Should You Trust Angelina Jolie or Your Doctor?

If you watched the TODAY show around, say, the year 2000, this might sound familiar:

Katie COURIC: Hi everybody. Here we are, in my kitchen. It’s about 18 hours, plus, before I get my first colonoscopy.

That’s journalist Katie Couric. In this clip, she walks her viewers through the entire process of getting a colonoscopy. From the prep —

COURIC: My first glass. Mmm, mmm, mmm, looking forward to it. Ugh, here goes nothing!

— to the procedure —

DOCTOR: How do you feel?

COURIC: Um, I feel, um, very lethargic.

— to the aftermath.

COURIC: I didn’t feel a thing. You’re brilliant, Dr. Ford. Thank you very much.

Couric’s doctor goes on to tell her that the results were normal. About three years before her on-air colonoscopy, Couric’s husband, Jay Monahan, hadn’t been so lucky. At the age of 41, Jay was diagnosed with stage four colon cancer, and he died just one year later.

An estimated 150,000 people in the United States will be diagnosed with colorectal cancer this year, according to the American Cancer Society. Though colonoscopies are incredibly safe and effective, they aren’t all that comfortable. A long, thin camera is inserted into a place where cameras don’t usually go — to detect changes or abnormalities in the colon. And the preparation isn’t so fun either. Because it involves changing your diet for a few days, and then drinking a laxative to clear out your colon.

Because of what happened to her husband, Couric wanted to ease people’s anxiety about getting a colonoscopy — and show her audience it was no big deal. And, that they should get one too.

COURIC: This is why you need to get tested because catching those growths before they turn into full-blown cancer is what it’s all about. So, make an appointment and make sure you go to someone who’s experienced.

Her intentions were good. But — did Couric’s message work?

From the Freakonomics Radio Network, this is Freakonomics, M.D.

I’m Bapu Jena. I’m a medical doctor and an economist. Each episode, I dissect an interesting question at the sweet spot between health and economics.

Today on the show: Celebrities influence a lot of what we do, from the headphones we buy, to the clothes we wear, to how we style our hair. But do they influence higher-stakes decisions about our health? And if so, what happens when their message conflicts with medical opinion?

When Katie Couric had a colonoscopy on live T.V., it was big news. No one had done — or seen — anything like that before. It caught the attention of this researcher, too.

 Peter CRAM: I’m Peter Cram and I’m a professor and the chair of the department of internal medicine here at the University of Texas Medical Branch in Galveston, Texas.

Peter didn’t happen to catch Couric’s colon-cancer screening live. When he heard about it, though, he and his colleagues had some questions.

CRAM: We jumped on this and said, “Is there a way to try and find some data to see whether this had any impact?”

As any doctor knows, it can be really hard to get people to change their behavior.

CRAM: This is an eternal struggle — lose weight, exercise more, eat healthy, all those New Year’s resolutions, get your mammogram, take your cholesterol-lowering medication.

Still, Peter suspected that Couric’s on-air screening would have some effect on the population. In the year 2000, the TODAY show had around 6 to 7 million daily viewers. He and his team looked at a database of 95,000 colonoscopies focusing on the time period before and after Couric’s screening.

CRAM: And by comparing that we could get an idea about whether those physicians were doing more colonoscopies, whether they were busier after Katie Couric’s on-air colonoscopy. So, what we found was about a 20 percent increase in the number of colonoscopies that these physicians were performing. And that’s important and it’s significant. We know how hard it is to get people to change behavior. So, to find that Katie Couric goes on T.V., has a colonoscopy, and it has an impact, sort of makes you rethink how much we as physicians can do. Or who do people really listen to? Maybe not their doctor.

Peter noticed something else in the data.

CRAM: The other part, though, that’s also really sort of cool is that we also found that the percent of colonoscopies being performed on women increased. So, more women were getting colonoscopies after. And then here’s where it gets sort of funky is that the average age actually decreased. So, there was a tendency towards more women and younger patients getting colonoscopies. And that gets into this tricky issue of unintended consequences or perhaps, are the right people getting screened? So, it’s good news but a little bit of sort of cautionary tale too, perhaps. It seems like Katie Couric increased screening rates, but it was in maybe some high-risk people, but also a lot of low-risk people. The celebrity message needs to get the right people to get screened, not the wrong people.

When Couric had her first colonoscopy — the one she had on-air — she was just 43 years old. At the time, colon cancer screening was recommended for adults starting at age 50, and for younger adults in some high-risk circumstances. Recently, the general screening age has been lowered to 45. But why 45? Why not start screening at age 44?

CRAM: It always is about the costs and the benefits. And the younger you are, the less likely you are to have colon polyps or adenomas. Those are precancerous lesions on your colonoscopy, but you still are going to have a risk of a complication from that colonoscopy. It’s small. Colonoscopies are extremely safe, but there’s always some risk. And then in addition, there’s this cost issue. So, the younger you are, you’re going to incur the same cost, and there’s a lower opportunity for benefit because when you’re younger your probability of having any adenomas or preventing a colon cancer is much lower. So, it’s really all about trade-offs.

This is especially challenging when you’re screening for diseases like cancer, since they run the risk of identifying other conditions that may never affect your health, which some doctors call “pseudo-disease.” Slightly abnormal prostate cancer labs or slightly abnormal mammograms — they can lead to lots of anxiety and sometimes unnecessary medical procedures, like biopsies. The age cutoffs we see for screening tests? They try to balance these considerations against making sure that we also screen people early enough to identify problems that we can do something about.

Peter’s paper was published in 2003 in the journal now known as JAMA Internal Medicine. That was nearly 20 years ago. How, and where we get news has changed a lot since then. So, what kind of influence might Couric’s screening have on viewers today? And what might be some limitations of the celebrity effect? We’ll talk about that right after the break.

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Now, more than ever, there are tons of places to get medical information. Some might say, too many.

 Sunita DESAI: Friends and family can be important influences in a patient’s healthcare decision-making. And then of course the physician, as well. Increasingly, the Internet is playing a role in patients getting their health information. In the social media age, the speed at which information can be delivered and the audience that information can reach has only been amplified. 

That’s Sunita Desai.

DESAI: I’m an assistant professor in the Department of Population Health at N.Y.U.’s School of Medicine. 

Sunita researches how patients make medical decisions. And as she said, people make their healthcare choices with information from all sorts of places — not just their doctor, but from their family and friends, and from the Internet and social media, too. Celebrities, of course, play a role in that.

Katie Couric isn’t the only celebrity to raise awareness for a disease. We see this all the time, actually. Sunita and I worked on a paper that looked at another example of how a celebrity’s messaging could affect preventive care.

DESAI: In May of 2013, Angelina Jolie published an editorial in The New York Times.

It was called “My Medical Choice.”

DESAI: In this editorial, Jolie announced that she had tested positive for the B.R.C.A. genetic mutation. Women who have the B.R.C.A. mutation have a significantly elevated risk of developing breast cancer and ovarian cancer. And so, in this article, she tried to raise awareness about the opportunity for B.R.C.A. genetic testing — urge women to go out and get it, especially if they had a family history of breast cancer or ovarian cancer.

Jolie’s mother died from breast cancer at the age of 56, after a decade-long struggle with the disease. As a result, Jolie was tested to see if she carried the B.R.C.A. gene mutation.

DESAI: The BRCA genetic test is a blood test. And it’s expensive. It runs at about $3,000 per test.

Her tests showed that Jolie had about an 87 percent risk of developing breast cancer and a 50 percent chance of being diagnosed with ovarian cancer. That’s even higher than normal for someone with the B.R.C.A. gene mutation. The test to detect this mutation is expensive for most people, but in Jolie’s case, it paid off. Then, she took another big step.

DESAI: She also announced her decision to get a preventive bilateral mastectomy. And this would significantly reduce or eliminate the risk of her developing breast cancer. 

In the editorial explaining her decision, Jolie wrote: “I wanted to write this to tell other women that the decision to have a mastectomy was not easy. But it is one I am very happy that I made. My chances of developing breast cancer have dropped from 87 percent to under 5 percent. I can tell my children that they don’t need to fear they will lose me to breast cancer.”

DESAI: This article did generate a lot of attention. It was one of the most-viewed articles in The New York Times that year. And, you know, up to that point, certainly one of the most viewed health-related articles in the social-media age. 

Sunita and I had an idea.

DESAI: We know that public figures have a lot of reach and influence, but we really wanted to understand whether the experience or announcement by a public figure about healthcare would actually impact people’s decision-making about their healthcare. 

We collected data on about 9.5 million privately insured women across the country. Then, we looked at rates of B.R.C.A. gene testing before the article came out, and after.

DESAI: We saw a pretty substantial and immediate effect on genetic testing rates following the publication of the article. So, just to put some numbers on this, in the 15 business days before the article, the testing rates were 0.71 tests per 100,000 women. And following the article in the 15 days after, testing rates increased to 1.13 tests per 100,000 women.

So, in other words, Jolie’s article led to a 64 percent increase in the likelihood of a woman getting the B.R.C.A. genetic test.

DESAI: I was surprised by the magnitude. And just the immediacy of it that, you know, in basically two weeks after we are seeing such a large jump. 

There are a couple of caveats I should mention. First, we weren’t able to look at the results of these tests, so we don’t know if the increased testing actually identified more high-risk women who had the mutation, but more on that later. Also, while we had a really large sample size, we only looked at women with private insurance. Our work did show that there was still a big cost with all of this testing.

DESAI: We did some back-of-the-envelope calculations and estimated that the article was associated with 4,500 additional tests being performed in our population, which translates to $13.5 million dollars in additional expenditures from the genetic testing. And these increases were also sustained through the rest of the year as well. So, this wasn’t just a short term, 15-day effect. 

Even though this blood test is expensive, it isn’t invasive. So, you can easily argue that the benefits of B.R.C.A. mutation testing — for some women — outweigh the costs, especially if they can afford it, and if they have a family history of breast or ovarian cancers. But, BRCA mutations are pretty rare. When Jolie wrote the article, she reached a lot of people — the large majority of whom did NOT have to worry about this problem. About 1 in 400 people have a B.R.C.A. mutation.

DESAI: When we have very low incidents of some underlying condition, as we do with the B.R.C.A. mutation, we really want to try to target screening to those that are at higher risk. Especially given that screening is so expensive.

Not to mention: most experts aren’t calling for universal B.R.C.A. mutation testing.

DESAI: There were some researchers at U.C.L.A. that estimated that if we were to screen every woman in the country, that would cost $400 billion. And again, given the low rates of this mutation, that would translate to $1 to $2 million to detect any single carrier.

There was more to our analysis.

DESAI: The second question we wanted to answer was whether this article also led to increases in mastectomy rates.

Remember, we didn’t have information on whether women who got tested for the B.R.C.A. mutation actually had the mutation. But, using the same data, we were able to look at mastectomy rates over a long period of time. We reasoned that if B.R.C.A. tests were positive in the women who decided to get tested because of Jolie’s op-ed, we would see higher mastectomy rates down the road.

DESAI: We did not find evidence that the article resulted in increases in mastectomy rates. And in fact, among women who had had the B.R.C.A. genetic test, we actually saw a small decrease in the rates of mastectomies, from 10 percent of women who had the B.R.C.A. test getting mastectomies before the article to 7 percent mastectomy rates, following the article. And so, the article didn’t necessarily target the high-risk women.

To put it another way: instead of targeting women who were at high risk of having the B.R.C.A. mutation, Jolie’s op-ed seemed to have encouraged more testing among the “worried well.” While it’s amazing that celebrities may be able to reach so many people and influence their healthcare choices, this work shows that there seems to be an inflection point.

DESAI: Celebrity health experiences and endorsements matter, and they can influence people’s behavior. And public-figure announcements, you know, can be a tool. They’re a pretty low-cost and effective means to raise awareness about a test like this or some other service or health message that needs to be delivered. However, our findings related to the mastectomy rates suggest there’s a little bit more nuance here, especially in terms of targeting. These types of messages might not target the subpopulations that need to be targeted.

The COVID-19 pandemic has presented an opportunity to learn — in real time — about the effects high-profile people can have on spreading health information for good and, for not-so-good.

DESAI: With the Covid vaccine, there were celebrities on both sides, right? There are celebrities who seemed to be, like, very publicly anti-vaccine, as well as those who are promoting vaccines.

Let’s take the example of podcaster Joe Rogan. He hosts a show called “The Joe Rogan Experience.” His comments about Covid-19 have been controversial, like his view that young, healthy people don’t need to be vaccinated. When Rogan had Covid last summer, he took the drug Ivermectin, which is NOT an effective Covid treatment. And then a couple of months ago, he had a doctor on his show who spread misinformation about the Covid-19 vaccine. Rogan apologized — sort of — but he also defended his actions.

Joe ROGAN: I will do my best to try to balance out these more controversial viewpoints. I’m not a doctor, I’m not a scientist. I’m just a person who sits down and tries to talk to people and has conversations with them.

Let me just say, there are controversial questions when it comes to Covid-19, things that we should be debating, areas where the science isn’t fully clear but where tradeoffs are certain, like whether to mask two-year-olds. But there are also areas where the science isn’t really in dispute, and in those cases a guy with one of the most popular podcasts in the country should probably strive to be right. He speaks directly to 11 million listeners each week. Which begs another question: how should we be thinking about healthcare advice from celebrities in the first place? Here again is Dr. Peter Cram, from the University of Texas Medical Branch.

CRAM: Charles Barkley, the basketball player, would say, “I am not a role model. I’m a basketball player.” Social media has spread and everybody now has a platform. You know, I tell people, “I don’t talk about Covid; I’m not a Covid researcher. I’m going to stay in my lane here.” And, you know, the gastroenterologists know colon cancer screening really well. The primary care physicians know colon cancer screening really well. I think that it really does behoove us as individuals to think about who are we getting our advice from?

All this is to say, Peter isn’t totally hopeless about harnessing the power of celebrities.

CRAM: I could envision a world where celebrities could significantly help public health in numerous areas. Be it screening, be it taking your blood pressure medication, controlling your diabetes, if the celebrity were carefully delivering a scripted message developed in concert with healthcare professionals. It could be extremely powerful. And in some cases, you know, celebrities have been a cause for good, where celebrities have reached out to certain communities to say,” If you’re worried about getting vaccinated against Covid well, I’ve been vaccinated and I am of the same political, racial, ethnic, gender group that you are.” And I think that when that’s done right, it can be a tremendous force for good.

In April 2017, the rapper Logic released a song called “1-800-273-8255.” That’s the number of the U.S. National Suicide Prevention Lifeline. The song is about a person thinking about suicide who eventually gets help.

LOGIC: I’ve been taking my time. I feel like I’m out of my mind. It feel like my life ain’t mine. I want you to be alive, I want you to be alive. You don’t gotta die today, you don’t gotta to die.

It ended up being a hit, and the music video racked up hundreds of millions of views on YouTube. Researchers from around the world wanted to know if this song had any effect on the suicide rate in the U.S. In a study published in the journal BMJ in December 2021, they looked at national suicide data around three major media events related to the song — its release, the Grammy’s, and the M.T.V. Video Music Awards. The researchers found that Lifeline saw a nearly 7 percent increase in calls and an almost 6 percent drop in suicides in the weeks after these events drew attention to the song. The researchers estimated that 245 lives were saved as a result.

Given the responses we saw to Katie Couric, Angelina Jolie, and Logic, you’d think that celebrity effects on our health are common. But we only hear about research that gets published, and there may be examples where people have looked for celebrity effects but not found them. I want to share an example with you. The actor Chadwick Boseman died in 2020 from colon cancer at just 43 years old.

You might wonder whether his tragic death, which got tons of attention in the media, led to increases in colon cancer screening overall, and especially in Black men. Well, I’ve actually been able to look at this because of you! A few weeks ago, I got two emails from listeners — one a colleague of mine, Max Jordan Nguemeni Tiako, who suggested this idea, and the second from a company called Truveta, an organization of large health systems in the U.S. that have partnered to share clinical data to accelerate research. With these data we were able to see if there were any increases in colonoscopies after Boseman’s death, and there were not — even among Black men, who we thought might have been most likely to respond to his death.

I wanted to mention this study because when it comes to research, we rarely know what we don’t know. Couric’s impact on colonoscopies — especially in younger women — was clear; why didn’t Boseman’s death have the same impact?

In the end, what Couric, Jolie, and others have done is brave. Their stories have probably resonated with people more than numbers or data points. And maybe, more than a conversation with a doctor. So, if there’s a way to bottle up that messaging power and make sure the most high-risk patients hear appropriate information, I say, “Let’s do it.” And if there’s a way to make sure that lower-risk patients don’t undergo tests that they don’t need, I think we have to try to do that too.

Because even if celebrities don’t think people should listen to them — many still do.

Coming up next week: Can we make dying less hard?

JACKSON: The vast majority are wondering, “Why was that not offered sooner?”

And, what stands in the way?

BARNATO: If I gave you the job of walking into a room and telling someone that it looks like their life is coming to a close — it’s not a topic that you want to bring up.

That’s next week on Freakonomics, M.D. If you’d like, send me your thoughts about this episode, or any episode really, at bapu@freakonomics.com. Thanks for listening.

Freakonomics, M.D. is part of the Freakonomics Radio Network, which also includes Freakonomics Radio, No Stupid Questions, and People I (Mostly) Admire. All our shows are produced by Stitcher and Renbud Radio. You can find us on Twitter and Instagram at @drbapupod. This episode was produced by Mary Diduch and mixed by Eleanor Osborne. Our senior producer is Julie Kanfer. Our staff also includes Alison Craiglow, Greg Rippin, Gabriel Roth, Rebecca Lee Douglas, Morgan Levey, Zack Lapinski, Ryan Kelley, Jasmin Klinger, Emma Tyrrell, Lyric Bowditch, Jacob Clemente, Alina Kulman, and Stephen Dubner. Our music was composed by Luis Guerra. To find a transcript, links to research, and a newsletter sign-up, go to Freakonomics dot com. If you like this show, or any other show in the Freakonomics Radio Network, please recommend it to your family and friends. That’s the best way to support the podcasts you love. As always, thanks for listening.

JENA: I don’t know, what celebrity would I take advice from? I don’t know, maybe Dr. Dre? I mean, he’s a doctor, right? You know, Dr. Dre has done some research on chronic disease!