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How accurate are websites on focal therapies for prostate cancer?

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The internet is a double-edged sword. For men with prostate cancer, the internet is an important source of information for them. It provides information about tests, treatments and clinical trials that is not forthcoming from doctors. But the accuracy of this information is often difficult to assess. This week’s blog describes a study that assesses the accuracy of popular websites about focal therapies for prostate cancer.

Men often rely on the internet to help them understand their prostate cancer and its treatment. Appointments with the doctor are often very short and require men to have a good memory for what is said. Doctors use medical jargon during appointments and convey a lot of information very quickly. The internet is therefore a very useful and important resource for men.

Men often go to the internet for information about prostate cancer before their doctor’s appointments. This information helps them to choose between treatments. For newly diagnosed men with localised prostate cancer, the internet will soon tell them about the side effects of surgery and radiotherapy. Men will often “do their research” by investigating the alternatives to these mainstay therapies – such as focal therapies.

Focal therapies for prostate cancer

Focal therapies are treatments for localised prostate cancer that are currently being developed and tested. Focal therapies aim to treat the cancerous part of the prostate without removing the whole gland. They are deemed suitable for men with low-risk, and some types of intermediate-risk prostate cancer.

It’s hoped that treating only the affected part of the prostate gland will reduce the side effects, compared to radiotherapy and surgery. But direct comparisons to ask whether this is the case have not been completed.

A focal therapy is most suitable for a cancer that has one “focus of origin”. These cancers have one specific region of the prostate from which cancer cells are growing. The majority of prostate cancers are multifocal; small tumours are found in various regions of the gland. Focal therapies are suitable for prostate cancers with only one focus, or only one region with tumours.

Focal therapies are generally considered experimental. As these treatments are very new, we have limited knowledge on how effective they are. Using imaging technology, doctors can predict that the tumour region has been removed by the treatment. Side effects such as incontinence and erectile problems can also be studied in the short term. However, studies that determine whether these treatments have an impact on cancer progression and survival take many years to complete. We don’t yet have results from studies comparing focal therapies to other types of prostate cancer treatment. So doctors cannot say whether focal therapies are any better or worse than other treatments – in terms of success and long-term side effects.

There are a number of different types of focal therapies. These include cryotherapy, focal high-intensity focussed ultrasound (HIFU), laser ablation, photodynamic therapy, Nanoknife, focal brachytherapy and radiofrequency ablation. Many of these are unavailable in Australia. Focal therapies are described in a research blog from 2016.

Focal HIFU (high-intensity focussed ultrasound)

HIFU for prostate cancer is available in Australia. During HIFU, a rectal probe emits soundwaves towards the tumour region. These ultrasonic waves heat up their target area, killing cells by causing bubbles to form inside them. HIFU can also be used to treat the whole prostate, rather than just the focal tumour region. A number of trials are ongoing in Switzerland, Canada and USA to determine whether focal HIFU is effective.

Cryotherapy

Cryotherapy is a type of focal therapy that is also available in Australia. Cryotherapy involves cooling to very low temperatures then thawing. This results in destruction of the cooled cells. During prostate cryotherapy, a “cryoprobe” is inserted into the prostate through the perineum to freeze the tumour. This procedure is guided using transrectal ultrasound or MRI.

A systematic review of cryotherapy studies from 2014 showed good short-term outcomes. Between 71% and 93% of men lived without recurrence of their cancer for up to 70 months. Incontinence rates were quite low, but erectile function varied. Longer and larger studies are needed to compare the success rates to other treatments – and also ask whether cryotherapy provides any benefits above active surveillance.

Accuracy of internet information about focal therapies

A new study published in the journal Urology has assessed the accuracy of information about focal therapies on popular websites. The authors of this study are urologists from Columbia University Medical Center in New York, US. They were led by first author Dr Denise Asafu-Adjei. These urologists noted an increase in the interest of their patients in focal therapies for prostate cancer. Many of their patients came to them with information about focal therapies gathered from the internet. These patients often did not realise that focal therapies are still considered experimental, and are only suitable for men with very specific types of prostate cancer. Were these men being misled by the websites they had visited?

Dr Asafu-Adjei’s research group predicted that some of the websites with information about focal therapies were misleading. Their study tested this prediction – specifically for HIFU and cryotherapy.

The researchers performed web searches using Google and Bing. They chose the top 50 websites describing cryotherapy and HIFU for prostate cancer, excluding scientific articles. They then assessed the accuracy of information provided by each website. To do this they used the AUA (American Urology Association) guidelines and scientific literature. They assessed the accuracy in reporting the expected success of the treatment and the expected side effects. They also recorded how well each site described the specific men for which the treatment was suitable.

For HIFU, 17% of websites were advertisements, 13% were public treatment centres, 29% were private practice and 24% were patient support websites. A similar pattern was seen for the cryotherapy websites.

Side effects  In general, a description of the possible side effects was present on most websites. Possible side effects from HIFU and cryotherapy include erection problems, rectal pain, urinary incontinence and urine retention. 70 to 78% of websites mentioned these side effects for the two treatments. However, this means that almost a quarter of websites did not accurately describe the possible side effects, which is concerning.

Expected success of treatments  The researchers did not provide the proportion of all sites that were accurate. So it’s difficult to say which of the different types of websites were the most accurate source of information. But they did make good comparisons between public and private treatment centres. Errors were made in describing the expected success of the treatments in 15% of public and 41% of private practices that described HIFU. For cryotherapy, errors were much more frequent. 73% of private and public treatment centres described the expected success rates incorrectly.

This is certainly very concerning. These results indicate that information from many of these practices about the expected success from prostate cryotherapy is inconsistent with the scientific evidence and AUA guidelines.

Criteria for treatment  Focal therapies for prostate cancer are not suitable for every man. They are most suitable for men with localised disease that has affected only one part of their prostate gland. Most cases of prostate cancer affect multiple parts of the gland. It’s preferable that websites about HIFU and cryotherapy explain this clearly.

For HIFU, 31% of public and 66% of private practices mentioned these criteria for treatment. For cryotherapy, these results were lower. Only 27% of public and 18% of private practice websites mentioned the cryotherapy treatment criteria.

These results are also concerning. A newly-diagnosed man who has read about HIFU and cryotherapy may become enthused about these treatments before learning that they are inappropriate for him from his own doctor. This can lead to many levels of misunderstanding. It’s possible that some men will believe that doctors are only selling their own treatments, then seek out the focal therapy when it’s not the best treatment for them.

 

The researchers have confirmed their prediction that many websites describing HIFU and cryotherapy for prostate cancer have errors and omissions. These errors may be the reason that increasing numbers of men are approaching their clinics having been misinformed about focal therapies.

The difficult question here is what to do about it? Foundations such as PCFA have an important role to play in disseminating correct and understandable information about prostate cancer treatments.

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