Health

Cancer connection: Screening gets star power

When celebrities reveal personal brushes with cancer, their stories have an impact on screening and prevention.

By Kathleen Phalen Tomaselli amednews correspondent — Posted April 16, 2007

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When a celebrity appears on the morning news saying, "I have cancer," it stops breakfast. The viewing public grieves alongside this trusted friend. And listening to details of the celebrity's diagnosis, struggle and, sometimes, even mortality, can lead viewers to search for clues to their own survival. What treatments did that famous person seek? How did the public figure find out? Did the person smoke? What did the celebrity eat? What is he or she eating now? And it is in this moment of shared intimacy that the onlookers feel a bit fragile, even vulnerable, wondering if they might be next.

"The announcement that Dana Reeve had lung cancer just two days after Peter Jennings died from it had many Americans wondering if they should get tested with a CT scan," says Steven Woloshin, MD, research associate with the VA Outcomes Group in White River Junction, Vt., and associate professor of medicine at Dartmouth College in Hanover, N.H.

This example is only one of many.

When former first lady Betty Ford talked publicly about her radical mastectomy in 1974, women followed her urgings to talk to their doctors about mammography.

"Detection rates rose dramatically in a phenomenon known as the Betty Ford blip," says Barron H. Lerner, MD, associate professor of medicine and public health at Columbia University in New York and author of the forthcoming book, When Illness Goes Public. "Celebrity says pay attention."

Personal accounts followed by big-name endorsements of cancer screening are increasingly common. Former New York Mayor Rudy Giuliani urged men to get screened for prostate cancer after his diagnosis, as did former Secretary of State Gen. Colin Powell and retired U.S. Army Gen. Norman Schwarzkopf Jr. Melissa Etheridge boldly performed bald at the 2005 Grammy Awards -- a result of chemotherapy she received for breast cancer treatment -- giving women and men reason to applaud her courage and galvanizing those already enduring this side effect.

"In our culture we are fixated on celebrity. With cancer, celebrity makes it more acceptable," says Robert Schoen, MD, professor of medicine and epidemiology at University of Pittsburgh's Cancer Institute. "It raises consciousness ... but celebrities have to be responsible and careful. They are not doctors. They have to make sure what they are saying is within the confines of what is accepted and appropriate."

According to a 2005 survey published in the Journal of the National Cancer Institute, the majority of respondents said they had seen or heard a celebrity talk about mammography, colonoscopy or PSA testing. Of those, at least 25% said this association made them more likely to undergo the procedure.

Take the impact of news personality Katie Couric's on-air colonoscopy in 2000, following husband Jay Monahan's unexpected diagnosis and death in 1998 from colon cancer at age 42. University of Michigan researchers found that colonoscopies jumped 20%, a rate -- quickly coined the Katie Couric effect -- sustained for nearly a year after she underwent the procedure while an anchor on NBC's "Today."

Trust and a story to tell

There was a time when the word "cancer" was barely whispered, as if talking about it might make it real. But women like Betty Ford, Happy Rockefeller and Shirley Temple Black changed public perception. "It was a revolutionary thing to come forward. They gave license to talk about it," says Dr. Schoen. "And until recently, colon cancer was still not talked about. Katie Couric put a pretty face on it."

"The thing is, if a guy who works at the local power company has prostate cancer and his father had it and his father's father had it, the media won't pick up on it," says E. David Crawford, MD, professor of surgery and radiation oncology at the University of Colorado Health Sciences Center in Aurora. "But if a celebrity has it, everybody pays attention."

Dr. Crawford, who chairs the Prostate Cancer Education Council, recalls that in 1989 this cancer was the most common one diagnosed in men. "Back then, women were talking about breast cancer, and we needed our celebrity," he says. "We needed to start talking about prostate cancer."

And so Dr. Crawford and the council began their search, initially asking comedic legend Bob Hope to step forward. Hope chose, however, not to go public with his diagnosis. "Our first person was Rocky Bleier, Pittsburgh Steelers running back."

The public's attention to celebrities as thought-leaders goes back a long way. It is the premise of much paid advertising and has been used with powerful effect by public health communicators, says Bradford W. Hesse, PhD, chief of the National Cancer Institute's Health Communication and Informatics Research Branch in Bethesda, Md. "Celebrity endorsements of any kind ... are effective because celebrities have access to the public media space. They have greater opportunity to promulgate a message," he says. "Celebrities convey a veneer of credibility."

Much like family and loved ones, the media and celebrity are viewed as trusted advisers, says Georges Benjamin, MD, executive director of the American Public Health Assn. "These people, if they are well informed, can be extraordinarily powerful. They have the power to tell a story."

But sometimes their stories move in the opposite direction.

Consider the tale of fast-driving, rustler-fighting Steve McQueen, known for his man's- man film roles. McQueen long denied tabloid cancer claims. But when his treatment in 1980 for mesothelioma at a Mexican clinic initially shrank his tumors, the star and his doctors went public with the details of his unusual regimen of diet, vitamins, coffee enemas and laetrile injections. In the wake of the subsequent media frenzy, marked by headlines such as "Tough-guy actor's terminal cancer reported in remission" and "McQueen's holistic medicine man," thousands of terminal cancer patients began flocking over the border in search of the cure. McQueen died just weeks later.

Public health implications

"The classic public health message broadcast after Yul Brynner's death, in which he exhorted the public not to follow his example, but to quit smoking, had a very positive and important impact on smoking cessation rates," says Dr. Hesse. "And years later, a positive impact on mortality due to lung and bronchus cancer. It grabs attention and creates motivation."

So what does all this star power mean to public health initiatives?

"We spend a lot of money in public health trying to find ways to educate the public, and it is in no means as effective as one highly known celebrity to make it real," says Dr. Benjamin.

"We believe prevention and early intervention work, and I think from a population perspective it is the most efficient tool that we have. ... Katie Couric's reach was phenomenal, and Lance Armstrong's message [that] you can have cancer and go on and be a long-distance cyclist is a phenomenal message."

Nonetheless there is a cautionary side to this tale, mostly surrounding the downside of emotional pleas such as, "Get screened now," or "Don't end up saying -- if only." Following Katie Couric's colonoscopy, the number of screenings for people younger than 50 also rose, despite the U.S. Preventive Services Task Force recommendation against the procedure for that age group.

Researchers at Dartmouth Medical School and the VA Outcomes Group found that celebrity endorsements of cancer screening tests reach the majority of American adults and influence many of their cancer-screening decisions. "These are typically one-sided messages either asserting that the celebrity's life was saved by a cancer screening test or suggesting that the life of a loved one was lost due to a failure to get screened," says Dr. Woloshin. "These types of well-meaning efforts to promote cancer screening contribute to public perception that screening is a responsibility and there are no downsides to being screened."

Celebrity encouragement should come with warnings, say some physicians. These persuasive messages to get screened are risky and can backfire if there is not a clear safety message to follow. "Screening is tricky because of its complexity," says Dr. Hesse. "Celebrities may do best to inform and raise awareness, rather than seek to persuade for a specific type of test."

There is a degree of alarm -- a degree of storytelling to get attention -- says Dr. Lerner. "When Katie says, 'My beloved husband died of this' ... that's compelling. People relate to a story. It's much more meaningful than statistics, but [the message] could be misleading at first blush about what you want to do."

Primary care impact: Burden or boost?

Primary care physicians can bear the brunt of patients who have heard about celebrity endorsements from the popular media, says Dr. Hesse. Nevertheless, data from the NCI's 2005 Health Information National Trends Survey, published in the December 2005 Archives of Internal Medicine, suggest that patients generally trust their physicians above all other sources.

"When someone comes into the office having heard of a popularized test, it will be crucial for physicians to seize the opportunity for discussion and education," he says. "A little information therapy, in which the consumer is given vetted information to read about the pros and cons of a particular test, can add to the interaction."

Family physician Todd Williams, MD, had several patients come in soon after Couric had her TV colonoscopy. "We talked about her story and her procedure," says Dr. Williams, who is medical staff president of Brown County Regional HealthCare in Georgetown, Ohio. "And they asked me if colonoscopy would be right for them."

Georgetown is small and rural, says Dr. Williams. "I have a close relationship with my patients. It's based on trust. Still, colonoscopy [discussions] came easier when they were more familiar after [Couric's] test," he admits. "I think it had an impact -- even if temporarily -- allowing me to get more colonoscopies performed. ... Katie personalized it, and for the patients who were on the fence, it allowed me to convince them of its importance. I heard less of, 'I'll consider that' and 'I'll let you know.' "

Couric's screening has not been the only influence in this community. "I've had others. A few men came in having heard from NASCAR drivers about screening," says Dr. Williams. "My wife is an avid cyclist, and I use Lance Armstrong's story sometimes when I talk to patients with a new diagnosis of cancer as an example of how cancer treatment has improved."

Dr. Williams says in the end it's all about getting information to patients. "Any way we can get the word out. ... Frankly, I'm all for it."

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ADDITIONAL INFORMATION

The public health impact of star power

In a survey published in the May 4, 2005, Journal of the National Cancer Institute, respondents said celebrity brushes with cancer affected them in several ways:

73% of women 40 and older had seen or heard celebrities like Rosie O'Donnell and Nancy Reagan talk about getting mammograms; 25% said this made them more likely to undergo mammography.

63% of men 50 and older had seen or heard celebrities like Norman Schwarzkopf talk about PSA testing; 31% said this made them more likely to undergo PSA testing.

52% of adults 50 and older had seen or heard celebrities like Katie Couric talk about getting a sigmoidoscopy or colonoscopy; 37% said it made them more likely to undergo one of those procedures.

Other studies concur:

  • A 2003 study published in the Archives of Internal Medicine found colonoscopy rates jumped 20% following Katie Couric's highly publicized on-air colonoscopy.
  • Also, a national trends health survey published in the December 2005 Archives of Internal Medicine found most patients obtain health information before talking to their physician; only 10.9% go to physicians first.

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The downside of celebrity health advice

Along with star power comes the downside of notoriety. "Celebrities are highly visible, and they are human," says Georges Benjamin MD, executive director of the American Public Health Assn. "When they do something embarrassing, their image is linked with the message."

And there is a danger in not reporting the science as exactly as they might, says Barron Lerner MD, PhD, associate professor of medicine and public health at Columbia University in New York. "Mammography recommendations for women between 40 and 50 are controversial and not recommended by the U.S. Preventive Services Task Force, yet if a celebrity says its lifesaving, [people] will do it," he says. "And there are vague ethical concerns. Celebrities like attention and they may tell their story in a certain way. ... There is concern that these stories contain elements of truth and myth."

In a survey by researchers at the VA Outcomes Group in White River Junction, Vt., respondents were so strongly affected by celebrity urgings that most said they would not listen to their doctor's recommendation against a particular screening. "The bottom line is, cancer screening will help some, and some will actually get hurt," says Steven Woloshin MD, co-author of the study. "Don't just take the word of a celebrity, talk to your doctor."

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Cancer touches political personalities

Reports were emerging late last month that White House spokesman and former Fox News personality Tony Snow was facing a resurgence of colon cancer -- a story likely to focus attention on this disease and on the importance of screening and detection.

This information surfaced just days after the news that a recurring cancer, now incurable, had been detected in Elizabeth Edwards, the wife of John Edwards, former U.S. senator and current presidential candidate. In the days since, public health experts have focused on how accounts of her experience will unfold.

"The story is largely unvetted; it is a natural slice of life and could go either way in its impact on public health," says Bradford W. Hesse, PhD, chief of the National Cancer Institute's Health Communication and Informatics Research Branch in Bethesda, Md.

The public first heard of Edwards' breast cancer just after the 2004 presidential election. And her recently published memoir, Saving Graces, candidly details the days leading up to the diagnosis. "I imagine that Elizabeth Edwards' openness, honesty and bravery will ... make it a little easier for people to talk about and perhaps deal with having a dangerous cancer," says Steven Woloshin, MD, research associate with the VA Outcomes Group in White River Junction, Vt., and associate professor of medicine at New Hampshire's Dartmouth College.

Because most coverage of Edwards' story has been positive, it should have a positive effect on awareness of the disease, Dr. Hesse says. "In this sense, the story can even open up teachable moments for journalists, public health professionals and physicians to use in conveying best recommendations for controlling the disease."

Nonetheless, because her story also opens the possibility for debate about screening, quality of life, social roles, career, cancer treatment and health care, the message could go awry. "If the debate is handled irresponsibly, if it focuses on unfounded speculations or fear mongering, the results can be terribly negative," he adds. "If [it] is covered with ... an eye toward understanding the impact of media stories on people's own health-related behaviors, the results can be positive."

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