The Science of Cancer Prevention:

Where Do Journalists Fit In?

Barry Kramer, MD, MPH,

Director, NCI Division of Cancer Prevention

January 2016

Disclosure Information
I have no financial relationships to

disclose.
Opinions are mine, not official positions

of the U.S. federal government or

National Institutes of Health.

Alarmism in Science

Scientists
make
meaningless
or ambiguous
statements.

Politicians
respond to
alarm by feeding
scientist more
money

The media
translates
statements into
alarmist
declarations

Important Roles of Journalists

Act as bridge and gatekeeper to the public: Whats

really valid and useful?

Serve as honest brokers of new information for the

public
Convey the strength of the evidence
Understand strengths and limitations of study designs
Report new findings in the context of existing

knowledge

The press, on its own, if it chooses, can make

the transition from cheerleaders of science to
independent observers The journalistic
trumpeting of medical cures on the basis of
wisps of evidence, even though accompanied by
sober cautions against optimism, deserves to be
severely throttled back, in recognition of an
unfortunate reality: Though news is sold around
the clock, major advances in medicine come
along infrequently.
Daniel Greenberg, Science, Money, and Politics, 2001

Core Issues in Screening and

Prevention
It is difficult to make healthy people

better off than they already are.

Strong evidence of benefit is

important when putting large

numbers of healthy people in harms
way.

Levels of Decision Making

Level I:

Would you have this done for yourself or for someone

else in your immediate family?
Influenced by ones personal experience with the disease
and capacity to deal with risk.
Affects few people.

Level II:

What would I recommend to my patient/client?

Physician making a recommendation for his/her
patients. Influenced by prior experience, but the
scientific evidence may play a greater role.
Affects possibly hundreds of people.

Level III:

What would I recommend to the nation, the

world?
Across-the-board recommendations for a
population. Must be based on rigorous
assessment of the scientific evidence.
Affects hundreds of thousands, even millions
of people.
7

Bastian, Scientific American blog

March 23, 2014

Questions to Ask About Medical Research

1.

What is the exposure and what is the

outcome?

2.

How certain is it that exposure causes

outcome?

3.

How important is the outcome?

4.

How big is the effect?

5.

To whom does it apply?

Analytic Framework (Prevention)

Targets
Population(s)

2
Interventions

Intermediate
Endpoints

Health
Outcomes

4
Toxicities/
Harms

10

Analytic Framework (Screening)

(Direct Pathway)

Persons
at Risk
Screening
Healthy

Early
Cancer
Detection

Adverse Effects
of Screening

Intermediate
Outcomes

Surgery for cure

Decreased late
stage disease

Adverse
Effects
of Treatment

Health Outcomes
Cancer Mortality
Overall Mortality
Quality of Life

Societal Outcomes/
Trade Offs
Healthcare
Utilization
Cost Effectiveness

11

NY Times, June 8, 1924

"Dr. Bloodgood of Johns
Hopkins declares elimination
[of cancer]almost sure in
early stage."

Deaths from cancer would be

practically eliminatedif
persons afflicted sought
medical aid immediately upon
the discovery of a foreign
growth in any part of
the body.
12

Lead Time Bias

Symptoms
Screen detection

Lead
Time
Bias

Death

14

Are Increasing 5-Year Survival Rates

Evidence of Success Against Cancer?
(SEER Statistics)

Absolute Increase in 5-Year

Survival 1950-1995, %

50
40
30
20
10
0
-100

Pearson r = .00
Spearman r = -.07

0
100
200
300
% Change in Mortality (1950-1996)

400

HG Welch, JAMA, 2000

15

A Closer Look at Outcomes

Health
Outcomes

Surrogate
Endpoints

Very Important

Unclear Importance

! ! ! ! ! ! ! ! ! ! ! !..? ? ? ? ? ? ? ? ?
Fewer
deaths,
period

Fewer
deaths
due to
specific
disease

Fewer
complicat
ions of
disease

Fewer
diagnoses
of disease

Better
test
results

Change
in risk
factor

16

Confounding Variables

Exposure

Outcome

Confounder
Confounding is the death of any
study!

17

Confounding is a concern in any

observational study!
Confounding is more likely when someones
choice (patient, doctor, etc.) determined who
was in the exposed and unexposed group

18

Confounding Variables
Fewer
accidents

Volvo

High SES
Safety conscious
?
Soccer mom
Age

19

Confounding Variables

Hormone
replacement

Lower rate of
heart disease

Health
consciousness
?
Health
insurance
Access to care

20

Confounding Variables

Vitamin/
Supplement
Intake

Lower rate of
Cancer, Heart
Disease

Health
consciousness
?
Health insurance
Access to care

Observational Studies

are guilty until proven innocent."

David Ransohoff, M.D., JNCI, 2006

22

Randomized
Controlled Double
Blind Studies

Randomized
Controlled Studies
Cohort Studies

Case Control Studies

Case Series
Case Reports
Ideas, Opinions

23

The greatest obstacle to

discovery is not ignorance it
is the illusion of knowledge.
Daniel J. Boorstin, 1983

24

25

Doubt is not a pleasant condition,

but certainty is absurd.
Voltaire

26

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