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Localized prostate cancer rarely helped by hormone therapy

Rating

4 Star

Localized prostate cancer rarely helped by hormone therapy

Our Review Summary

This is a story about a large scale study which demonstrated that the use of hormone therapy in older men with localized prostate cancer failed to reduce the chance that they would die of prostate cancer or increase the length of time that they would live.  It provided a lot of facts and figures taken from the study which are informative and yet it obscured the very simple and clear take home message of the study.

The results of the study in question show that at least in this case (older men with localized prostate cancer) that the drive to do something does not necessarily result in doing better.  As the story indicated, hormone therapy, like most treatments, is not without important side effects that affect health and quality of life and so its use needs to be considered in terms of the benefit it has been demonstrated to provide.

While the article provided useful information about hormone treatment outcomes and complications, these important messages were obscured by the following flaws:

  • The story never defined "primary therapy" but used the term three times. 
  • It should have been clearer about the distinction between localized/early-stage vs. aggressive vs. advanced-stage cancers.  These terms were used but not explained and an understanding of them is crucial to an understanding of prostate cancer.
  • It never talked about the use of the PSA test finding more prostate cancers of unknown significance in elderly men, leading many of them to pursue the hormonal therapy in the first place.  The fact that useage fell off because of a cut in Medicare reimbursement should have been a telling statement for many men – a point begging for elaboration. 

Criteria

Does the story adequately discuss the costs of the intervention?

Not Satisfactory

We’re told how much the nation spent on the drug but we’re not told how much individuals were charged. 

Does the story adequately quantify the benefits of the treatment/test/product/procedure?

Satisfactory

 The story was about a lack of benefit in terms of overall death or prostate cancer specific death.  The story was clear that hormone therapy for the treatment of localized prostate caner does not increase survival time.

Does the story adequately explain/quantify the harms of the intervention?

Not Satisfactory

The story provide information about the side effects of the treatment in relative terms as opposed to the absolute risk of their occurrence.  So when it says "including a 10% to 50% increase in the risk of fractures, diabetes, heart disease and sudden cardiac death; a 500% increase in hot flashes; and a 267% increase in impotence,"  readers should ask 10-50% of what?  Or 500% or 267% of what? See our primer on absolute vs. relative data. 

Does the story seem to grasp the quality of the evidence?

Satisfactory

The story included information about the source of the study (published in the Journal of the American Medical Association). Reading between the lines, as the story mentioned that the data came from national databases, it is possible to glean that this was a cohort study as opposed to a randomized clinical trial.  It would be best to clearly explain that type of study the information came from and where that type of study ranks in terms of the hierarchy of evidence.  Not all studies and study types are equal and journalists should begin educating readers about the differences in the quality of the evidence.

Does the story commit disease-mongering?

Not Satisfactory

 The article should have been clearer about the distinction between localized/early-stage vs. aggressive vs. advanced-stage cancers.  These terms were used but not explained and an understanding of them is crucial to an understanding of prostate cancer.  Hormone therapy is most useful for treating symptoms of advanced-stage cancers (where it has no survival benefit).  There is no convincing evidence that it is a "powerful tool" when combined with surgery in treating aggressive cancers, though it does confer a survival benefit when combined with radiation.  However, the "aggressive" tumors in these studies were also localized.  Similarly, the comment about earlier studies showing less benefit from hormone therapy in less advanced tumors confuses the distinction between aggressive (based on the appearance of cancer cells) and stage (localized vs. advanced).  The earlier studies showed less benefit for less aggressive cancers.

The story could have (should have?) commented on the use of PSA testing which has lead to a dramatic increase in the incidence of early-stage cancer.  What we have been witness to is an increase in prostate cancer diagnosis without a change in rate of death from prostate cancer.  This begs the question of whether diagnosing early stage prostate cancer, especially in the elderly has any value. 

Does the story use independent sources and identify conflicts of interest?

Satisfactory

There were two physicians interviewed for this story in addition to one of the authors of the study detailed in the story.  While the story did not explicitly mention that these two were not associated with the recently published study, they did not appear to be connected with it.

Does the story compare the new approach with existing alternatives?

Satisfactory

 The story was about whether hormone therapy was a useful approach to treating prostate cancer in older men who chose to avoid surgery or radiation treatment.  The story provided a good explanation for why some men choose hormone therapy (i.e. because they want to avoid surgery or radiation and yet were not comfortable with expectant management).  It should have pointed out that even though expectant management may feel like ‘doing nothing’, the men who adopted this approach had similar outcomes to those who decided to have hormone therapy to fulfill a desire to ‘do something’.

Does the story establish the availability of the treatment/test/product/procedure?

Satisfactory

The story explained that " the use of the drugs surged a decade ago, with an estimated 30% to 50% of such patients receiving the therapy" and then fell off in recent years after Medicare reduced reimbursement. So we get a sense of how widely available the therapy has become.

 

Does the story establish the true novelty of the approach?

Satisfactory

It’s clear from the story that the treatment has been use in for a long time and that, as one expert said, ""There is no clear data that has ever shown that patients with early-stage disease benefit from primary hormone therapy . . . and this is further evidence to support that." (However, the story should explain that medicalese jargon of what "primary" therapy means.) 

Does the story appear to rely solely or largely on a news release?

Satisfactory

Does not appear to rely on a press release.

Total Score: 7 of 10 Satisfactory

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