Editor’s Note: The following guest post by Gary Schwitzer is reprinted with permission from his HealthNewsReview blog, an indispensable resource for tracking the best and worst of healthcare journalism.
A critical analysis of ABC & Bill Weir’s “lifesaving test” story
by Gary Schwitzer
ABC News is in the midst of a major promotion of Dr. David Agus’ book, “The End of Illness.” In the course of their reporting, they sent Nightline host Bill Weir to see Agus, whom he referred to as “a rock star of science.” Weir had tests as part of his reporting and writes:
As a way to illustrate the kind of technology he uses, Agus put me through a battery of various tests, including a full-body CT scan. It was all very fun and interesting right until the moment he showed me a picture of the calcification in my heart and told me that if I didn’t make some changes, I’d drop dead within five years.
So it was a $1,300 ride through that radiation doughnut that probably saved my life — a test most insurance company would probably reject and some doctors would resist, for fear of “false-positives.” This is the one main thing Agus is trying to change.
“Reimbursement for preventive medicine’s always difficult in our country,” he told me. “You know, the problem is most people change health plans all the time. So if you’re that health plan, why should you spend money on something that’s not going to affect a person until a decade from now? And so one of things we really have to change is we have to push prevention… a heart attack costs hundreds of thousands of dollars. A couple hundred dollar tests along with a drug can prevent it. Obviously it’s cost effective as a return on investment.”
As for the fears that CT scans could both scare and bankrupt a person by showing a scary speck that turns out to be nothing, Agus argues that is no reason to reject them entirely.
“There are false positives or false negatives with any technology,” he said. “It matters who does it and where it’s done. And so, like with anything, any person can pick up a camera and take a picture. But very few people are a Cartier-Bresson, one of the great photographers. It’s the same thing here.”
Rather than frightening the worried well with this one reporter’s anecdote, the piece could have explained what evidence-based recommendations state. They could have explained different risk categories.
“The U.S. Preventive Services Task Force concludes that the current evidence is insufficient to assess the balance of benefits and harms of using the nontraditional risk factors (including coronary calcium scans) to screen asymptomatic men and women with no history of coronary heart disease to prevent coronary heart disease events.”
ABC itself, in the past, posted this independent expert’s quote:
“Calcium scanning is one of the worst examples of medicine gone wild,” said Dr. Steven Nissen, chairman of the department of cardiovascular medicine at the Cleveland Clinic. “It’s taken on a ‘cultlike’ following.”
The American Heart Association and American College of Cardiology’s guideline on this screening is this:
The body of evidence supports measuring coronary calcium score in asymptomatic adults at intermediate cardiovascular risk or low to intermediate risk, but not in low-risk individuals.
There are a number of problems with the story:
1) getting information about coronary calcium may change one’s predicted risk somewhat, but it is not clear that it affects how they should be managed (we are actually studying this right now)
2) the change in risk is usually modest (making the language used in the article over the top)
3) the advice given about treatment is no different than what is recommended without the calcium results (so how has it helped?)
4) no discussion of the adverse effects of getting the information (anxiety, both for the “patient” and his family)
5) no discussion of adverse effects (radiation, incidental findings)
A more realistic scenario might be:
• A man is “on the fence” about whether to start a statin based on a low-intermediate risk (7% chance of heart attack over 10 years)
• The man gets a calcium scan
• If the scan is negative, he continues to work on exercise and healthy eating
• If the scan is positive, he continues to work on exercise and healthy eating, and also takes statin
This is not quite as dramatic, but is more realistic. Whether it is cost-effective depends on the cost of the scan (has to be low) and the cost of the statin (has to be relatively high or otherwise it’s just better to treat without doing the scan.)
Of course, the flip side to the reporter-involvement angle was this piece by ProPublica’s Marshall Allen: “Body Imaging Business Pushes Scans Many Don’t Need – Including Me.”
But that wasn’t the only high-tech promotion ABC engaged in related to its promotion of Agus’ book.
In the midst of the ABC online story about Weir, there’s a link to a piece, “6 Devices That Could Change the Standards of Medical Care.“ It’s another promotion of Agus’ beliefs and statements, including:
Dr. Agus offers a timeline for when he suggests these devices and tests will likely be standard in medicine – some even in your homes – in the next decade.
His timeline predicts 2012 – this year – as the year that full body positron emission tomography (PET) scans will become the standard of care. But the story doesn’t explain: standard of care for what? “To detect disease early on” – as the piece suggests? I don’t think ABC or Agus will have many join them in that prediction of 2012 – or the foreseeable future.
Agus’ ABC timeline also projects 2014 as the year his own DNA test will become a standard of care.
The Navigenics Test, developed by Dr. Agus, analyzes your DNA for genetic risk markers associated with 40 different types of diseases and the reaction your body might have to certain medications used in treatment of those diseases.
No independent perspectives appear. This is nothing but promotion.
Let me emphasize: Perhaps it is good for him that Weir got his scan. We’re happy for him that he’s pleased with his discovery. We’re not given enough details in the story to be able to critically evaluate the doctor’s warning that he’d “drop dead within five years.” But it is not good journalism to present this one anecdote in isolation while waving off false positives as happening with any technology – without including an independent (and easy to find, dissenting) opinion. That’s not sound journalism. We cited several evidence-based perspectives. The story should have as well.