Sunday, February 2, 2014

Be SMART about how you read the marketing. For prostate cancer, conditions apply.

I normally do not read inflight magazines from airlines as they find them quite boring. They are generally full of articles about travelling to exotic places or buying expensive products that only those who have so much money (that they do not know what to do with it) will have any interest.  This week, I was flying on the luxury carrier Emirates for the very first time and during the process of checking out all that they had to offer on my very long haul flight from Sydney to London via Dubai, I flicked through their inflight magazine. 

I was taken by surprise to see a very prominent advertisement by a urological surgeon offering his surgical services for the treatment of prostate cancer.  Given that I practice in this same subspecialized area of surgery, this naturally caught my attention.

Prior to seeing this advertisement, I had become aware of Dr David Samadi for all the wrong reasons. I had become aware of his name through overhearing discussions amongst US urologists over a number of years when attending the Annual Meeting of the American Urological Association.  I would frequently hear urologists discussing him with the gist of the discussion being summed up with the frequent rolling of the eyeballs or groan every time his name was mentioned.  Whilst urologists were careful not to verbally state anything negative about him, it was clear that they did not think favorably of him.  At the time and as an outsider, I really didn’t take that much notice as any gripes US colleagues had about him were not particularly relevant to me. 

So when I saw this advertisement in the Emirates inflight magazine, I immediately recognized his name and remember it being associated with groans and eyeball rolling.  As I read the advertisement, I now found myself rolling my eyes and groaning in disbelief.  It was almost like US urologists saying to a previously disinterested me, ‘told you so’.

Mobile phone captured image from the January 2014 Emirates inflight magazine
The statement that really got my attention was his claim of a “97% prostate cancer cure rate”.  When we talk about cure of cancer, we generally mean total and permanent eradication of the disease. Whilst one could argue through dictionary meanings that cure can mean recovery from disease or restoration of health, I think that the average person would interpret cure of cancer being total and permanent eradication of cancer.  My personal view is that prostate cancer doctor can come close to providing a 97% cure of prostate cancer and data shows that this is probably impossibility unless the subjects were all men with such low volume indolent disease that they did not need surgery in the first place.  Why is this an issue?  The statement can give cancer sufferers unrealistic expectations.  The statement is unquestionably a draw card to consider his services as it gives hope and promise of an exceptional chance of success but I am sure that. I did call him out on Twitter to clarify his claim of 97% cure rates and was not surprised that he chosen not to respond.

I did call him out on Twitter to clarify his claim of 97% cure rates and was not surprised that he had chosen not to respond.

The statement “96% of patients regain continence” is not defined.  Continence as far as I am concerned means a man who does not leak urine at all.  If we look at the prevalence of incontinence in ageing men, a 96% continence rate is higher than for men who have not undergone prostate cancer surgery.  It would be very easy to make a ridiculous suggestion that the surgery seems to give better urinary control rates than if you did not have surgery and one should therefore line up to have surgery with cancer being a mere technicality. – again I emphasise that this is a ridiculous suggestion but it does raise the question as what is meant by this claim.  What is meant my continence? Does it include the men who are wearing one pad per day or doesn’t wear a pad but drips urine everytime he has a cough or sneeze.  Undefined, the figure is very impressive and all those attracted by such figures should seek to clarify exactly what is meant be this.  The population of men in whom you operate can make a difference as well – older men are more likely to have incontinence than younger men as one example.

Same applies to erectile function recovery. I personally think that statement that “85% men regain sexual function” is very vague but nonetheless will be interpreted by most readers that it refers to erections.  My own overall figures do not come close to this.  However, if I were to narrow it down to my younger men in whom the cancer was considered to be well localized and they were candidates for nerve sparing (nerves that spare erectile function) surgery, then this might be a more realistic figure. 'Regain' implies recovery to where they were prior to surgery – that’s how I interpret it but I know that some may argue otherwise.  I have quite a number of men who have lost erections following prostate cancer surgery, particularly when I have had to sacrifice the erectile nerves in order to clear the cancer but they remain sexually active in that with their partners they achieve a pleasurable orgasm with a flaccid penis. I have men who are sexually active with the assistance of medications such as Viagra and Cialis or even with the use of medications that they inject into their penis in order to stimulate an erection (eg Caverject, trimix) but should that constitute ‘regain’ of sexual function?. 

For both continence and sexual function, definitions are everything and without them, I am concerned that presentation of such exceptional results will create unrealistic expectations.  I am sure that the man with locally advanced cancer will be appropriately counseled that he would not fit in the group with such good results but the advert would have done its job of pulling him in through the consultation door so that he can then told what he really can expect. Should there be a asterixed disclaimer as in every good advertising offer that 'conditions apply'.

The statement “When you’re the best in the world” also raises questions. What evidence does he have that he is a superior surgeon clinically and technically than anybody else in the world?  How does he benchmark this?  Is it fair to claim that just because you have had patients from 40 different countries that this must mean that you're are the best?  Is this international spread of patients have any relationship to international based marketing strategies?

I am currently registered as a medical practitioner with the Australian Health Practitioners Regulatory Authority.  AHPRA has strict advertising guidelines. There is also a code of conduct published by the Royal Australasian College of Surgeons (and endorsed by the Urological Society of Australia and New Zealand) that dictates my appropriate behavior as a surgeon.  If I were to have written such an advertisement, I would unquestionably be investigated by AHPRA and run risk of punitive actions and I would also stand a significant chance of being stripped of my surgical diploma from the RACS for breaches to our code of conduct. Dr Samadi is not required to adhere to Australian licencing regulations or code of conduct but in my opinion, there appears to be a lower bar for this behaviour in the United States. In Australia, any statements that have a likelihood of being misinterpreted as well as not being able to be substantiated are taken seriously and run a high risk of punitive sanctions and reputational loss.  Having previously been registered with the General Medical Council of the UK (when I worked there years ago), I can also say that their guidances on these matters are equally, if not more, restrictive.  It is important to state that these restrictions are not to make life harder for doctors to promote their practices, but to protect the public from misleading or unsubstantiated claims.

As a urological surgeon, I personally feel embarrassed to see such a colleague resort to advertisements in international inflight magazines to market their surgical practice. Maybe I'm just a bit old fashioned with my attitude to medical advertising. I was further embarrassed as a surgeon to see Dr Samadi refer to his twitter followers as fans. I hope that does not include his patients.


  1. Your comments are very perceptive and accurate. It is offensive to read such self-serving misinformation deliberately aimed at deluding patients. There are ethical concerns with any type of medical advertising, but such gross misrepresentation is deceitful and demeaning. Physicians should internally regulate their profession in order to avoid further outside scrutiny, embarrasement and distrust. Hopefully your astute comments will serve to ignite the appropriate reprimands.

  2. Dr. Woo is to be commended for further exposing this charlatan. the reason that none of his exaggerated outcomes are published is because they would never survive vigorous peer review and he knows it. this guy is nothing more than a used car salesman. Take heart, everyone the regulators are reviewing him as we 'speak'!

  3. Fully informative blog for the knowledge of Prostate Cancer..Thia blog is very helpful for the readers to gain their knowledge.Its really very useful article for common a person.Thanks for sharing this excellent blog with us.

  4. Thank you for the above comments. My personal belief is that self regulation can fail us in that physcians are often reluctant scrutinise their colleagues for borderline (or even frankly inappropriate) behaviour. Physician based organisations act in the interest of the profession but independent external organisations act are more likely to act in the public interest. My understanding is that the discussion that has arisen from this blog piece as well as those on Twitter have lead to professional organisations taking notice and time will tell if it is believed that this behavior is acceptable or not. To now do nothing would be complicit to this behaviour.