Overall impressive: News media coverage of NEJM study on treating vs not treating prostate cancer

Joy Victory is deputy managing editor of HealthNewsReview.org. She tweets as @thejoyvictory

An important new study published in the New England Journal of Medicine provides clarity on outcomes of men with early prostate cancer who either received surgery, radiation or “active monitoring,” which means patients were given routine checks and only treated if the cancer was growing.

Confusion , Direction , ArrowThe study–the first of its kind to investigate this question using a randomized controlled trial, is a big deal–and, encouragingly, received the attention it deserves from U.S. news media, making headlines in many major publications.

We were pleased to see the coverage was overall solid, too: Robust sourcing, level-headed patient anecdotes and an accurate description of the findings were the norm in the dozen or so stories we looked at after the news came out this week.

Patient anecdotes revealed both positive and negatives of the treatment options

Too often, we see patient anecdotes in news stories that focus entirely on the benefits of treatment–overshadowing the hard truth that nearly all treatments come with side effects, harms and costs.

In this case, though, we appreciated the range of anecdotes we saw. For example, in STAT’s thorough and well-sourced story, we hear from a man who chose active monitoring when he was diagnosed with early prostate cancer in his 40s. We learn, importantly that he “dreaded the possibility of side effects of surgery or radiation, including incontinence and impotence.”

And CBS News’s story included input from two different men in the study, one who was assigned to surgery, and the other who received active monitoring. For both, we get a well-rounded sense of how the diagnosis and treatment affected them, helping exemplify how important it is for men to make a measured, informed decision before choosing a treatment.

“Maybe the first option shouldn’t be surgery or radiotherapy,” one man told CBS. “I’m quite happy to have avoided any of those side effects. I feel just fine now so maybe I never needed anything else.”

We did notice that several news stories (CBS, the New York Times) included interviews from the same study participants, which is a common public relations issue we’ve warned readers about recently. In this case, though, the patients’ stories seem to be relatively balanced depictions instead of the one “best-case scenario” that we usually see.

The Times story included not just patient stories, but also was the only one we saw that included the study’s findings on the mental impact among the men randomized into different treatment groups. We learn “there were no differences among the three groups in anxiety, depression or their feelings about how their health affected their quality of life.”

One hiccup: Stressing relative risk over absolute risk

“Men who were otherwise largely healthy and chose to be monitored were twice as likely as the others to see their cancer spread over the 10-year study period,” HealthDay’s story states in its third paragraph.

But this gives the readers the wrong opening impression, because the raw numbers themselves were very small. This is why we have repeatedly called for journalists to include absolute numbers.

To their credit, HealthDay did so, but much farther down in the story: “…cancer spread in 33 of the 545 men in the monitoring group compared to 13 of 553 in the surgery group and 16 of 545 in the radiation group.” We also learn that despite this, there were “no significant differences in the death rates between the three groups.”

NBC News also included relative risk numbers, citing the same stat that men in the watchful waiting group were “twice as likely to have their cancer spread” than those in the treatment groups. However, we learn that it was “nonetheless a very low number,” and an American Cancer Society physician says “the truth is, it’s 6 percent versus 3 percent at 10 years… it is much less than even I thought it would be.” Later in the story, actual numbers are given, too.

A missing factor from every story we looked at: The costs of treating vs not treating 

Alan Cassels, a frequent contributor to this site and co-author of “Selling Sickness: How the World’s Biggest Pharmaceutical Companies are Turning us All into Patients,” has long believed that prostate cancer has been overtreated and the harms overlooked. Part of this is due to the persistent idea that PSA screening should be done on all men over 40–an issue we just looked at this week in “Despite thumbs down from professional groups, mass prostate cancer screening events continue, often with misleading promotions.”

The harms of overtreating prostate cancer include the personal and economic toll this takes on the bottom line. Yet cost was not discussed as an advantage of the active monitoring group in any of the stories we looked at.

“The big savings would come from the avoided cascade of costs related to surgery, chemo and drugs,” he said, “these can cause incontinence and impotence, resulting in needing all the related paraphernalia–the diapers, sexual enhancement aids, and other things you need to deal with the collateral damage of the treatment.”

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Comments (7)

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Chris Carmichael

September 15, 2016 at 3:02 pm

I had my brush with a sky-high PSA about 6 years ago. My GP and urologist both labeled me as “suicidal.” for not agreeing to a biopsy plus. Luckily my wife is a gerontologist and I was able to do a pretty good lit review that confirmed what the USPSTF recommended about six months later. Some observations:
1) PSA’s give a lot of false positives and false negatives. They especially give false positives when the physician doesn’t explain that PSAs are invalid if the man has ejaculated during the previous 48 hours. If the man has had a vasectomy, then it is 1-2 weeks.
2) About 1/3 or urologists revenue stream is related to “prostate cancer.” They are vigorously protecting their income. Be careful and ask a LOT of questions.
3) There is a growing body of evidence that biopsies (and within those the number of sticks) have a role in fast-growing PC. Full prostate biopsies frequently show slow-growing cells throughout the prostate, but the aggressive cells along the needle scars. Use google scholar and “needle tracking” or “needle trace tracking.” to see more.

The bottom line as said by my wife is, “You get to choose between having a heart attack playing volleyball or having a heart attack shopping for Depends.”

    Ed Dwulet

    September 15, 2016 at 4:45 pm

    Chris – You may also find this article interesting reading. Written by a Stanford M.D. and Prof of Medical Ethics in 1996 … 1996! He warned about the inadvisability of PSA testing as screen for prostate cancer. It was totally a profit driven health “care” disaster that ruined the lives of millions of men over the past 20 years. All of his predictions have come true:
    “The great American pseudo-epidemic of cancer of the prostate”
    http://www.issuesinmedicalethics.org/index.php/ijme/article/view/1765/3803

Ed Dwulet

September 15, 2016 at 4:38 pm

Great article. Great comment my Chris below but it isn’t just a possible needle tracking issue with biopsies — its the inflammation caused by repeatedly biopsying a known cancer that is potentially a cause of the higher metastatic rate in the “active” surveillance group. No one knows how or why or when pc progresses and there is no non-invasive way to measure progression. The one way we have to (only marginally and inaccurately) attempt to measure progression i.e. biopsies … may itself inherently provoke progression via the inflammation caused by the procedure. There is ample scientific and anecdotal evidence that inflammation, including that caused by biopsy, may play a part in cancer progression and metastases. Please review the following before subjecting yourself to any more biopsies: http://demarzolab.pathology.jhmi.edu/docs/reprints/nrc2090_published.pdf
http://ucsdnews.ucsd.edu/archive/newsrel/health/03-07Prostate.asp
http://www.renalandurologynews.com/prostate-cancer/serial-prostate-biopsy-may-increase-inflammation/article/278984/
http://www.ncbi.nlm.nih.gov/pubmed/23715631

Additional reading with respect to the potential danger of continuing active surveillance with inflammation causing biopsies from the Department of Pathology, Microbiology and Immunology, University of South Carolina School of Medicine, March 2016: It reads: “Overall, the diagnosis of prostate cancer using sampling biopsies collected via transrectal ultrasound guidance seems apprehensive with peril as 25% or more of men with “negative” biopsies show prostate cancer on a subsequent biopsy within months to a year.”
http://www.hindawi.com/journals/au/2016/3140372/

    Stephen Cox, MD

    September 22, 2016 at 11:21 pm

    Ed, these articles from 2007 and 2016 are interesting but certainly do not prove biopsies cause prostate cancer. Please inform us if you see more evidence than I appreciate.

      Ed Dwulet

      October 7, 2016 at 1:36 am

      Steven Cox M.D. My posts suggested that inflammation caused by biopsies of know cancers may cause metastasis? Are you asking me to prove that? If you are you can’t be serious? Do you have any idea what kind of study that would entail?
      Look, all I’m saying is that its an established fact that biopsies cause inflammation. Its an established fact that inflammation has been implicated in cancer progression and metastasis. How about proving to me and the world and to all those men who have been shuttled into your active surveillance programs that any number of repeat prostate biopsies is going to conclusively identify the point in time when any particular cancer is in danger of progressing and NOW is the time to operate. Just where is that data? Where is that study? What is that tipping point? Why aren’t you asking your medical establishment for that proof? You and I know that it simply doesn’t exist either!

      A good analogy here may be the observer effect in quantum physics (it refers to changes that the act of observing will make on the phenomenon being observed). Take two identical twins with identical prostate tumors — (the lucky) one is unobserved (not biopsied) and the other is observed (biopsied). The current medical establishment considers both tumors identical — but all this research suggests that the biopsied one may be forever changed with respect to metastatic potential — having being affected by the inflammation caused by being biopsied. Let’s see … maybe we can get the NIH to fund that twin study and after about 20 years we’ll see which group of twins fairs better — then we’ll have your “proof.”

      I’m saying that the higher metastatic rate in the active surveillance arm of this study lends some support to the idea that it may be due to the inflammation caused by repeat biopsies.

Ara Karamanian, MD

October 14, 2016 at 9:27 pm

There are new, more precise and minimally invasive treatment options for localized prostate cancer, such as MRI guided focal laser ablation. Unfortunately, there does not seem to be much media coverage of this treatment option, even though it uses cutting edge technology and has low risk of side effects.

    Gary Schwitzer

    October 15, 2016 at 4:53 pm

    We published a piece about how one university medical center was promoting MRI-guided focal laser ablation by promoting a single patient anecdote to journalists. Maybe it’s good that there isn’t more news coverage of new technologies when they’re promoted in this manner.

    Gary Schwitzer
    Publisher