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Pity the Poor Consumer

¹ The Oncologist ² Jackson Clinic, Jackson, TN

We have observed through the years that newspaper reporting of cancer news is often sensationalized but usually the text contains accurate data. On the other hand, headlines may be totally misleading. Given that many readers may have time to read only headlines and others may not have the necessary knowledge to draw reasonable conclusions from the article, it is imperative that the headline writers take reasonable care to get it right. Seldom have headline writers not gotten it right more glaringly than in the recent stories by The New York Times (NYT) and The Boston Globe. On the same day, September 12, 2002, both papers reported the results of a prostate cancer trial that compared surgery (radical prostatectomy) with watchful waiting in men with clinically detected disease. The study was published in the New England Journal of Medicine a day later [1].

The NYT proclaimed "Prostate Cancer Surgery Found to Cut Death Risk," whereas The Globe trumpeted "Two Studies Find No Advantage to Prostate Surgery."

Both newspaper articles referred to a ten-year Swedish study comparing immediate radical surgery with watchful waiting. After a median follow-up time of 6.2 years there was a significant reduction in deaths due to prostate cancer in the surgery group (4.6% versus 8.9%), but a smaller relative improvement in overall survival, which did not reach statistical significance. An accompanying quality-of-life study found, not surprisingly, that impotence and urinary incontinence were more frequent in the surgery group, while complications of local progression of cancer, such as difficulty in passing urine, were more frequent in the watchful waiting group [2]. Clearly this study does not (yet) demonstrate a decreased overall death risk, as implied by the NYT. Neither did it show that surgery was ineffective, as implied by The Globe. It will require longer follow-up time and confirmatory trials to clarify whether or not the decreased death rate due to prostate cancer does result in improved overall survival. Unfortunately, such trials require many years for data to reach maturity.

A further point is that the study, reported with such fanfare, has limited relevance to most patients diagnosed with prostate cancer in 2002. The patients in this study had disease detected by digital examination or other clinical intervention, and thus represented a more advanced stage of disease than the current prostate cancer population, most of whom have disease detected on the basis of prostate specific antigen (PSA) elevation before it is clinically apparent. The fact that surgery significantly lowered prostate cancer specific death rates in the Swedish study gives cause for optimism about the potential for even greater benefit in our current younger patient population with less advanced disease. With improved surgical techniques, the rates of incontinence and impotence should also be less. And with the decline in cardiovascular mortality, postponing or preventing death due to prostate cancer may now have greater impact on overall survival.

In truth, we still do not know with certainty the benefits of surgery, nor for that matter the long-term benefits of radiation therapy. The jury is still out, despite what the headlines say, but the evidence for benefit is growing. This is a particularly difficult disease to study because of its early diagnosis, indolent course, and the confounding issues of quality of life and comorbid disease. The Veteran’s Administration (VA) is repeating the study comparing surgery to watchful waiting in men with primarily PSA-diagnosed disease. Accrual has been slow. It will take another 6 years to complete follow-up to the trial, which began in 1997 [3]. One wonders whether, 6 years from now when the VA study is reported, the results will be relevant to the practice of oncology at that time. Whatever the result, one can only imagine the headlines.

Bruce A. Chabner, M.D. Editor-in-Chief The Oncologist

Dwight Kaufman, M.D., Ph.D. Jackson Clinic Jackson, TN

REFERENCES

1. Holmberg L, Bill-Axelson A, Helgesen F et al. A randomized trial comparing radical prostatectomy with watchful waiting in early prostate cancer. N Engl J Med 2002;347:781–789.[Abstract/Free Full Text]
2. Steineck G, Helgesen F, Adolfsson J et al. Quality of life after radical prostatectomy or watchful waiting. N Engl J Med 2002;347:790–796.[Abstract/Free Full Text]
3. Wilt TJ, Brawer MK. The prostate cancer intervention versus observation trial (PIVOT). Oncology (Huntingt) 1997;11:1133–1139.[Medline]

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