# Presentation: 263339

##       “The Challenge of Effective Communication of     Risk Versus Benefit on Menopausal Hormone Therapy”

- Presentation by Susan Dentzer
*The NewsHour with Jim Lehrer*
-  to the NIH Scientific Workshop
-           October 23, 2002

## For news media, study’s end presented multiple challenges

- Overcoming public’s confusion over terminology: all “hormone replacement therapy” now of concern or just one drug?
- Possible distinction over safety of short-term use versus long-term use of drug
- Prempro study ended but Premarin study continued
- Which risks and which benefits are we talking about? Not everyone understood WHI focused on prevention, not symptom relief and other “quality of life” benefits

## Based on prior experience, our NewsHour hypothesis: 

- A leading cause of mood swings and hot flashes among women had been the seemingly contradictory information from various studies about the benefits and risks of hormone therapy!

## Challenge of conveying risks because of poor “numeracy”

- The 1993 National Adult Literacy survey showed 47% of adult Americans couldn’t calculate difference between regular and sales prices in an advertisement
- A group of mostly high school-educated older female veterans were asked how many times a fair coin would come up heads if flipped 1,000 times. Almost half (46 percent) answered incorrectly (most answered 25, 50 or 250).
- Source: “The Role of Numeracy in Understanding the Benefit of Screening Mammography.” By Lisa M. Schwartz, M.D., MS; Stevel Woloshin M.D., M.S.; William C. Black, M.D., and H. Gilbert Welch, M.D., MPH.  Annals of Internal Medicine, 1 December 1997, 127:966-972

## Among news organizations and members of the public, there was

- Lack of grasp of concepts of  absolute and relative risks
- Tendency to focus mostly on sharp increases in relative risks (emphasized in NIH and JAMA press releases)
- Resulting tendency to go with one “side” of the story versus the other– the sharply increased relative risks or the still tiny absolute risks

## Large and important differences between concepts

- Relative risks for breast cancer increased 26 percent over the five study years in Prempro group versus placebo group
- Absolute risk of breast cancer for an individual woman  = approximately 0.3 percent per year; Prempro use added 0.1 percentage point of risk per year

## “The test of a first-rate intelligence is the ability to hold two opposed ideas in mind at the same time and still retain the ability to function.”	        --F. Scott Fitzgerald

## News Coverage: Emphasizing the Relative Risks “

- “...Researchers found significant adverse effects, even in areas they didn’t expect. Specifically, the women who had been on hormone therapy had a 22 percent higher incidence of heart disease, a 26 percent higher incidence of breast cancer, a 29 percent higher incidence of heart attacks, and a 41 percent higher incidence of strokes.”
- Source: *The NewsHour with Jim Lehrer*, July 9, 2002. Introduction to interview with Marcia Stefanick, PhD, read by Margaret Warner, accompanied by on-air graphic.

## News coverage: Citing the  absolute risks

*Chicago Tribune:* “...the pills now happily being taken by millions of postmenopausal women cause breast cancer, heart attacks and other serious side effects.”
- Second paragraph of story: “ The **absolute risk** is small: Only about 1 percent of the women who took estrogen plus progesterone during the five years of the study had a problem. Nevertheless, the study authors concluded, [don’t take drug to prevent heart disease].”
- Source: “Doubts cast on hormone therapy; Breast cancer, heart risks cited.”  Chicago Tribune, 7/10/02.

## News coverage: Fudging it without the numbers 

*Washington Post*: Prempro use “does more harm than good”
*Atlanta Journal-Constitution*: “the drugs create what [researchers] consider an unacceptable risk”
*Los Angeles Times*: “...a slight but significant increase in the risk of breast cancer (etc.)”
- Sources: “Hormone Treatment Is Called Harmful; Menopause Study Cites Health Risks.”  The Washington Post, 7/9/02, A-1. Also “Health Risk to Women Halts Hormone Study.”  The Atlanta Journal-Constitution, 7/9/02. “Risks of Hormone Therapy Stop Study.” LA Times, 7/9/02, A-1.

## News coverage: Absolute risks but with no basis of comparison

*The New York Times,* 7/9/02: “The data indicate that if 10,000 women take the drugs for a year, 8 more will develop invasive breast cancer...An additional 7 will have a heart attack, 8 will have a stroke, and 18 will have blood clots. But there will be 6 fewer colorectal cancers and 5 fewer hip fractures.”
- Base rates in placebo group not cited
- Source: “Study is Halted Over Rise Seen In Cancer Risk.” The New York Times, 7/9/02, A-1.

## How women responded: the anecdotal evidence

- Many women appeared to us to respond in one of two very different ways
- Focusing on sharp relative increased risks of disease, panicking and going off drug immediately
- Focusing on tiny absolute risks and saying, what’s the big deal?

## Women’s reactions: Focusing on increased relative disease risks

*Atlanta Journal-Constitution*: “ ‘It’s terrifying for those who’ve been told we’ll be on HRT for life,” said Dory Ingram, 55, who’s been on the drug for 15 years, first for early menopause and then for osteoporosis....Thin brittle bones left her grandmother and mother with a dowager’s hump...“She also had some family history of heart disease...‘It is devastating to feel that what you have been doing for yourself all this time has been harmful when you believed it was beneficial.”
- Source: Atlanta Journal-Constitution, “Women React to Finding on Hormone Replacement Therapy,” 7/10/02.

## Women’s reactions: Focusing on small absolute risks

- New York Times, 7/10/02: “I’ve read the reports,” said Rosemary Herpel, 59, of Shaker Heights, Ohio. “We’re talking about 8 more people in 10,000 who got breast cancer. I just think that’s not significant enough to make me stop.”
- She continued, “I’m very concerned with bone loss. I have friends who haven’t taken hormones, and they are experiencing bone loss.”
- Source: “Patients Weigh Quitting Drug After Research Indicates Risk,”  The New York Times, July 10, 2002, A-16.

## Women’s reactions: Focusing on small absolute risks

*Atlanta Journal-Constitution*: “Shirley Osterneck, 61, isn’t as concerned. ‘I’m more worried about the stock market,’ she joked...”
- Source: “Women React to Finding on Hormone Replacement Therapy,” Atlanta Journal-Constitution, 7/10/02.

## At last we get our act together: The NewsHour with Jim Lehrer, 	    October 3, 2002    “Women’s Health Debate” 

## Is there an even better way to convey absolute risks versus benefits in a way that patients can more readily understand? Yes: Schwartz and Woloshin Dartmouth Medical School/VA Medical Outcomes Group,   White River Jct., VT

## Importance of “framing”

- Research suggests that “both patients and physicians presented with two equally efficiacious medications or treatments preferred the one whose benefit was given in relative as opposed to absolute terms.”
- “Best” presentation in screening mammography study was absolute risk reduction with baseline risk – though even in best case, only one third of the women in the study sample accurately applied the information.
- Source: Schwartz et al, Annals of Internal Medicine, 127: 966-972

## Show change in risks (harms) over time

- Most news stories didn’t present data to show how risks (harms) grew worse over the 5.2 years of the study
- Citing the absolute risks on an annual basis makes them look smaller than they in fact are over time
- Schwartz and Woloshin solution: the following tables

## Benefits of drug/no drug for the next year

| 
  BENEFITS 
 | 
DO NOT TAKE DRUG | 
TAKE DRUG |
| --- | --- | --- |
| HIP FRACTURES | 2 in 1,000
women will experience | 1 in 1,000 women will experience |
| COLON CANCER | 2 in 1,000 women will experience | 1 in 1,000 women will experience |

## Benefits of drug/no drug for the next five years 

| 
BENEFITS | 
DO NOT TAKE DRUG | 
 TAKE DRUG |
| --- | --- | --- |
| HIP FRACTURES
 |  8 in 1,000 women will experience |  5 in 1,000  women will experience |
| COLON 
CANCER  |  8 in 1,000 women will experience | 5 in 1,000 women will experience |

## Risks of drug/no drug for the next year

| HARMS | DO NOT TAKE DRUG | TAKE DRUG |
| --- | --- | --- |
| Heart disease | 3 in 1,000 women will experience | 4 in 1,000 women will experience |
| Stroke | 2 in 1,000 | 3 in 1,000 |
| Blood clots | 2 in 1,000 | 3 in 1,000 |
| Breast cancer | 3 in 1,000 | 4 in 1,000 |

## Risks of drug/no drug for the next five years

| HARMS | DO NOT TAKE DRUG | TAKE DRUG |
| --- | --- | --- |
| Heart disease | 15 in 1,000 women will experience | 19 in 1,000 women will experience |
| Stroke | 11 in 1,000 | 15 in 1,000 |
| Blood clots  | 8 in 1,000 | 18 in 1,000 |
| Breast cancer | 15 in 1,000 | 20 in 1,000 |

## What are women really worried about now? Our impression:

- The risk/benefit calculus they’re now focused on is not the prevention equation – i.e., risks of heart disease etc. versus benefits of osteoporosis and colon cancer prevention
- The risk/benefit calculus they want information on is disease risks versus benefits of symptom relief and “quality of life”

## What are women really worried about now? Our impression:

- Women want much more information about different doses, drugs, supplements and other therapies
- Especially urgent since no other therapeutic options have been demonstrated to be as effective in symptom relief as Prempro, Premarin and similar drugs

## News coverage couldn’t offer women much to go on

- Why? Because there isn’t much scientific information to go on
- Sample article, *Los Angeles Times*: “In light of the recent findings, other doctors and women are wondering if natural hormones [estradiol, estrone and estriol derived from plants] are a safer alternative. The answer is that no one knows.”
- Source: “’Natural’ Is No Guarantee; Although more doctors are prescribing hormones derived from plants, no one knows if they are any safer than the traditional type.” Los Angeles Times, 8/5/02, Health Section, Part S, Page 1.

## Some conclusions from this episode

- Future announcements of this magnitude should be accompanied by even more concerted efforts to brief the news media thoroughly in advance
- Closer cooperation with medical professional groups and clinicians before a major announcement would help them provide both the news media and patients with better and more timely information

##                THE END