Overselling the goods … no wonder patients get confused!

One of the problems every patient faces in making decisions about prostate cancer therapy is, “Who do you believe?”

Sadly, some elements of the health care community have a history of “over-hyping” the value of the techniques that they practice (and that they certainly believe in). Here are just three prostate cancer-specific examples from the past week’s media:

  • “Our data show that focal cryoablation is as good for prostate cancer control as any other treatment — including surgery, radiation and hormone therapy — but it is less invasive and traumatic for patients, preserves sexual and urinary function and has no major complications …” according to Dr. Gary Onik of the Center for Safer Prostate Cancer Therapy in a media release issued this morning.
  • “A long-term study revealing the longest reported Prostate Cancer Cure Rates in the world [was] presented at the annual meeting of the American Society of Clinical Oncology in Orlando, last week,” according to a media release from the Dattoli Cancer Centers & Brachytherapy Research Institute. This release went on to make the point that, “Already the extreme and often damaging radical surgery of the past 20 years is disappearing, as men now have proven options that defeat the cancer and preserve the quality of their lives after prostate cancer.”
  • “The Belgravia Centre report[s] that a lot of fuss is made about the possible short-term side-effects of Propecia, especially from its competing, but less effective products. But new evidence seems to indicate that Propecia may in fact significantly reduce the risks of prostate cancer.” This from a media release on March 6 from a London-based hair-loss clinic!

[Editorial note: All bold italic type in these quotations has been added for emphasis.]

In the case of Dr. Onik’s statement, cryotherapy is well known to be associated with major complications that can include formation of fistulas, incontinence, erectile dysfunction, and so-called “urethral sloughing.” A bad cryotherapist can make just as much of a mess of a patient as a bad surgeon!

In the case of the Dattoli data, they defined a “cure” as “actuarial freedom from biochemical (disease) progression.”  That isn’t a “cure.” That’s a statistical construct based on PSA data. And regarding the “extreme and damaging surgery of the past 20 years,” certainly it has been disappearing … only to be replaced by some improvements combined with the still extreme and damaging effects of poorly executed robot-assisted laparoscopic prostatectomy (among other things).

Finally, in the case of Propecia, there is no evidence whatsoever that a 1 mg daily dose of finasteride (the active dose of finasteride in Propecia) prevents prostate cancer at all. The active dose in the PCPT trial that showed a reduction of risk for prostate cancer was five times higher at 5 mg of finasteride per day.

It would be easy to come up with literally dozens of examples this sort of inappropriate and over-hyped claim for the effectiveness and safety for all sorts of specific treatments … but making this sort of claim misleads patients who are at risk of believing what they read — particularly when it is said by someone with the letters “MD” after their name! And so that we are clear, this sort of over-hyping of the results of specific types of therapy has been and is as common in the surgical community as it is in the cryotherapy, brachytherapy, radiotherapy, and other treatment communities.

The “New” Prostate Cancer InfoLink is of the opinion that this type of over-promotion and unreasonable claim is just sad and unnecessary. Every form of treatment for prostate cancer has adverse effects — most of them well understood and well-described. The medical community should be making more strenuous efforts to curtail this type of marketing, which is just as irresponsible and inappropriate as some of the examples of over-promotion that have been conducted by the pharmaceutical and biotechnology industries over the years and which receive extensive media coverage. By comparison, the over-promotion of specific techniques by the medical community is almost completely ignored.

It would be nice to be able to believe that every physician who treated a prostate cancer patient gave that patient the unbiased and unvarnished truth about the risks and potential harms of the treatment that they were recommending — in addition to the potential benefits. Unfortunately we don’t believe that there is much probability that this will ever happen. What is so sad about this is that it reflects poorly on the community as a whole — not just on those providers who seem unable to control their “marketing gene.” In all too many ways, the physicians and surgeons who do their very best to give patients reliable and unbiased guidance regarding their options are affected by this behavior more than the “marketers.”

As for the patient … Who should he believe? And how on Earth is he meant to know?

5 Responses

  1. Most of what you cite: “formation of fistulas, incontinence, erectile dysfunction,” and so-called “urethral sloughing” is associated with whole gland treatment, not focal therapy. Dr. Onik is seeing relatively little of that with the patients he’s treating.

    You are very right — “A bad cryotherapist can make just as much of a mess of a patient as a bad surgeon!” Just go to the good ones: Onik, Barqawi, Bahn and Katz, and any other established cryosurgeon who can show a proven track record regarding prostate procedures. There aren’t many of them out there at this point, so caveat emptor. Maybe the group conducting the focal cryo clinical trial will produce more.

    We can safely assume that Dr. Onik is not being sent patients by many urologists or radiation oncologists, so publicizing his successes has to be one of the only ways he can make his presence known and get new patients. That article is the most enthusiastic of any of his stuff I have read to date. His web site is pretty low key.

    His “overselling” is more than offset by the dearth of information on the risks of mainstream treatment on most sites including the ACS site and this one. The odds of coming out of an RP without significant side effects are over 50%. That’s what we do KNOW, but that’s the LAST thing you see anywhere in print. (Source: Sanda MG, Dunn RL, Michalski J, et al. New England Journal of Medicine 358;12:1250-1261).

  2. There is criticsm of Dattoli defining ‘…..a “cure” as “actuarial freedom from biochemical (disease) progression.” That isn’t a “cure.” That’s a statistical construct based on PSA data.

    Aren’t all prostate cancer “cures” defined in this way in every study. Aren’t all the promises of cure made by surgeons, radiologists, Uncle Tom Cobley and all based on the non-progression of the disease as measured by a test that is not even disease specific?

    I don’t know why Onik and Dattoli are being picked out here. There are examples closer at home where claims are made that cannot be substantiated.

    Talk about the pot calling the kettle black!

  3. Too many dominos? I find it frustrating in the extreme that there seems a dearth of readily available information on side effects for most of these treatments. The long-term effects of radiation, brachytherapy, HIFU, and cryotherapy, along with the dangers of recurrence associated with each are difficult to tabulate and compare in a more than simplistic fashion.

    In addition, for the patient attempting a long range plan for his life (life? survivability, recurrence , QOL), information on repeatability of treatment, cost of same, and especially more complete data on what alternatives are available for salvage therapy as back up for each one, are needed (i.e., brachytherapy, cryotherapy, or surgery after failed HIFU or focal cryotherapy).

    But this is just my opinion.

  4. Dear Dave: To quote Bill Clinton, “We feel your pain.” Unfortunately there are very few unbiased, multi-center trials comparing any of the different forms of treatment (when used as first or second-line therapies) that allow such comparisons. In the USA, cost data vary from state to state and institution to institution. Outcomes commonly depend on the specific surgeon or radiation oncologist by and/or center at which a specific form of therapy is being carried out.

    We have provided summary information about the various second-line therapies when first-line therapies fail, but that summary could not be based on directly comparative information (because such information is not available). It is what it is. Even when the provider community has tried to develop and implement trials that would allow for direct comparison of first- or second-line treatments (which has happened on occasion), patient recruitment has (generally) proved near to impossible because patients want to chose their form of treatment.

  5. Dear Mike:

    Thanks for the quick response and the links.

    I guess we all want the best information and statistics on treatment in order to select the “best” options for ourselves, even if it means non- participation in these important trials for ourselves. An example of NIMBY in medicine. (Yes I want/need these studies to take place, but Not In My Back Yard.)

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