When “Dueling Technologies” are Mistaken for Progress

Prostate cancer is increasingly being diagnosed at an early stage. Because these tumors are organ-confined, they have a favorable prognosis and an expected long survival, often without therapy. Despite data (1) suggesting overtreatment of newly diagnosed patients, the majority of patients will receive definitive treatment, with only 8.2% electing deferred treatment, according to a recent US survey.(2) The need to produce a safe, effective, and easily applied method to treat these cancers has prompted both academia and industry to respond with new technologies in a duel to claim progress in treatment. It is no surprise then that a proliferation of refinements in surgery and radiation and new technologies to deliver alternative energy sources have been applied to control favorable-risk prostate cancer. However, many of these approaches are applied clinically with little formal evidence to support their relative efficacy and toxicity claims. The reasons for the lack of robust evaluation of these new technologies are valid. Studies to demonstrate improved efficacy are lengthy and costly. Given the favorable prognosis of patients in this category, efficacy often cannot be determined for many years if ever. The proliferation of these methods—and the claims of efficacy and reduced morbidity—are creating confusion in the health care community and among patients. The landscape of therapy for men with low-risk prostate cancer has become a contest among costly, competing technologies without supporting rationale. These technologies require a framework to test their validity (Figure 1). Central to this framework is acceptance of the principle of “incremental gain.” Although the principle may appear self-evident, the allure of new technology has proved difficult to resist. As a consequence, “feasibility” with limited evidence of safety and efficacy has often been regarded as sufficient for clinical application. A framework to guide development and establish criteria for the acceptance of new technologies is required to establish order from chaos. Three broad criteria must be considered in this framework: (1) improved efficacy, (2) improved morbidity profile (complications), and (3) broader health care considerations such as ease of application, training, and cost. It is beyond the scope of this Commentary to comprehensively review data or to make comparisons among the many new technologies. I provide here selected examples of technologies that have achieved a level of clinical application in localized prostate cancer. My goal is to illustrate how the information promoted by these technologies is insufficient for physicians and patients to make knowledgeable decisions about care. It is my hope that the resulting discussion will prompt the development of an efficient and methodical approach to the application of new technologies in prostate cancer therapy. Figure 1 Establishes a framework to guide investigators through initial development and feasibility testing with specific milestones for each category. Critical to success is establishing by criteria and stage of therapy development the pragmatic milestones that ...