It's Consumer's Choices as Guidelines Change
It's been a hard day. A glass of wine would take the edge off, and, as an added bonus, it's good for my heart. But wait a minute—a new study just came out saying that same glass of wine may increase my risk of breast cancer.
Or does it, because another study…
Welcome to the ambivalent world of healthcare, where confusion reigns as shifts in science and guidelines seemingly raise more questions than they answer. It was once said of flattery that only three groups of people are susceptible: men, women, and children. The same principle applies to guidelines confusion; no one is immune.
What's a Woman to Do?
The wine conundrum is interesting but hardly unique. A study that came out last year shows for the first time that a compound in red wine, resveratrol, has health benefits in humans. Previous studies were in mice, so this is regarded as a milestone and scientific confirmation of the French Paradox (eat fois gras, drink wine, live long).
However, just as I was thinking of uncorking that nice Pinot, another study caught my eye. A Harvard study, published in the New England Journal of Medicine showed that women who consume 3-5 glasses of wine a week were 15% more likely to be diagnosed with breast cancer. The link between alcohol and breast cancer has been known for some time, but it was believed that women who drank less than 14 glasses a week, or two per day, were not at risk. This study shows that even very moderate levels increase a woman's risk of cancer.
But wait, just when the link between alcohol and breast cancer seemed absolute, another “just-released” study says that red wine may protect a woman against breast cancer. It seems that there is a property in red grapes that lowers estrogen levels, a known risk in breast cancer.
It is understandable that women feel whipsawed by these studies. Dr. Wendy Chen of Harvard Medical School says that women may make their choices based on family history and overall health risks. A woman may feel the value of wine to heart health may outweigh the cancer risk, and heart disease kills more women than cancer. The study on red wine may make this an easier choice, but what if the woman prefers Chardonnays?
Wine choices aside, what about something as simple as an annual physical? Recently, the U.S. Preventative Services Task Force (USPSTF) revised guidelines on PAP tests, saying that only women between the ages of 21 and 65 should be screened and that should be every three years. This revision is not extremely controversial and is supported by the American Cancer Society and other medical groups. Still, it comes as a surprise to many women who have the PAP test yearly as part of their “well woman” checkup. One more sacred totem of healthcare is knocked down as public health studies challenge the “conventional wisdom” of past guidelines.
Guidelines for women's health have been in flux for a long enough time that shifts in recommendations no longer surprise. In 2009, the USPSTF recommended against routine mammography screening for women in their 40s. This produced howls of protest from the American Cancer Society (ACS) and other healthcare groups, resulting in a Congressional hearing. The Task Force has stood by their guidelines despite a storm of criticism that has not abated. ACS has also stood firm in continuing to recommend a yearly mammogram starting at age 40.
Science is not helping to settle this issue; two new studies only add to the confusion with findings that support and negate the value of mammography. Most recently, studies presented in 2011 at the Radiological Society of North America annual meeting suggest a dip in breast cancer detection resulting from a drop in screenings. This drop in detection most impacts women in their forties, a group that accounts for nearly 20% of all breast cancers.
In May of last year the USPSTF came out with new guidelines recommending against the use of hormone replacement therapy in post-menopausal women. This is causing some consternation in women's health circles as many physicians believe that dangers of hormone replacement were overblown in the landmark 2002 Women's Health Initiative study and that hormones have clear benefits for bone and heart health. In fact, recently published research shows a heart benefit in younger women taking hormones. However, the Task Force found limited evidence that hormones in post-menopausal women protect against bone fractures and heart disease, and put women at slight risk for blood clots and other disorders.
As a result, the Task Force put out a recommendation in October that women should take hormones only for the relief of menopausal symptoms and not for longer term disease prevention. For the one out of five post-menopausal women in America who take hormones, this information will create a new decision point in their healthcare. Yet there will not be strong consensus from the medical community to guide that decision.
Most recently, the USPSTF caused another tremor in the world of women's health by recommending against routine screenings for ovarian cancer. Results from a large clinical study revealed no benefit to women from the screening, and there is some risk of unnecessary surgery based on a false-positive test.
Guideline Confusion Has No Gender BiasMen are not immune to the confusion and angst caused by new science and shifting guidelines. Recent recommendations of USPSTF regarding the routinely performed Prostate-Specific Antigen (PSA) screening for prostate cancer have caused quite a stir. In the past year, the Task Force recommended against routine screening based on large population studies that showed little value, and possible harm to men, when the test is conducted.
As if this news wasn't startling enough, to find that a once sacrosanct screening was now “recommended against,” the American Cancer Society offered a clarification that was anything but. Men could “start the discussion” with their physician at age 50, or if they are at higher risk, age 45. Older men, we are told, may not benefit at all since the risks of screening may outweigh the benefits of treatment. Men are urged to “make informed choices” but left to determine how to do that.
Another study was recently published in the Journal of the National Cancer Institute that supports the Task Force's recommendation. This large clinical trial showed that routine PSA testing in men age 55-74 did not prevent prostate cancer deaths. Yet the research findings were not without controversy. Dr. William Catelona, prostate cancer surgeon at Northwestern University, notes, “It is a flawed study.” Flawed or not, it is a study getting a lot of attention and adding little clarity to the screening debate.
A year ago, USPSTF came out with yet another guideline on the PSA test, this time saying definitively that doctors should not perform the screening, that it does more harm than good. This is the equivalent of upgrading a hurricane warning from a category three to a four. The medical community was hardly running for shelter. According to a survey in the Archives of Internal Medicine, only one in two doctors agree with the recommendation, and nearly all agreed that they did not intend to follow the guideline in practice.
In another head-spinning development, while Vitamin E has long been thought to help prevent prostate cancer, it was shown in a National Cancer Institute study that men who take high daily doses of the vitamin have a 17% greater risk of developing cancer. This study, just published in the Journal of the American Medical Association (JAMA), flies in the face of previous studies that touted the benefits of the vitamin in the prevention of prostate cancer.
The treatment front can be just as confusing for men. A National Institute of Health (NIH) panel has just recommended that men with early stage prostate cancer should put off treatment in favor of medical monitoring of their condition. This “go slow” strategy is based on research findings that surgery or radiation does not increase survival and that these treatments often worsen quality of life. In fact, there is discussion about re-branding low risk tumors and calling them something other than “cancer.”
The Kids are Alright (Right?)
Children are not exempt from the whipsaw of healthcare guidelines. The National Heart, Lung, and Blood Institute (NHBLI) just issued recommendations that say all children between the ages of 9 and 11 should have their cholesterol tested. Previously, testing was recommended only if there was a history of high cholesterol or early heart disease in the family. Accumulated research reveals, however, that high cholesterol in childhood can lead to early signs of heart disease.
Despite an endorsement from the American Academy of Pediatrics, this recommendation is not without criticism. Dr. Nortin Hadler, professor of medicine at the University of North Carolina, expressed “grave reservations,” noting that elevated cholesterol levels do not necessarily lead to heart disease. In another wrinkle on the cholesterol front, a new study disputes that raising LDL, “good cholesterol,” levels have any effect on heart health.
Perhaps the most controversial new guideline aimed at children is the one issued by the Advisory Committee on Immunization Practices (ACIP) recommending that boys at age 11 or 12 receive the HPV vaccine. As some politicians have recently discovered, this vaccine is still controversial for girls, even though it offers clear protection against cervical cancer. The argument for vaccinating boys is less compelling, though the vaccine will prevent genital warts and certain cancers, as well as the chance that they will spread the virus. Still, this may be a tough sell for parents who question the value relative to the cost.
So What Does All of This Mean?
On the policy front, the Affordable Care Act mandates that health screenings be paid for by insurance plans without co-pay deductions. This is intended to encourage consumers to get recommended screenings. All health professionals endorse this concept, but the ambiguity lies in what those screenings should be and for whom. Healthcare communicators have a special obligation to understand this dynamic and to help consumers navigate the choices they must make. As studies continue to change the calculus of benefit versus risk in many areas of health, we can expect even more fluidity in guidelines and fewer “clear choices.”
Still, amidst this swirling shift of science and lack of certitude, some conclusions can be drawn:
- Confusion is not going away anytime soon. The adage of medicine being more art than science has never seemed more true. Guidelines change in response to evolving science, and this is a good thing. The unfortunate byproduct, however, is the confusion left in the wake of these changes.
- Physicians are influencers, not deciders. Consumers used to look at physicians as the ultimate deciders on issues of health. Now physicians are positioned as influencers, with the weight of decisions increasingly borne by consumers. We are urged to “partner with our physician” in making decisions, but, ultimately, the patient is the final arbiter in matters of health.
- Consumerism is on the rise. Fueled in part by the plethora of available information online, the rise of consumerism in healthcare has been dramatic. Healthcare is the number one reason that women access the internet. Websites, blogs, mobile apps and other social media offer content on every conceivable health condition. As a result, consumers are more educated than ever before.
- Being passive is not an option. While much of this is empowering, it also puts the burden on the consumer to seek out accurate and credible sources of information. Passivity will not cut through the fog of ambiguity. You have to make informed choices, sometimes on a daily basis.
Nancy Hicks is Director of Ketchum's North American healthcare practice. A 25-year veteran of the health PR business with expertise in corporate reputation, issues management, product launches, branding and consumer education campaigns, she published “Health Communication: New Media, New Methods, New Message” in 2011 and in 2009 received the PRSA Health Academy Lifetime Achievement Award.