Anecdote and expert opinion triumphed over science and good journalism in a story on the regeneration of knee cartilage in USA Today.
The article focused on autologous chondrocyte implantation (ACI), an expensive procedure intended to regenerate articular cartilage in the knee involving two operations and an arduous 18-month rehabilitation process.
Unwarranted Assumption of Benefit
From start to finish, the article seemed to assume that ACI is a beneficial treatment. It examined the outcomes of ACI through the prism of a single patient, who is apparently making a good recovery 12 months after the procedure.
That the journalist chose to present the experiences of a celebrity—Olympic swimmer Dara Torres—only adds to the allure of this invasive therapy. But it is certainly open to question whether the experiences of a highly disciplined Olympic athlete are generalizable to other patients undergoing this treatment.
The article offered a misleading statistic from Torres’ surgeon, who stated that 92% of his more than 600 patients have had “success” with ACI.
Yet the USA Today story never defined the indications for surgery in these patients— or what “success” meant.
No Mention of Scientific Evidence
In an era of evidence-based journalism, the article went astray in never citing a single scientific study or attempting to quantify the expected benefit of ACI.
It didn’t specify the availability or costs (an estimated $20-$35K) of this procedure. It didn’t address specific treatment alternatives for cartilage damage.
It didn’t discuss the possibility of adverse effects related to ACI. Yet in some studies, up to 50% of patients who opted for ACI have had to undergo an additional surgical procedure for cartilage problems down the road. (Genzyme, Highlights of Prescribing Information, Genzyme.com)
Two outside experts did offer some tempering remarks but didn’t actually question the effectiveness of ACI. And like the other contributors to this article, they didn’t cite a single scientific study.
What Does the Scientific Evidence Say?
A few sentences on the scientific evidence base for ACI would have brought the entire article into focus—and provided a real benefit for individuals considering this procedure.
And what does that evidence show? The most recent systematic review found evidence that ACI can provide benefit over the short-to-intermediate term. So its long-term effectiveness hasn’t been established. (Harris JD et al., AACI: Systematic Review, JBJS, Sept 15, 2010)
It is not clear if ACI is superior to many other common treatments for pain and dysfunction related to articular cartilage damage. Well-designed randomized trials comparing ACI to usual care would be valuable.
So in short, while the evidence on ACI is promising, the jury is still out. This observation should have been the starting point for the USA Today article.
Identifying treatments that can heal injuries to knee cartilage is something of a Holy Grail in musculoskeletal medicine.
Hyaline articular cartilage plays a vital role in the function of the knee joint, acting as a shock absorber and mechanical interface on the surfaces of the bones that meet in this weight-bearing joint.
Articular cartilage has a limited ability to heal. So in the absence of effective treatments, cartilage defects are to some extent permanent injuries and potential on-going mechanical triggers for knee degeneration.
Not all articular cartilage abnormalities lead to pain and dysfunction. And it is not completely clear what differentiates pain-free from painful abnormalities.
However, even isolated cartilage defects can lead to vexing symptoms and the accelerated progression of knee degeneration. And when they occur in a knee with extensive degeneration their effects can be even more debilitating.
Though there are numerous treatments for articular cartilage damage, it is not yet clear that any of them can return the knee to full health and alter the natural history of symptomatic knee degeneration.
The article does not mention costs at all. This is an important issue for patients, healthcare providers and insurers. According to various estimates, the costs of ACI range from $17,000 to $35,000, depending on geographic location and associated surgical and rehabilitation expenses. Because of a lack of conclusive documentation of ACI’s benefit, many insurers are reluctant to provide universal coverage for ACI. So prospective patients may have to deal with the prospect of daunting out-of-pocket expenses.
The article did not adequately frame the benefits of ACI or make any attempt at quantifying them. It suggested that swimmer Dara Torres is now able to walk and climb stairs without knee pain—and that her knee is stronger than it was prior to surgery. But it didn’t provide any quantification of the expected benefit of ACI in terms of pain relief and functional improvement in the broader group of patients who opt for this procedure.
The article did not address complications or adverse events related to ACI. Yet patient and provider information at the Genzyme website makes it clear that ACI can lead to a wide range of adverse events— and that up to 50% of patients in some clinical trials have required an additional operation following ACI.
The article did not make any attempt to evaluate the quality of the evidence on ACI. It did not mention a single scientific study or systematic review on ACI.
On balance, the article did not engage in disease mongering.
The article provided a number of points of view, including those of two experts who weren’t involved with the treatment of Dara Torres. The article did not discuss conflicts of interest. But the journalist would have had to dig into the previous research of the contributors to even find suggestions of conflict.
The article presents ACI in isolation, without any mention of other specific treatments (e.g., debridement, microfracture, transplantation) for cartilage problems in the knee. It does discuss knee replacement as an end-stage treatment. And it mentions exercise and weight loss as nonoperative therapies. We’ll give it the benefit of the doubt on this criterion.
The article did not discuss the availability of this treatment. This is an important issue, as all surgeons who employ autologous chrondrocyte implantation have to take a training course from Genzyme. In addition they have to recruit a surgical team that can meticulously apply this demanding therapy and a group of professionals who can manage the careful 18-month rehabilitation program that follows ACI.
This a close call. But the article didn’t discuss the development of ACI or how it differs from other therapies aimed at cartilage defects.
The article did not appear to rely on a press release. There was extensive original reporting in this article—though no discussion of the scientific evidence.
Systematic, Criteria-Driven
We’ve written about the hype of liquid biopsies for years (see link in comment below). And now this…. https://www.statnews.com/2022/01/12/medicare-shouldnt-cover-liquid-biopsies-early-cancer-detection/
Case counts still matter. “(There) are stories that may not be told adequately if only hospitalizations and deaths are emphasized.” @garyschwitzer interviewed by @dbauder of @AP. https://apnews.com/article/omicron-changing-news-outlets-covid-data-da9272f7c4c8a109c3bfb56bed9e9c76
My friend Gary @garyschwitzer wrote to his city council representative in a Minnesota town about a Viva Las Vegas event scheduled for January.
The response he got seems to perfectly capture where we are now.
https://www.healthnewsreview.org/2021/12/2021-ends-with-covid-craziness-in-sports-and-politics/
Comments
Please note, comments are no longer published through this website. All previously made comments are still archived and available for viewing through select posts.
Our Comments Policy
But before leaving a comment, please review these notes about our policy.
You are responsible for any comments you leave on this site.
This site is primarily a forum for discussion about the quality (or lack thereof) in journalism or other media messages (advertising, marketing, public relations, medical journals, etc.) It is not intended to be a forum for definitive discussions about medicine or science.
We will delete comments that include personal attacks, unfounded allegations, unverified claims, product pitches, profanity or any from anyone who does not list a full name and a functioning email address. We will also end any thread of repetitive comments. We don”t give medical advice so we won”t respond to questions asking for it.
We don”t have sufficient staffing to contact each commenter who left such a message. If you have a question about why your comment was edited or removed, you can email us at feedback@healthnewsreview.org.
There has been a recent burst of attention to troubles with many comments left on science and science news/communication websites. Read “Online science comments: trolls, trash and treasure.”
The authors of the Retraction Watch comments policy urge commenters:
We”re also concerned about anonymous comments. We ask that all commenters leave their full name and provide an actual email address in case we feel we need to contact them. We may delete any comment left by someone who does not leave their name and a legitimate email address.
And, as noted, product pitches of any sort – pushing treatments, tests, products, procedures, physicians, medical centers, books, websites – are likely to be deleted. We don”t accept advertising on this site and are not going to give it away free.
The ability to leave comments expires after a certain period of time. So you may find that you’re unable to leave a comment on an article that is more than a few months old.