MEDIA HYPE IN THE MEDICAL LITERATURE: WHAT’S A DOCTOR TO DO?

In an effort to provide a constant stream of new information the clinical medical literature is beginning to sound indistinguishable from the lay press. Analysis in depth seems to be relegated to editorial comments instead of scientific contributions. The result is a growing information deficiency among practitioners, and erosion of the physician role of wise consultant and responsible care giver. Not so many years ago the medical literature was hard to access. There were relatively few journals, few fellows and other potential authors, a relatively decreased subject matter and a fairly long publishing time. Reviewers were limited because of the number of submissions and the lack of subspecialization of reports. The readership consisted almost entirely of the medical community and was often further limited to 1 specialty within that community. It was not difficult for the readership to keep abreast of developments, especially since they felt no urgency to implement immediately what they read. New information was valued but newness for its own sake was not particularly prized. Nowadays all that has changed. The insatiable demand to fill the pages of innumerable medical periodicals has created conditions that favor the simplistic view, one that may be encompassed in the limited pages allotted to each article. For example, consider bladder neoplasia. We are told by basic scientists, whose studies appear with increasing frequency in the clinical literature, 1 that science will soon unlock the secrets of life. Armed with this knowledge and a few computer programs the diagnosis may be individualized using inexpensive DNA screens. Patients knowledgeable about their DNA will make informed choices. Keeping abreast of the field pharmacogenetics will tailor drugs to treat or prevent whatever does or may ail the potential patient. We will all live longer and healthier, and presumably die suddenly in our beds at age 125 years. Using this information in a clinical sense results in a certain scenario. 2‐5 Of bladder cancer 75% of cases are superficial. The connotation is that they are precursors of bad cancer but not bad yet. These tumors often recur. The connotation is that the same lesion grows again at the same site because of incomplete resection. There is a 20% chance that recurrent tumors will be bad, that is invasive, high grade, genetically abnormal, chromosomally abnormal, enzymatically abnormal—you define it. Therefore, methods must be developed to determine when these bad things have happened or will occur because early detection is the best (only) way to cure these patients. Urinary cytopathology, currently the single best noninvasive method for early detection, is deficient because many superficial bladder tumors are not discovered with this type of testing. Fortunately a new genre of molecular based testing is on the horizon which includes objective, laboratory based techniques that reveal abnormalities in individual genes, microsatellites on chromosomes, adhesion molecules, protein products—you name it. When these tests are applied to patients monitored for bladder cancer, detection will be earlier, treatment will be earlier, cures will increase, earlier detection and treatment will save money because patients will stay healthy and die suddenly in their beds at age 125 years. The story sounds good but the narrative is achieved by an uncritical approach. Several issues come to mind. The connotations elicited by terms such as bladder cancer, superficial tumor, recurrence and 20% progression are not entirely accurate. The actual substances being detected early by molecular testing are not completely defined as to their nature or their role in carcinogenesis. Comparisons of medical consultations based on cells and tissues (cytopathology and histopathology), and noninterpretive laboratory tests are not completely valid. The benefits of early detection may not be realized in all patients. Many may actually be harmed by this information. Adding an array of laboratory tests designed to determine the level of risk rather than the presence or absence of a neoplasm may add costs to the patient and/or society not only directly through increasing the expense of monitoring, but more indirectly as successes are achieved and patients live longer to have the chronic diseases and disabilities associated with extreme age.