Regular readers will remember that I wrote about Zetia back in November.  That post had some important background for this week’s news, and a handy lesson about the difference between clinical and intermediate outcomes in medical studies.  If you missed it, you may want to check it out.  This week, Merck released the data from a study comparing the growth of cholesterol plaques in the arteries of patients taking Zocor (a cholesterol lowering medication proven to prevent strokes and heart attacks) to those taking Zocor and Zetia.  The bottom line: Zetia didn’t help shrink the cholesterol plaques and may have actually accelerated their growth slightly.  Media hysteria ensued, including this article in the New York Times.  Thousands of patients have been calling their doctors, confused about what to do.

The American College of Cardiology tried to calm the situation by releasing a statement reminding patients that “this is not an urgent situation and patients should never stop taking any prescribed medications without first discussing the issue with their health care professional.”  The statement also included a position about the appropriate role of Zetia and Vytorin, which has not changed with the release of this study.

“The ACC recommends that Zetia remain a reasonable option for patients who are currently on a high dose statin but have not reached their goal. The ACC also notes that Zetia is a reasonable option for patients who cannot tolerate statins or can only tolerate a low dose statin.”

Statins have always been first line for cholesterol treatment because of their proven reduction of strokes and heart attacks.  Zetia has never been proven to prevent strokes and heart attacks, and should only be used if more statin can’t be tolerated.  Nothing about that changed this week.

(I’m grateful to Dr. Mark Urman and Dr. Yaron Elad who each pointed me to the American College of Cardiology statement.)

Tangential Miscellany:

There will not be a medical news post next week.  The weekly post resumes the week of January 28.

Change is always painful, even when everyone benefits from it.  We usually do our best to ignore slow trends, keeping our comfortable habits and pretending that the world will never surprise us.  I’m sure long after Ford started selling cars there were plenty of horse buggy makers who were sure that the car would always be an expensive frill for the very few.

I don’t think anything in the last 15 years has revolutionized our lives as much as the internet.  It has transformed how we shop, communicate with each other, gather news, get entertainment, and even form communities.  It has radically democratized journalism, entertainment and advertising.  Now anyone at a disaster can report what she has seen on her blog.  Anyone can shop for obscure items from sellers all over the world.  Anyone can share his art with a nearly unlimited number of fans.  Like all technological progress, this brings even more power to individuals, and away from large powerful groups.  But like all change, this too is painful.  (Just ask a screenwriter.)

The internet has narrowed the difference between the expert and the novice.  Experts no longer have a monopoly on information.  Patients can access as much information as doctors, and frequently notice new studies before their physicians do.  Some doctors are annoyed by this.  Defensive about their eroding knowledge gap, and (like everyone) fearful of change, some doctors cling to the role of expert and refuse their new role of teacher.  They can’t stand patients who bring in 5 studies from the internet and challenge their recommendation, or email them about an article that just came out today, or send them links to websites that advocate sheer quackery.

I love that.  Any professional who thinks their value is in finding information that no one else has is in for a rude awakening.  Google can do that cheaper and faster.  I have no information that my patients can’t find without my help.  The value doctors deliver is in exercising their judgment, and in teaching.  “This herbal product has never been tested and the website that praises it is the same one trying to sell it to you.”  “This family of medications has been proven to prevent kidney failure.  Here’s a link to the study.”

Yesterday, Salon published a great article that argues convincingly that the internet has been a boon for both patients and doctors.  More doctors should read it; otherwise, we’re just perfecting our horse buggies.

(I’m grateful to Luetrell T. for pointing me to the Salon article.)

I’ve written before about the controversies in screening for and treating prostate cancer.

Prostate cancer presents a unique challenge because it is extremely common, affects men who on average are older than patients with other cancers, and usually takes many years between diagnosis and disability or death.  In 2007, approximately 1 in 6 men in the United States were diagnosed with prostate cancer, and 1 in 34 died of it.  The median age at diagnosis was 68 years, older than that for any other cancer.  Because prostate cancer strikes men whose life expectancy is usually limited by age or by other diseases, it has been difficult to prove that screening for prostate cancer saves lives, or that any treatment for it is better in terms of survival than any other.

Last week’s New England Journal of Medicine had a very useful review of treatment options for localized prostate cancer (that is cancer that has not spread beyond the capsule of the prostate).  Treatment decisions are based on the following factors: the patient’s age, life-expectancy, Gleason score (microscopic appearance of the cancer), the PSA (prostate-specific antigen, a blood test used to screen for prostate cancer), and the clinical stage (roughly related to the estimated volume of the tumor).

Expectant management
Expectant management, also called active surveillance, involves frequent re-evaluation of the PSA, the digital rectal exam, and prostate biopsies with the hope of detecting progression of the cancer when it is still curable.  This strategy is thought to be appropriate either for men who have a life expectancy of less than 10 years, or for healthy men 65 or older with low-volume low-grade prostate cancer.  Some small studies suggest that this strategy is no worse for survival than the other two, and it is much less invasive.

Radiation therapy
Radiation therapy offers the promise of a potential cure of the cancer with treatment that is somewhat less invasive than surgery.  New technological improvements have made it possible to better spare normal surrounding tissues while targeting the radiation to the prostate.  Nevertheless 40 to 60% of patients suffer impotence and 18% have rectal bleeding requiring transfusion or invasive intervention.  (Expectant management sounds better now.  Right?)

Surgery
Surgery is thought by some to be the most likely to be curative (again, without much evidence).  The complications, however, include urinary incontinence (3% of patients) and impotence (30% of patients in the hands of the most experienced surgeons).

What is truly startling, however, is that there are no studies to help patients definitively choose the right treatment option.  Treatment options of millions of men are made largely with well-intentioned hunches.  Three large randomized trials are in progress to answer if screening and treatment for prostate cancer saves any lives.  We may have some answers when two of the trials reach completion five years from now.

In the meantime, patients who opt for radiation should use centers with extensive experience and with beam shaping technology that minimizes injury to surrounding tissues.  Similarly, patients choosing surgery should be referred to surgeons with extensive experience in radical prostatectomy.

And, in my opinion, patients should receive guidance from an oncologist experienced in prostate cancer treatment, an experienced urologist, and a radiation oncologist, before making any decision.