Friday, 20 July 2012

Prostatectomy: doctors just don’t get it.


The results from the latest randomised trial comparing prostatectomy to non-operative treatment for prostate cancer are all over the news, but what caught my eye was the response from a senior clinician in my country. I will address his comment, and a related comment, below.

The study (here) recruited 731 men less than 75 years of age and found that the overall mortality after 10 years was 47% in the surgical group and 50% in the non-operative group. The difference was not statistically different. If it were, you would have to weigh that benefit against the 88% erectile dysfunction and 17% incontinence rates in the surgical group (2 -3 times higher than the non-operative group).

“The whole problem is selecting the ones which need to be operated on”

This was the response from the chief of the Cancer Council.  It is not the whole problem. It is not even part of the problem. The problem is that despite patients with prostate cancer being no better off with surgery, thousands of prostatectomies are still being done every year, with all the attendant harms and costs.

I think he was getting at selecting subgroups for which surgery may be effective. Finding a subgroup in which your treatment may be effective does not trump the main findings of the study, it may not be valid, and it smacks of confirmation bias: looking for something that confirms your beliefs.

"People with prostate cancer usually decide to have a prostatectomy, because people sleep better at night knowing that the cancer has been removed”

This is a comment from a urologist. My response to that is that they would sleep even better, literally (from less incontinence) and metaphorically, if they were never diagnosed in the first place.

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