Pride and Prejudice
October 11, 2010 -- Today The Washington Post ran an excellent op-ed by Veneta Masson, the Washington, D.C. nurse practitioner and writer, based on an article she wrote for this month's Health Affairs. Explaining why she no longer gets annual mammograms, Masson discusses the research about the flawed test, finding no evidence that it actually saves lives. And she points to downsides including the severe harm many suffer from unnecessary treatment following false positives. The Post rightly describes Masson as a "nurse practitioner," even though she no longer practices, because nursing is a profession. But a story on the mammogram debate that aired today on National Public Radio's Morning Edition was not so good for nursing. Richard Knox's piece includes a brief statement by Masson, but it refers to her as a "former nurse practitioner." By contrast, it's unusual to hear a reference to a "former physician." In addition, NPR cites Masson only as a "patient" to provide balance for the views of another patient who supports screening but who has no evident health expertise. Then the piece shifts to quotes from "experts," implying that Masson is not one, despite her 20 years as an NP and the fact that her articles discuss the relevant research in some detail. NPR does include as an "expert" a public health physician who chaired the Federal Task Force on Mammograms but who appears to have no professional expertise in oncology. The online version of the NPR story at least mentions Masson's Health Affairs article, but the broadcast does not. We thank Masson and the Post for helping the public understand that nurses are articulate, informed health advocates.
Expert or patient?
Nurse practitioner explains why
Masson's Post op-ed is headlined, "Nurse practitioner explains why she refuses to endorse routine mammography." Masson describes her personal decision to stop getting annual mammograms, including her interactions with others about it, but she also provides her analysis of the research that informed her decision. So the piece is a mix of personal and policy analysis.
Masson begins with her own visit to another nurse practitioner some years earlier to get a prescription for a bladder infection. Although it was not the purpose of the visit, this NP also wondered why Masson had not recently had a mammogram. Masson says that the NP seemed unable to grasp that the reason Masson had stopped getting annual mammograms was that she did not believe they were useful, rather than any lingering distress related to the early death of Masson's sister from breast cancer. Masson left the NP's office with the prescription she needed, but she wishes she had said more to explain her views about mammograms:
My sister's cancer, discovered in her early 40s during the course of a routine physical exam, sent me into the medical literature with an insatiable hunger for information. It's this search for answers and 20 years of experience caring for women -- many of whom bore physical or emotional scars acquired in the aftermath of suspicious or inconclusive mammograms -- that led me to decide that I could no longer endorse the tests as routine screening measures for me or any other woman.
Thus, Masson writes not only from her personal experience, but from her professional experience and expertise. She includes other passages that underline these two aspects of her search, including reading Dr. Susan Love's Breast Book.
I was impressed by how plainly and intelligently Love, a breast surgeon, presented the research findings about mammography. I began to go through research studies online and in the medical library. I studied the wordings of my patients' and my own mammogram results. They were almost never reported as normal, but as "benign findings" or "no evidence of malignancy at this time." Keep coming back, they seemed to predict, and we'll find it. In my practice and personal life, I saw how women embraced the well-intentioned but relentless messages from medical, workplace and women's groups to "take the test, not the chance." Mammograms save lives, we were reminded.
Masson argues that the "engine of breast cancer awareness" has resisted the studies that have appeared questioning whether the benefits of routine mammography "for a few women" are worth the "significant cost in unnecessary follow-up and treatment for hundreds of others." She notes that other women tell her how early detection and treatment saved the life of their loved ones. But she quotes from a review of the relevant research presented online in 2008 by Denmark's Nordic Cochrane Center:
"If 2,000 women are screened regularly for ten years, one will benefit from the screening, as she will avoid dying from breast cancer," the pamphlet says. "At the same time, ten healthy women will . . . become cancer patients and will be treated unnecessarily. These women will have either a part of their breast or the whole breast removed, and they will often receive radiotherapy, and sometimes chemotherapy. Furthermore, about 200 healthy women will experience a false alarm. The psychological strain until one knows whether or not it was cancer, and even afterward, can be severe."
The pamphlet also explains that there is no evidence that those who get regular mammography screening live longer than those who do not get it. Masson also cites "a January 2010 commentary in the Journal of the American Medical Association that breast cancer is just as treatable and just as deadly regardless of screening."
But Masson says she is not surprised about the fierce debate that began in late 2009 when the U.S. Preventive Services Task Force recommended that women in their 40s and those older than 75 "talk to their doctor" about how often they should be screened, and that even those in between those ages be screened only every two years. She says that the public, "including most health professionals, clung to the belief that early detection saves lives." Masson acknowledges that metastatic breast cancer is terrible. But she says that she simply disagrees that early screening presents an overall benefit, even though her own risk might be higher because of her sister's cancer, explaining that "that fact doesn't make screening any more valuable to me than it would be to another woman -- unless I believe that early detection will guarantee a better outcome for me. I don't." Masson says she would have a diagnostic mammogram if she found a lump, though she would also seek additional opinions because of the high rate of error in diagnosing breast cancer at early stages. And she is prepared to change her mind about routine screening if there are dramatic breakthroughs that increase the value of early detection. But for now, she notes:
I will always mourn my sister's untimely death, which took place three years after her diagnosis despite state-of-the-art treatment. If it were in my power, I'd honor her by redirecting the $5 billion this country spends each year on screening mammography to the study of how breast cancer starts and what we can do to treat it more effectively.
Masson closes by noting that, "in the meantime, it's been 10 years since my last mammogram." The note at the bottom of the op-ed describes her as "a nurse practitioner and writer" whose "most recent book is a collection of poetry, Clinician's Guide to the Soul." And the Post notes that Masson's "essay was excerpted from October's edition of Health Affairs magazine," telling readers that it "can be read in full at www.healthaffairs.org."
Masson's essay is a well-written and well-reasoned piece of advocacy. Regardless of readers' perspectives on annual mammograms, this piece conveys that nurses are thoughtful, informed, and articulate health practitioners. Masson explains clearly the factors that have persuaded her to adopt her position on the screenings. Yet she is not unduly harsh with those who disagree, even though she has obviously experienced some negative or uncomprehending reactions, as she did with the nurse practitioner to whom she went for the infection. That NP does not come off incredibly well, but her raising of the mammogram issue during an unrelated visit at least reflects advanced practice nurses' holistic approach to care. And it is clear that the NP is at least trying to be sensitive. The NP's view of mammograms simply represents that of most health providers. And the simple fact that Masson visited the NP for her primary care, with no mention of a physician, also conveys that APRNs are fully capable of providing that care themselves. Given this, Masson's characterization of the Task Force recommendation about talking to the "doctor" seems odd, but maybe she is just adopting the Task Force's language. Especially given Masson's own counterexample, readers are unlikely to draw any negative conclusions about nurses generally. A similar analysis applies to Masson's praise for physician Susan Love. It might be a problem for a piece to present a physician as far more evolved and informed than a nurse on a particular health topic, but not if the author of the piece is herself a well-informed nurse who agrees with the physician after conducting her own rigorous analysis of the evidence.
In presenting Masson's views, the Post pretty much does everything right. The decision to run the piece at all--the opinions of a nurse!--is commendable. Rarely do major newspapers run op-ed pieces by nurses, though the occasional pieces by Theresa Brown in the New York Times and elsewhere are notable exceptions. The piece also puts Masson's status as an NP front and center, right in the headline, clearly suggesting that her profession is relevant--in other words, read this because it is the view of an expert, or at least of a health provider with the judgment and experience to have important information. The piece does not say that she is a "former" NP. The editors do note that Masson is also a writer, mentioning her latest book of poetry (in 2005 we reviewed a "VidLit" (flash animation work) based on her compelling poem "The Arithmetic of Nurses"). And the editors conclude by telling readers that Masson's essay is based on a longer piece in Health Affairs, with the location of the website--nurses write for health journals!
Expert or patient?
The NPR story about the mammogram debate aired the same day, but the messages it conveys about nursing are very different. Morning Edition host Linda Wertheimer begins by noting that the federal task force's 2009 recommendation that annual mammograms be "optional" for women under 50 "caused quite an uproar," and that recent studies have had a similar effect. Reporter Richard Knox explains that these studies reach contrary conclusions about whether the screenings save lives, then says, "the experts can't agree, and patients don't either." The first patient Knox quotes is Carol Rabinovitz, "a Massachusetts woman who's convinced mammograms saved her life" and "doesn't think problems like false positive tests matter, even if they cause millions of women to get needle biopsies that turn out not to find cancer. In fact, she has no use for people who dwell on those downsides." Rabinovitz feels strongly:
I just can't believe that anybody would say that people in their 40s shouldn't be getting mammograms. . . . Why [needle biopsies] would be a downside - my God. If it is cancer, wouldn't you want to know? And if it isn't cancer, hooray. And so you were uncomfortable for a minute and a half.
This dismissive attitude might be justified if all we were really talking about was a moment of discomfort, but of course, as the actual research Masson discussed in her essays showed, that is not the case--there is a high incidence of unnecessary treatment and extensive resulting harm. Masson is the "patient" to whom Knox turns for a contrary view. Knox notes that Masson is a "former nurse practitioner" who "stopped getting mammograms 10 years ago" even though "her sister died of a breast cancer that was missed on a mammogram" (actually, we take Masson's point to be not just that the regular screenings miss cancers, but that there is no evidence the screenings improve patient outcomes even if they do detect cancer). The story quotes Masson:
I thought: Why am I doing this? There was no strong scientific basis for continuing with doing mammograms as a means of saving women's lives. . . . I would say that mammography was a worthy attempt, but it's a failed attempt. Let's let it go.
Knox does not address the research Masson cites, or use any further analysis of that research from her. Instead, he observes that, "in their recommendations to American women, the experts are just as divided as the patients." He turns first to "Dr. Otis Brawley, the American Cancer Society's chief medical officer." Although the Society still recommends regular mammograms for women under 50, despite the task force recommendation, Brawley concedes that it's not a very good test, and Knox explains how much mammograms miss compared to other tests. Brawley's comments focus on how unfortunate the intensity of the debate is, but they do not address the "downsides" that Masson explained in such detail or discuss how we should balance them against what Knox calls the "modest" benefits of screening. Instead, Brawley simply advises women to "stay the course" and keeping getting screened. The next expert quoted, however, does at least address this balancing. He is "Dr. Ned Calonge, chairman of the federal task force," who notes that younger women are more likely to get false positives, and to be (in Knox's words) "treated for cancers that may never cause a problem." Calonge explains:
That's why we think it should be in the hands of the woman herself. As the harms mount and with the relatively small potential benefit, a woman should understand that and make her own decision.
Including this vague reference to "harms" at least suggests that unnecessary treatment is a problem, but does not begin to convey how severe a problem it is, as Masson's Post essay does. In addition, though Calonge did chair the task force, his online biography does not indicate that he has any particular expertise in oncology; as the chief medical officer of the Colorado Department of Public Health and Environment, his background seems to be in preventative health and family medicine.
Knox closes the piece with a short description of the reaction of women generally to the ongoing controversy. He consults "breast cancer survivor" P.J. Hamel, who says that because the scientists do not agree, "we're just going to continue to get our mammograms." Knox concludes that "it's not a great tool for detecting breast cancer early, she says, but it's the best one we have right now." Of course, that doesn't quite address whether it's a tool worth using.
There is one significant difference for nursing in the online version of the story. In describing Masson's decision to stop annual screenings, that version mentions that she "spells out her decision in an essay in the journal Health Affairs." Listeners of the radio show don't get that information.
We appreciate that NPR included Masson's perspective, said that she was an NP, and at least included a mention of her Health Affairs piece in the online version. But other elements of the story send less helpful messages. First, of course, the piece refers to Masson as a "former" NP, suggesting that nursing is not a real profession. More fundamentally, even though the piece does mention that, it clearly tells readers that Masson belongs in the general category of "patients" rather than "experts"--even though it is open to including as an "expert" a person with no more evident professional expertise in breast cancer than Masson has. Why mention that Masson is an NP at all if she is being quoted merely as a "patient"? You could also argue that setting Masson up as a counter to a patient who has understandably strong views but who seems to have such a limited awareness of the actual debate about screening is disrespectful to Masson, whose views on the issue are nuanced and well-informed, whether you think she is correct or not. Finally, though we realize we can't expect NPR to provide a complete account of the view of each source it consults, we wish it could have conveyed more of Masson's actual reasoning, instead of choosing mostly quotes with little content (e.g., "Why am I doing this?"; "Let's let it go."). The piece does get in a reference to the downsides, but it is inadequate and linked to Calonge.
On the whole, in terms of conveying what Masson actually has to offer on the subject of mammography, we would say that the NPR story is a worthy attempt, but a failed one.
See the article "Nurse practitioner explains why she refuses to endorse routine mammography," by Veneta Masson, posted on the Washington Post website on October 11, 2010.
See Veneta Masson's essay "Why I Don't Get Mammograms," in the October, 2010 edition of Health Affairs magazine.
See and hear the NPR report "In Mammogram Debate, Differences Aren't So Big," by Richard Knox, posted October 11, 2010. Email him at email@example.com and please copy us on your letter at firstname.lastname@example.org.
See our analysis of an earlier NPR piece by Richard Knox about access to ventilators following mass casualty events, "The ventilated elite," from March 12, 2006.