BMJ  2005;330:1156 (14 May), doi:10.1136/bmj.330.7500.1156

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End celebrity endorsement of screening, say researchers

The convict tradition runs deep down under. When a company promoting full body computed tomography was looking for a celebrity to help sell its wares, it turned to the star of that highly successful Aussie soap opera Prisoner, Val Lehman. So on any given Sunday morning this year, many Australians leisurely flicking through the papers have found themselves face to face with the daunting image of prison heavyweight character Bea Smith urging them to go out and get screened for everything. Likewise, former Ashes winning Australian cricket captain Alan Border has been brought in to bat for an advertisement series on body scans.

Sadly for Val and Alan, the image of full body computed tomography has become a little tarnished in Australia and elsewhere. Indeed, an Australian state health authority was so concerned about the failure to properly communicate risks and benefits in some of the promotion that it issued a public health alert in 2004: "Full body scans... involve doses of radiation that health experts do not consider to be justifiable in terms of a health check."

Until now we have had no real idea what sort of impact celebrities like Val Lehman and Alan Border have on those sleepy Sydneysiders reading their Sunday papers. Now a snappy little study just published in the United States gives us some hard data on the effects of celebrity selling, and some cause for grave concern about the way stars are influencing their adoring public.

Researchers from the prestigious Dartmouth Medical College, led by Robin Larson, have produced one of the first rigorous investigations of how celebrities affect enthusiasm to seek screening services. The paper specifically looked at screening for breast cancer and colon cancer, and PSA (prostate specific antigen) testing for prostate cancer. It was published in the Journal of the National Cancer Institute last week ( 2005;97: 693-5).

Following telephone interviews with 500 US households, the researchers found that more than half of the respondents "had seen or heard a celebrity talk about" each of the three screening programmes. Given the representativeness of their sample, this suggests that half of the entire adult population has seen celebrity endorsements for screening, some of which are extremely aggressive in their language. Two examples cited in the paper include former New York City mayor Rudy Giuliani's statement about PSA testing for prostate cancer, "Of course, we probably wouldn't be talking about this if I hadn't gotten screened..." and his following plea, "If you're over 50 or in a high risk group, please get screened—now." US journalist Katie Couric made a similarly powerful plea to undergo colonoscopy screening for colon cancer: "Don't end up saying `if only.' Get tested."

The obvious problem with this simplistic emotional rhetoric is that it is simplistic, emotional, and it is rhetoric—it is not rational or scientific and it is designed to persuade rather than inform. As the science of screening unfolds we learn more every week that the costs, harms, and benefits of screening programmes to society and individuals are complex and uncertain. As the Dartmouth researchers make clear, there are many people who will benefit from these tests, but there are others for whom the early detection of cancer will bring unnecessary testing and treatment: "Screening is increasingly recognised as a two-edged sword," they wrote.

Getting noticed by the public is getting harder because of a more global media environment. Developments like the internet, mobile phones, and multiple TV channels have fragmented the marketplace. Celebrities can break through this information overload, because they are instantly recognised and have their own personal "brand," which they lend to the product or service that they are endorsing or selling, whether they are paid or not.

In Britain, some public health researchers were outraged last year to learn that the US biotech company marketing a test for human papilloma virus, HPV, had worked with a global public relations company to orchestrate a major lobbying campaign involving celebrities including the one-time girlfriend of Hugh Grant, Liz Hurley. According to a powerful investigative report in the Observer, some of the stars did not even know that they were endorsing a campaign, covertly organised by the test maker and its PR company.

One of the strongest critics of that example of celebrity selling was Dr Angela Raffle, who oversees screening programmes for more than one million people in and around Bristol. She told the BMJ last week that while there were scientific trials underway to assess the value of the HPV test in the wider cervical cancer screening programme, the celebrity selling was designed to "bypass the science" and create an atmosphere where politicians could accuse the scientists of "dragging their feet" by insisting on rigorous, but slow, assessments of potentially valuable new technologies.

The problem according to Dr Raffle was that there was no strong evidence that the widespread use of HPV testing would "make any measurable difference to the deaths prevented." On the downside she suggested that there was evidence that widespread use of the test could actually increase the anxiety and uncertainty for women, which is already an issue with the current programme. In the interest of fairness and self flagellation, it is important to add another of her comments. "Even the BMJ fell for the celebrity campaign," she says, citing an enthusiastic news story from 2002, when the company backed celebrity campaign was already underway ( BMJ 2002;324: 1118[Free Full Text]).

The problem is that celebrities don't tend to make statements based on evidence, according to leading cancer expert and Sydney University professor Bruce Armstrong. "Just because Mayor Giuliani believes his life was saved by screening is of no evidentiary value."

Professor Armstrong says that alongside the benefits there are risks: "A few people will experience benefits, such as early diagnosis, but many will experience some harm—anxiety, further testing, and costs, or even unnecessary surgery as a result of being screened." He also has a strong message for the authorities: "While governments or other bodies may promote the benefits of screening, not enough attempts are being made to present an accurate picture of what the downsides are."

Echoing Dr Raffle's and Professor Armstrong's call for scepticism and action, the Dartmouth researchers conclude their recent JNCI paper with a powerful call for reform: "We see no obvious role for celebrity endorsement of cancer screening."

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BMJ raymond.moynihan{at}verizon.net

Australia

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BMJ 2002 324: 1118. [Extract] [Full Text]