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    "When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov

    ''Once you tell people there's a cure for something, the more likely they are to pressure doctors to prescribe it.''
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    Sunday, March 05, 2006

    Speaking of Spin: Glenn Reynolds was asked by a reporter about blogs, PR releases, and ethics. He correctly points out that the mainstream media and professional journalists are not immune to press releases, and quotes (within the context of his own book) Daniel Boorstin on the subject:

    Most reporters aren’t scoop-hungry investigators. They’re wage earners who want to please their editors with as little effort as possible, and they’re happy to let you provide them with ideas and facts for publishable stories. That is why most publicity is positive for people and their businesses.

    You’re still not convinced? Go to the library and glance through a few days’ issues of several newspapers, including the Wall Street Journal, USA Today, and some local papers. You’ll discover that the same stories appear over and over again. That’s because they were initiated by the companies being covered, not by an eager young reporter looking for a scoop.

    This is especially true in science and medical journalism. Here's Exhibit A from my local paper - a story about a wonderful new procedure being performed at a local hospital. The procedure is transmyocardial revascularization, in which lasers are used to burn tiny holes in the heart muscle:

    Other standard treatments for angina include stents, which are placed in arteries to improve flow, and open-heart bypass surgeries.

    But sometimes those procedures don't work, or they're not options, Espinal said. That's when TMR can help.

    Patients undergoing TMR get 20 to 40 tiny laser holes in the portion of their heart that's not getting enough blood flow. The holes seal over immediately, Espinal said.

    No one's sure exactly why TMR works. But doctors think the holes might reduce pain by deadening nerves and stimulating the body to send more blood to the treated area.

    Studies have shown that TMR is more effective than medicines alone in treating extreme angina. At least one study published in the New England Journal of Medicine found that people who underwent the procedure also had fewer cardiac events a year later.

    Steele still suffered pain after undergoing bypass surgery and getting nine stents placed in his arteries during a five-year period.

    But he noticed improvement immediately after his TMR procedure earlier this month.

    ``I don't get the pains I got before,'' he said.

    He now plans to start playing golf again this spring -- something he hasn't been able to do for three years.

    The procedure does seem to improve symptoms better than medical therapy does, but it doesn't necessarily improve mortality. (In this much smaller study it did.) Either way, the biggest improvement the surgery claims is symptom improvement, and it could just be that we're seeing a placebo effect rather than any real improvement in the blood flow to the heart. It's happened before with cardiovascular surgery, as this letter to the editor noted:

    In the era before direct coronary revascularization, internal-thoracic-artery ligation was touted as a method to increase myocardial blood flow and relieve anginal symptoms. Initial reports by Ellis et al. and Kitchell et al. indicated that 68 to 75 percent of patients had clinical improvement, including approximately 35 percent who had complete relief and 42 percent with objective improvements, as measured electrocardiographically. These investigators were honest and intelligent but not impartial observers. Double-blind studies conducted later by Cobb et al. and Dimond et al. demonstrated that a sham thoracotomy alone could decrease the need for nitroglycerin and increase exercise tolerance and that it produced subjective improvement in more than 35 percent of patients. These results are similar to the improvement among 34 percent of the patients in the British study of transmyocardial laser revascularization mentioned by Lange and Hillis.

    When perfusion scans do not correlate in time or magnitude with the patient's clinical improvement, the more subjective data on improvement of symptoms must be approached with great skepticism. As was the case in earlier studies, the thoracotomy incision alone may have an important effect directly or indirectly on the patient's perception of pain. The fact that a patient has already undergone the surgical procedure of last resort has a high likelihood of affecting a physician's choice of treatment plans, and thus study outcome.

    It may be completely correct that transmyocardial laser revascularization benefits patients with chronic angina. However, given the substantial morbidity and mortality (9 to 15 percent mortality among the patients who were crossed over to transmyocardial laser revascularization in the studies by Frazier et al. and Allen et al. discussed by Lange and Hillis), the potential for a placebo effect must always be remembered.

    The newspaper article doesn't mention the moribidity and mortality rates. Read the story (which was a large, above the fold front page feature in the print version) and you come away with the idea that this is the best thing since sliced bread. And where do you think they got the idea for the story? From the hospital's PR department, of course. It was a very nice, free ad for their new surgery department.

    posted by sydney on 3/05/2006 05:34:00 PM 0 comments


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