Cancer connection: Screening gets star power

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."