This story just didn’t deliver vital context, analysis and independent perspect ive on this study. Taking these drugs would not necessarily reduce the risk of dying from prostate cancer–the ultimate goal of a prevention drug–because they appear to reduce the risk for only the moderately aggressive cancers. Men could still develop and die from the more aggressive cancers, but chemoprevention would lead to substantial drug costs and subject men to treatment complications.
No one was interviewed to counter what one expert said in this story, "The question might be, why isn’t every man taking one of these drugs?" Yet it wouldn’t take much to find others who’d be happy to answer that question.
The $3.23 cost of Avodart is mentioned. But we would have preferred an analysis of the NNT or number needed to treat in order to prevent one case of prostate cancer – an analysis that would show this to be a very costly proposition. An AP story, for example, stated:
"To prevent a single case of cancer, 71 men would have to take Proscar (finasteride – a similar drug) for seven years."
And/or we would have liked to see a cost effectiveness analysis. There is an article by Zeliadt et al (Am J Med 2005) that estimates the cost per quality adjusted life year (the accepted metric for cost effectiveness) of finasteride to be $130K/QALY. Given that finasteride is now generic, the cost effectiveness ratio would be more favorable. However, these are guestimates because we don’t actually know whether this chemoprevention reduces the risk of prostate cancer deaths.
But the story only told us cost per pill.
Quantified in both relative and absolute risk reduction terms – although more emphasis placed on the more-impressive-sounding 23% relative risk figure than on the 5% absolute risk reduction stat.
However, it should be noted that we have no idea whether reducing the risk of cancer reduces the risk of dying from cancer. Additionally, the risk of cancer in the control group was 25%. Given that the lifetime risk for prostate cancer is only 16%, this group of high-risk men was either truly at very high risk–or else being in the study and subjected to screening and biopsy artificially inflated the risk making it difficult to interpret the "benefit" of treatment.
Not a single mention of the heart failure problem discovered in the study, which Barry Kramer of the NIH called an "important detail" in the AP story. AP thought it was so important they put it in their headline, "Study finds possible heart risk with prostate drug."
That might be too much weight, given that the absolute risk for heart failure was very small, but it WASN’T EVEN MENTIONED in this story.
The study could not properly determine that dutasteride was "slightly more effective" than finasteride or that it was "a better drug" because the drugs were not evaluated in a head-to-head comparison. Differences in patient populations and protocols make it difficult to compare results across studies. Also, while the proportion of men who had prostate cancer on biopsy was significantly lower in the treatment group, 15% of study subjects never were biopsied–which could bias results.
Several sources were used, but none balanced the discussion as both WebMD and AP did with their stories. This is not a slam dunk as this story and its sources would lead you to believe.
The story mentions finasteride (Proscar) as the primary alternative to Avodart for chemoprevention of prostate cancer.
The availability of dutasteride is clear in the story.
Adequate discussion of Proscar and Avodart research in this area. No inordinate claims of novelty.
It’s clear the story did not rely on a news release.
Systematic, Criteria-Driven
The tale of two “negative” studies. Or, how spin is applied to make research findings look more impressive. A must read. https://johnmandrola.substack.com/p/the-tale-of-two-negative-studies
The @nytimes chose to interview one of the editors of the @AnnalsofIM (publisher of this paper) who "gushed with extraordinary glee: It’s huge! There are very few things that reduce your mortality by 30%."
Turns out coffee is not one of those few things despite all that glee. https://twitter.com/garyschwitzer/status/1533202075928215558
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