Monthly Archives: February 2012

Unhealthful News 201 – Cutting breast cancer screening funding (sadly, for the wrong reason)

I have watched with great scientific curiosity the fracas surrounding the Komen breast cancer foundation’s decision to stop giving money to Planned Parenthood to provide breast cancer screening, and the subsequent reversal of that decision.  The initial defunding (and the possibility that still exists to simply not grant further funding in the future — the politics are still in play) is generally attributed to right wing attacks on Komen to not support an organization that provides a portfolio of reproductive health care services that includes elective abortions.  The “right wingers” in question are those who favor unplanned parenthood — their enmity toward Planned Parenthood is usually attributed to the abortion issue, though there are a lot of them who are opposed to contraception in general as well as anything that tends to empower women.  The excuse for the defunding was a trumped-up “investigation” by one congressman, but that was obviously rationalization and not the real reason.

(If you missed the story, here is one analysis to link into the story.  I choose this one not because it is particularly good or comprehensive, but because it embeds a video statement from a Komen official whose title is apparently “ambassador”; if you look at it (the initial still is sufficient — you don’t have to run the video), see if you share my take, which was, “huh? is she the ambassador from 1950?”)

Whatever one might think about the ethics and politics involved, it should seem strange to see rhetoric that suggests that one “charity” (Komen is more of a business, making money with licensing the pink ribbon logo and such) giving money to another charity is some kind of entitlement, and its withdrawal is a violation akin to government interference in free choice.  It should not be seen as surprising or scandalous that a single-issue special interest political lobbying group decides it does not want to alienate potential supporters, either donors or those in power, by supporting an organization that is best known for something that is fiercely hated by many.

(Aside: I am particularly amused by the bullshit claim that people who think that abortion is murder should not be so incensed toward Planned Parenthood because they only spend 3% of their budget on abortion services.  That is sort of like saying that we should not be so down on al Qaeda because they only spent 3% of their budget on the 9-11 attacks, and they did some good work in Bosnia.  I trust EP-ology readers are smart enough to not freak out like… well, let’s just say like some people I know, and say “Phillips is saying that PP is like aQ! he is evil and I will listen to nothing he says!”  I trust regular readers will guess that I am generally favorably disposed to PP, and I trust that you will understand the point.)

It is important to realize that the sum involved is modest — a mid-six-figure sum that probably comes out to a single-digit number of pennies for every person who became incensed about the defunding.  Indeed, the last figure I saw put the protest donations flowing into Planned Parenthood over the few days of the controversy at about five times the loss, including $250,000 from Michael Bloomberg.

The whole fight seems less absurd when we recognize it for what it was, pure “our team” versus “their team” power politics.  Anti-liberals (for lack of a better descriptor — it has the advantage of capturing those who opposed liberalism in both senses of the word) are constantly trying to apply pressure against any organization, company, university, etc. that does anything they do not like — if it were organized crime doing this, we would call it extortion or a shakedown, as in “if you want to do business in our neighborhood, you are going to need to pay some dues”.  In this case, Komen caved to the thuggery (which was undoubtedly supported by a fifth column, as is pretty much always the case when any of the aforementioned organizations cave to anti-liberalism).

But the liberal (as in “American activist left”) side saw this case as a good one to fight back.  Unlike trying to save ACORN or engage in stimulus to get us out of the Lesser Depression, this did not require standing up and trying to argue against someone, an act which seems to cause the limousine liberal left to cower in fear.  The lefty politicos realized that no one would express opposition to funding to support breast cancer screening, so they brought out their thugs.  That is, they mobilized mass political action from their base to threaten Komen’s funding, and it worked.  The message was really about more than a few hundred thousand dollars that was already replaced, it was about saying to everyone, “do not give into the opposition’s thuggery, because we can mobilize just as big an army and hurt you just as much as they can.”  The similarity to criminal gangs fighting for territory is no accident, though this should not make it seem odd or even nefarious.  This is mass political mobilization in action, the same force employed in the US civil rights movement, Tahrir Square, or the fight against internet censorship.  It does a lot of good; we should just not pretend it is not what it is.

Notice that this entire analysis involves no mention of health.  Indeed, the saddest part of the whole thing is the “no one would express opposition” bit, along with the fact that there was never any chance that this would cause any fewer mammograms to get done.  This is sad because it continues to be clear that mammography is done far too much in the US and several other countries, and perhaps doing any population screening at all is too much.

A new popular press book by the leading breast cancer screening expert, Peter Gøtzsche, presents the whole case against current screening regimens.  Regular readers of this blog will recall several previous posts about how mass screening for fairly rare diseases in average-risk populations is almost never a good idea (I mentioned the only two exceptions I could think of).  For the case of mammography, the case against is stronger than average — there are the standard screening problems of having to do a huge number of (expensive) screens, the costs of false positives, and the many technically-true positives that would never have progressed to the point they caused harm (I think Gotzsche’s number for this is 1/3; I once calculated that it was closer to 1/2, but I am inclined to defer to him).  But there are also the problems that mammography involves ionizing radiation, and thus causes some cases of breast cancer, and how often the (often unnecessary) treatment is quite injurious.

The biggest cost seems to be unnecessary treatment that is captivatingly difficult to avoid once the screen result is in.  In other words, the case against breast cancer screening is similar to the case against prostate cancer screening, which has now been pretty widely accepted as convincing.  Breast cancer screening, however, has a much stronger lobby of clinics and charities that make a fortune from it.  An article in the Guardian about the book and the topic tells of plans for the UK government to review their current screening recommendations and funding, which are less aggressive than those in the US.  I am not exactly optimistic that science will prevail over the politics.

I will admit that I do not expect to read the book I am sort of plugging here since I am pretty confident I know what it says — I have been following Gotzsche’s work since we were both working on this topic ten years ago.  So I will quote from the Guardian article instead:

The data, Gøtzsche has maintained for more than a decade, does not support mass screening as a preventive measure. Screening does not cut breast cancer deaths by 30%, it saves probably one life for every 2,000 women who go for a mammogram. But it harms 10 others. Cancerous cells that will go away again or never progress to disease in the woman’s lifetime are excised with surgery and sometimes (six times in 10) she will lose a breast. Treatment with radiotherapy and drugs, as well as the surgery itself, all have a heavy mental and physical cost.

“I believe the time has come to realise that breast cancer screening programmes can no longer be justified,” Gøtzsche said. “I recommend women to do nothing apart from attending a doctor if they notice anything themselves.”

So how much health press coverage did Gotzche’s book get?  In addition to the Guardian article, the Telegraph ran an abbreviated version of the same article, suggesting this to not be a left-right issue in the UK.  Beyond that, the same article ran in Australia and there were a collection of non-English-language reports from across Europe and a few other places that I cannot read, but that seem to be basically the same content.  I appears that the Guardian reporter, the health desk editor, deserves credit for the high-quality article and inspiring all the coverage; article sameness would normally mean that they were just all press-release transcriptions, but in this case it is pretty clearly a work of genuinely good journalism.

The limited of coverage is not too surprising, given the politics:

He compares screening advocates to religious believers and argues that their hostile attitudes are harmful to scientific progress. A lot of false evidence has been put forward to claim that the screening effect was large, he writes. Those who tried to expose the errors came under personal attack, as if they were blasphemers.

“I cannot help wonder why many people shrug their shoulders when they learn of scientific misconduct and why many scientists don’t care that they deceive their readers repeatedly and betray the confidence society has bestowed on them, whether for a political gain, for fame, for money, for getting research funding or for any other reason. People may keep on being dishonest, may get away with it and may publish in the same journals time and again, to the hurrahs of like-minded people who are often editors of the same journals,” he writes.

Some of the screening trials were biased or badly done, the book says, for instance by deciding on the cause of death of a woman after researchers knew whether she had been screened for breast cancer or not. The best trials, it says, failed to prove that lives were saved by screening.

(See the trend in what characterizes issues I have become interested in during my career?)

As for coverage of the book and story here in the US, I could find no evidence that it was picked up by any newspaper or broadcast outlet even though the Guardian story was available on the UPI wire service.  With that in mind, it is no surprise that there was no mention, regarding the defunding of Planned Parenthood’s screening, that funding fewer mammogams might not be a bad idea.  As I said, the fight was not about health, it was about proving that the left can exert financial pressure too — not enough to fight Wall Street, but enough to fight the right-wing churches.

I have to say that I find it to be a little odd that people actually give money to Komen.  It is a hugely profitable quasi-business, with a budget that makes anything an average person can donate completely inconsequential, and that spends the money on a cause that is ridiculously over-funded (even apart from the money wasted on too much screening).  Giving money to them seems like giving money to the NIH or the Bloomberg Foundation.  Surely people must care about homeless puppies, or educating African girls, or their local youth center, or something else that desperately needs more funding.  Giving to Planned Parenthood, for example, would make a lot more sense.

And finally, there might actually be a bit more behind the political action by the Bloomberg types than just showing that limousine liberals can mobilize effective counter-thuggery.  Consider that women can be persuaded to get a mammogram at age 40 and every two years thereafter, even though that regimen is clearly doing more harm than good (that is undoubtedly true, even if getting a few between 50 and 65 might be justified).  These women are then perfectly primed to be useful idiots in support of anti-smoking, anti-drinking, anti-sugar, etc. campaigns.  “I am taking the time to engage in prevention and be healthy, so those other people should not be allowed to misbehave and impose costs on the rest of us”, she thinks self-rightiously, oblivious to the fact that breast cancer screening causes a huge net increase in health care spending.  This makes her a perfect soldier for the oligarchs who want to turn the proletariat into focused and healthy means of production, rather than people who want to enjoy their lives for their own sake.  It is astonishingly sad that this is where the “left” decides to draw their line in the sand.  Fights over reproductive freedom are one of the best things to ever happen to the oligarchs, with fights over heavy-handed “public health” interventions running not too far beyond.

Unhealthful News 200 – Peer review: the McDonalds of intellectual discourse

One of the great frustrations I have, trying to exist in the borderlands between science and science-related policy and popular discourse about scientific topics, is the naive view of what it means for a paper having “peer reviewed journal article”.  The failure to understand how little peer review means is shared by some lay people, many policy makers, and even a lot of people who write scientific papers or have titles in that category (being a scientist is a way of thinking, not a credential).  I have a collection of motivating observations, details, and other bits which I will cover in some follow-up posts.  Which to facilitate reading I will come back and catalog in the following space with updates:


But for today, for #UnhealthfulNews 200, I wanted to skip the news and explore an extended metaphor that might help clarify what I am trying to explain.

My father and his contemporaries, who were on the road in middle America a lot, recall the appearance of hundreds of McDonalds restaurants along the highways as a great thing.  Before McDonalds, there were diners and burger joints along the road, of course.  But you always had to worry about quality, including in particular whether the food might make you sick.  It was not necessarily quick or easy to find someplace to eat, the menu had to be navigated and second-guessed, and there was always the possibility that “your type” was not welcome in that particular establishment.  Readers who have never experienced such a world have probably heard related rules-of-thumb, like eat where the truckers are stopping because they have better data on those issues than you do (though I don’t think the word “data” appears in the cliche version of the saying).

Readers without such travel experience probably wonder what is so great about homogenized roadside fast food places, especially those who would never eat at McDonalds, or perhaps even despise the very existence if it and its ilk.  Figuring out the local dining is part of the fun of travel, isn’t it.? Indeed, it sometimes is, but sometimes you are just trying to make time on the highway.  Fast food is as beneficial for that as being able to drive at 60 miles per hour.  From that perspective, the invention of McDonalds (and a few of its contemporary early chains) was a technological breakthrough at the level of having a GPS and search engine on your mobile phone.

Pier Review

Peer reviewed journal publishing in the health sciences (I will address a bit about some other sciences in the followup posts) has very similar benefits as McDonalds:

Convenience:  McDonalds has roadside billboards directing you to the next location and easily spotted buildings.  Journals have indexes.  Whatever someone might claim about really liking the fries (believing in the superiority of the content), this is undoubtedly the biggest draw for a non-local (non-expert) venturing into unknown territory and needing to rapidly get nourished (very roughly educated about a scientific topic).

Safety:  McDonalds has amazing quality control; the chance of getting at least a little bit sick from a random roadside eatery might be as high as 10%, while at McDonalds (assuming the food is something you can eat) it is about 0% .  The journal review process lowers the chance that what you are reading suffers from utterly incompetent analysis or gross bias.  Unfortunately, in public health it does so only by something like the same 10 percentage points.  In other areas of health science it does rather better, but certainly does not eliminate those problems, though few non-experts probably understand the limits of this benefit.

Familiarity: The same quality control means that McDonalds food tastes the same everywhere in the country, and the fare is the same too so for those who do not want to read a menu no thinking is required.  Journal articles almost always follow the same familiar format, and the abstract tells unsophisticated readers what they are supposed to think so for those who do not want to read the study, no thinking is required.

Some of the preceding praise is, of course, not exactly high praise.  Still, I would not want to imply there is no value in either institution.  (Though, I will note for the record that even though I liked it as a child, I have not eaten at McDonalds in 25 years; exception: I just had to try it in India where the beef is replaced with veggie burgers.)  For centuries, what passed for scientific communication in health consisted mostly of the half-assed opinions of physicians, reporting from the basis of their “professional experience”.  The current journal system is obviously as much as improvement on that as McDonalds is over a rat-infested diner that lacks a working sink in the employee restroom.

But then there is the problem of the downsides that exist, even beyond recognizing that the benefits are more modest than many people think:

Homogenization:  Even as standardization and strict recipes create some benefits, they also eliminate the variety of what can be eaten (analyzed) and force everything into the same mold — perhaps appropriate for fast food, but clearly not good for making truly great food (studies that require something other than the standard recipe).  So, for example, a paper that uses atypical methodology that is clearly better than the standard practice is very likely to get rejected.  It might seem like this is not really about peer review as practiced, and it is not entirely, but that is part of the problem.  Assessing what is better requires a lot more effort and specific skill; but the current review process creates a McDonalds-like assembly line, where it is assumed that any vaguely skilled person can be made into a cook (reviewer) and the incentives are for only speed and adhering to standard practices.  Indeed, because so many papers need to be peer reviewed and the qualification for being a reviewer is basically “submitted a paper vaguely related to the topic”, the average quality of the people who review papers in health science is necessarily the about the same as the average quality of those who write them.  They are no more capable of judging what is better (or even good) than McDonalds cooks are of becoming chefs; with a few exceptions, they are both technicians, with no plan, and perhaps no potential, to become chefs (serious scientific thinkers).  Assembly lines fill stomachs and journals with amazing efficiency, but do nothing to create either cuisine or good science.

Frozen in time:  Science thrives on creativity, as does dining (as opposed to mere feeding).  The tyranny of the health science journal publishing system has stifled advances in thinking and methodology for longer than I have been in the field.  If you were to Copy a research report on a topic that is still of interest from moderately decent journal from 1980 and submit it today, and chances are none of the reviews would suggest the methods are archaic.  This definitely differs from many sciences, of course, where the editor would immediately reject, perhaps asking “have you been in a coma for the last few decades?”  Yes, the McDonalds menu has changed, with much fanfare, by about one item a year since the 1970s, and health science journal articles have seen a similar level of evolution, has  but science should be a bit more dynamic.

Unhealthfulness exclusivity: Some would argue that eating any McDonalds at all is actively harmful for your health.  That does not fit my metaphor — there is obviously no harm in consuming journal articles, and indeed there would be terrible harm from ignoring them all (as opposed to never eating at McDonalds, which would be harmless). So we shall acknowledge the departure and set it aside, and instead continue the metaphor with a “Supersize Me” diet of just McDonalds. Eliminating from your diet anything that is not served at McDonalds and its ilk would obviously be a terrible idea.  We would probably agree that anyone who insisted on doing that was seriously misguided. We should realize that the same applies for anyone who claims to be expert on a public health topic, but whose scientific knowledge is limited to the information that appears in journals.

Just like a chain fast food restaurant is a sensible place to eat when you are just passing through, a quick review of just what appears in the journals is not a bad strategy if you only have an hour or perhaps half a day to learn something about a topic.  But if you are in town two days, such an approach is kind of sad.  Claiming to be an expert but only being familiar with the journal literature is kind of like writing a local restaurant guide based on eating at only the restaurants with a drive-through.  Finally, believing something to be true just because it is in a journal is kind of like believing that a McDonalds cheeseburger offers perfect nutrition because it contains all four food groups (if you are under 30, you might have to look up that reference and also search “reagan ketchup”).