people getting preventive cancer screenings well beyond the ages recommended by the task force. We even found dozens of 98-year-olds getting mammograms.

I not only looked at why so many doctors and patients were ignoring the task force's recommendations , but also at why Medicare began paying for all these tests in the first place. Not surprisingly, I discovered all kinds of political wranglings and financial conflicts of interests.

So, how can you delve into this important topic?

First, for background, I encourage you to read Dr. Welch's book. Also, I always set up a Google Alert, when I'm embarking on a new project. I made an alert for "medical screening test" and every day, received a number of interesting articles that proved helpful in the course of my reporting.

There are some terrific sources willing to talk about screening.

Dr. Welch and his colleagues at Dartmouth were very generous with their time. Also, members of the the U.S. Preventive Task Force are quite accessible. I reached them, after speaking to Karen Migdal, karen.migdail [at] ahrq.hhs [dot] gov, who arranges press for the members.

The American Cancer Society is also a great resource. Otis Brawley, the medical director, is perhaps the most outspoken -- and quotable -- source I've ever interviewed. His colleague, Dr. Len Lichtenfeld, is also quite helpful. He also writes a terrific blog, which is a great source of potential story ideas.

Also, you may want to read or contact Rosemary Gibson, the co-author of The Treatment Trap. Gibson has an interesting webpage. She also helps write the "Less is More" series published in the Archives of Internal Medicine.

Topics to look at?

You could easily focus on PSA testing right now, which is so much in the news. Look at the buses sponsored by Project Zero, which come to many towns around the country offering free screenings. Dr. Brawley, of the American Cancer Society, is concerned that people are getting screenings, but no counseling. Is that really true? Is counseling changing now that the task force is questioning the need for the tests?

Talk to people who go for testing to see if they received any counseling about the benefits and harms of such screenings.

For cervical cancer, you might want to look at how often women are getting Pap smears and HPV tests from their OBGYNS. If women get both tests, they don't need to go for annual screenings any more. But is that happening? If not, ask OBGYNs why they are ignoring the new screening methods.

For stories about breast cancer, you may want to look at the use of digital mammograms in your area. Check out Joe Eaton's story about digital mammography on the Center for Public Integrity website to see what the most important issues are.