The issue of surgery vs. stents for stroke prevention is a contentious one in medicine. So when two large new trials–an American study dubbed CREST and the ICSS trial from Europe–report apparently conflicting conclusions about the benefits of each approach within 24 hours, we need skillful reporting that can help the average consumer make sense of it all. While this LA Times story did an adequate job of explaining the main findings of each study, its coverage tilted excessively toward the CREST team’s view that stents are equivalent to surgery for preventing strokes. The competing New York Times story did a better job of challenging or at least questioning this interpretation.
Strokes are a major cause of death and disability, and carotid artery stenosis is an important contributing factor to this problem. Although stents have been growing in popularity as a less-invasive alternative to open surgery for stenosis, there has been no definitive evidence to show that stents are equally effective. Whether the CREST study provides this evidence is an important issue for patient care.
If stenting and surgery are both "effective ways to limit stroke risks," as the story headline says, shouldn’t the cost of each procedure be an important factor in deciding which one to choose? This story, regrettably, did not even nod in the direction of cost.
Again, the story lays out these studies’ primary findings in reasonable quantitative detail. It could have done a better job, however, of examining which study’s results are more likely to reflect the experience of the typical patient. The story suggests that the highly trained American CREST surgeons were more skilled at inserting stents, and this is why they achieved better results than their less experienced European counterparts in ICSS. That may well be true, but the typical patient in the U.S. won’t be operated on by a CREST surgeon; their surgeon will probably be less experienced, and their outcomes may be less favorable.
The story gives us the key essentials regarding what happened to patients in both studies and their risk of major complications such as stroke or heart attack. However, we feel the story could have done a better job of questioning the notion, aggressively advocated by the CREST investigators quoted in the story, that stents and surgery are equally effective for preventing strokes. As the data reported in the story show, the risk of stroke immediately after the procedure was significantly higher in the stent group compared with the surgery group (4.1% vs. 2.3%). It was only after heart attacks were included in the analysis that the two approaches were considered equivalent. The finding of more postoperative strokes with stents is consistent with other research suggesting that angioplasty might well cause strokes by causing artery plaque to break off and cause a blockage that might not have occurred otherwise.
The studies covered in this story were both large randomized controlled trials that can be expected to provide high-quality clinical evidence. However, the story failed to point out an important difference: the CREST results were presented at a scientific meeting and have not yet been subjected to rigorous review by outside experts, whereas the ICSS data were published in a peer-reviewed medical journal, The Lancet. The story suggests that it is possible to make an apples-to-apples comparison between these two studies, but until the complete results of the CREST study are reviewed and published, this isn’t really the case.
No disease-mongering in this story.
The study quotes a number of experts, some of whom were affiliated with the CREST study as well as others who were not. This normally would be more than enough to earn the story a satisfactory rating, but in the case we feel that the story should have gone a bit further. The story is primarily a comparison of results from the CREST and ICSS studies, but we hear plenty from the American CREST investigators and nothing from the European ICSS team or anyone with a European perspective. We realize how difficult it can be to get a quote from European sources on short notice, but if you’re going to allow someone to claim, as this story did, that "North American surgeons do the job better," you have to be prepared to offer the Europeans a chance for a rebuttal. The benefits of a European voice were on display in the competing New York Times piece, which more forcibly questioned the idea that stents and open surgery are equally effective treatments.
A second shortcoming: the story noted that the CREST trial used Abbott stents exclusively, but it didn’t explain that Abbott was a sponsor of the study. Abbott’s participation could conceivably have influenced the results in favor of the stent group.
The story gives short shrift to discussion of drug treatment instead of surgery for asymptomatic patients. This is a controversial issue in medicine, and these results are unlikely to end this debate.
The story states that carotid artery surgery has been around since the 1960s and is quite common and that stenting, although newer, also is a fairly common procedure.
Both of these procedures have been around for some time and the story does not mischaracterize their novelty.
The story includes multiple interviews with expert sources, so it clearly didn’t rely on a news release.