A moving YouTube video shows a doctor breaking bad news to a woman: she has “an invasive form of breast cancer.” The encounter is staged as an example of how to break bad news. The actor playing the patient responds understandably: she’s always had checkups and mammograms. How could this happen, she asks. The doctor replies that cancer can be found in anyone, even with regular checkups.
This video was presented as a “good” way to break bad news. The doctor gets many things right She asks the patient how she likes to process medical knowledge. She creates a space without time constraints, leaving her pager with her assistant. She answers questions as thoroughly as possible and outlines the next steps.
But she doesn’t address the patient’s very reasonable concern. Doctors and nurses urge women to get yearly mammograms. Educational information on hospital websites will say, “Mammograms save lives.” But I’ve never seen any medical professional add disclaimers acknowledged by the American Cancer Society, like, “You could be one of the 13% with a false negative.” Or ” “treating a small tumor does not always mean it can be cured.”
The FTC will crack down on businesses that misrepresent food content. For instance, a business owner went to jail for promising “low-fat donuts.” I couldn’t make this up.
So as a marketer, I couldn’t understand how the medical world gets away with promises of “preventive medicine,” The idea sounds good. If you can prevent people from getting sick, you save money because you don’t have to provide expensive treatments.
There’s only one problem. “Preventive medicine” (sometimes written as “preventative medicine”) rarely prevents disease. So is It appropriate to call screenings and warnings “preventative?”
[important: I am not a medical professional. My Ph.D. is in business. Nothing in this article should be considered medical advice.]
It’s hard to discuss this with doctors. When I’ve asked, “What do these tests prevent?” they usually sputter something like, “Well, death.” They also suggest I go elsewhere for medical services.
An article in Frontiers in Neurology, discussing Alzheimers, sheds some clarity.
“The World Health Organization (WHO) categorizes preventative interventions as primary, secondary, or tertiary prevention. Primary prevention aims to avoid disease or its associated pathology before it occurs, whereas secondary prevention entails screening to recognize disease in its earliest stages, before symptoms occur, to slow or stop its progression. Tertiary prevention involves the treatment of disease to prevent complications and minimize disability.”
So early detection has been renamed “secondary prevention.” That’s even more confusing than “pre-owned cars.”
Early detection can’t always save lives. In his excellent book, Less Medicine More Health, Gilbert Welch identifies 3 kinds of cancers: birds, turtles, and rabbits. Birds are cancers that move so fast, they’ll kill you as soon as you find them. Turtles move so slowly they may never kill you; going after the turtles can be wasteful and create more problems from treatment. Only rabbits might be caught and stopped early.
A lot of lifestyle interventions are called preventive, but they’re really all about risk reduction. When you lower your blood pressure, you (according to some sources) lower your risk of dying from cardiovascular disease. But you aren’t preventing anything.
In his book, How Medicine Works And When It Doesn’t, Perry Wilson explains that certain measures, such as blood pressure and cholesterol, are surrogates for disease – not endpoints themselves.
“Do you want them to be normal because you want to lower your risk of heart attack and stroke?” he asks. Or do we want to focus on numbers?”
The relationship between these numbers and deadly outcomes isn’t always straightforward. Dr. Wilson summarizes research from the Sprint study on blood pressure, showing that the difference in outcomes between 120/80 and 140/90 isn’t that great when you look at absolute differences. He’s careful to urge readers not to toss their blood pressure medicines, but to (politely) question their doctors.
Colonoscopies also offer risk reduction rather than prevention:
“,,,The lifetime colon cancer risk among those who didn’t get screened was more than 34 per 1,000. This compared with less than 27 per 1,000 among those screened by doctors who were the least adept at spotting polyps and under 13 per 1,000 for those screened by the most skillful polyp spotters.”
So screening by a less skilled doctor reduces risk by 7 per 1000; screening by a skilled doctor reduces risk by 21 per 1000, compared to no screening. How do you apply these findings? It’s totally up to you and your medical team.
As for cholesterol, a JAMA article reported recently that statins reduce the risk of cardiovascular events by one percent or less.
Wha can we take away from this discussion?
Many sources (including Perry Wilson’s recent book) claim they want to increase trust in the medical field. A good first step would be to regulate terms.
The term “low fat” has been carefully defined in terms of fat grams per ounce.
Why not similarly limit “preventive” to something that can be prevented, which is almost nothing?
To their credit, the journal Cancer Causes & Control published an article by two public health specialists associated with Columbia University. They recommend replacing the words “cancer prevention” with “cancer risk reduction.” They specifically note the “confusion and potential harm to patients from the inaccurate use of the words ‘cancer prevention.’”
As they point out, the concept of “risk reduction” will be especially useful among those who are genetically at risk for cancer. In breast cancer, for instance, 5 to 10% of cases“are caused by an inherited genetic mutation,” while other risk factors can be traced to “unplanned changes that occur during an individual’s lifetime.”
Most importantly, these authors say,
“Many [cancer survivors] would agree with the sentiments shared that hearing ‘cancer prevention’ gives a false assurance. Though those that use ‘cancer prevention’ may want to convey hope, it actually creates emotional upheaval when a diagnosis is received. False assurances do not allow a person to be realistic and/or prepared for all possibilities. Everyone deserves honesty.”
As a marketing professional and as a writer, I’ve always been skeptical of exaggerated claims. I’m aware that advertisers have to be careful of the words they use to describe everything from the fat content in food to the effectiveness of laundry detergent.
I’m not a medical professional so I’m not advising anyone to take or not take specific action related to health. But I would like to see more of us question the words we see and hear when we get medical advice.
“Risk reduction medicine” and “early detection” aren’t as sexy or appealing as “preventive medicine.” But those phrases are a lot more accurate and could save many people – especially cancer patients – from emotional stress.