Getting a Second Opinion for Cancer Surgery

Second opinions for medical advice is nothing new and an accepted part of modern day medical practice. Practically all doctors are happy to provide second opinions for patients who seek them.  It goes without saying. My own surgical practice has a significant proportion of patients who come through such channels.  I usually ask them how they came to see me and in the vast majority of circumstances it was due to a recommendation from a friend or acquaintance who had been treated by me for the same condition.

Procedural specialties have particularly taken to having an on line presence for marketing of their services.  It makes a great deal of sense.  The more patients you can attract so as to be able to perform procedures, the more income that is generated.  Increasingly we are seeing offers of seeing patients for second opinions appearing on the websites of surgeons. Often there will be a form to complete where you type in your basic demographics and some basic information about one's condition which in turn invites the surgeon or designated staff member to make contact and subsequently encourage the patient to make an appointment.

What concerns me is that the second opinion marketing is mainly directed to newly diagnosed cancer sufferers.  These patients are vulnerable and on the steep learning curve with the acquisition of knowledge about their condition whilst trying to cope with the unknowns that lie before them. The second opinion websites often boast the achievements of the cancer surgeon being promoted but with very little possibility of the reader being able to verify the statements.  

We see statements such as 

“I was the first…” 

“I have done the most…..” 

“I pioneered the introduction of ……..”

Not uncommonly these statements bear zero relationship to the consultative or clinical or technical skills of the surgeon.

Rather than allow these websites seed one's mind about that the current care being received is inadequate, readers should instead consider why is it that such great efforts are being made to promote the availability of a second opinion service.  It is nothing more than a mechanism to goad patients into switching doctors when at their most vulnerable time. There should not be a need to promote that second opinion services are available as this goes without saying. If a surgeon had such a good reputation, why would they need to market for those second opinion cases. Do they have a deficiency of work that necessitates such action?  

There is nothing wrong with seeking out information on suitable surgeons to see for a second opinion but perhaps one could do better than a cold call to a website.  Consider other sources for recommendations. Start with the family doctor and additionally, staff who work at the hospital you would like to attend, if you know any.  Look the overall digital footprint of the provider and in particular independent sources of information.  When searching provider websites, be wary when there is over the top self promotion and whether you feel that a second opinion form is being thrust into your face. If it was from anything other than a medical provider website, you would probably consider it differently.  Remember that marketing is marketing and I'm afraid to say that even doctors partake in provision of information under the guise of marketing.

As a junior specialist, I recall being advised by a senior colleague that my patients would be my best ‘advertisement’.  All I had to do was to treat them with respect and compassion and to do what I would wish to have done for myself or my close relative. This was sound advice and I continue to uphold this principle.  I am grateful that my practice is sufficiently busy to never feel a need to market for second opinions - but why should I need to market for them when it is after all, a normal part of medical service provision.

Note- this piece is written in the context of Australian medical practice

Dr Glatter and Dr Samadi - Together in Forbes!

Dr Robert Glatter is a medical doctor who is a regular contributor to Forbes, a huge global print and on line portal for news and opinion.  

He started writing for Forbes in February 2012 and has been contributing on almost a weekly basis.  It was not until December 2013 that he wrote his first piece on prostate cancer entitled "Inflammation Noted In Repeat Prostate Biopsies Linked To Reduced Future Prostate Cancer Risk".  This was actually quite a well written informative piece.

He next wrote about prostate cancer on 7 March 2014.  All of a sudden, prostate cancer has become the flavour of the month with further articles on 6 April 2014, 10 April 2014, 21 April 2014, 4 June 2014 and the most recent piece on 20 September 2014.  

It seems rather odd that there is this sudden interest in prostate cancer.  He does write a lot of articles on other subject matters but the frequency of prostate cancer topics has been disproportionately higher during the course of this year.  This made me wonder as to whether there was some explanation for this.  The most glaringly obvious common binding feature about all of his articles on prostate cancer this year has been the mention of Dr David Samadi.  

Briefly, Dr Samadi is a celebrity urological surgeon who has a program on the Fox Channel called Housecall.  He cites amazing figures for prostate cancer surgery outcomes that defy the academic literature, particularly with his claims of providing a 97% cure rate from prostate cancer. He also earns a great deal of money and was the highest earning doctor in 2012 according to a New York Post investigation stating "The city’s top earner was urologist and prostate-cancer specialist Dr. David ­Samadi, whose 2012 compensation came to $7.6 million."

Okay, back to Dr Glatter.  Who is he?  I have never met him and only discovered him through reading articles on the Forbes website where my friend and colleague Dr Benjamin Davies is also a contributer. The easiest way to start is Google.  The first hit is his work at Forbes.  The second hit is his twitter account.  His bio states the following:- "Emergency Medicine Physician-Lenox Hill Hospital /Media Spokesperson/Forbes Contributor/WebMD Editor/DR 911 housecall practice" and also provides a link to a website.  

Hang on a second - Lenox Hill Hospital?  Isn't this where Dr Samadi does his work?  I don't know the relationship between Dr Glatter and Dr Samadi but if there is any conflict of interest, it should be declared on the Forbes website.  In particular, the fact that Dr Glatter works at Lennox Hill Hospital is not listed anywhere that I can find on the Forbes website. It may be all innocent but in the context of this sudden increase this year in prostate cancer articles, all of which lavishly cite Dr Samadi, raises questions on transparency.

On a final note, the most recent article from 20 September 2014 is a far cry from Dr Glatter's excellent first article on prostate cancer in December 2013 (incidentally, he does not actually mention Dr Samadi at all in this first article).  Not only does he promote the hashtag #samadichallenge but also makes ridiculous comments such as "In case of a positive diagnosis, urge men to seek Treatment immediately" - this demonstrates a lack of insight of the biology and natural history of prostate cancer.  It goes totally against the direction taken by leading urologists which is to be less aggressive in treating clinically significant prostate cancer.

Statements like "Symptoms of prostate cancer may include changes in urinary function including a burning sensation, blood in the urine or semen, frequent urination, as well as a weak or interrupted flow" only create fear and alarm amongst men with urinary symptoms.  It is uncommon for prostate cancer to cause urinary symptoms when clinically localised - any clinician would know that it is the non-cancerous condition of the prostate called benign prostatic hyperplasia (BPH) that causes the symptoms.  It is these symptoms that lead men to get checked by their doctors who then serendipitously diagnose their cancers.  It is not a cause effect relationship.

The hashtag #samadichallenge with a doctors name in it? Is the aim to achieve awareness about the doctor or about prostate cancer? I am happy to be instructed on this. 

And Dr Glatter, is there any relationship of any sort between yourself and Dr Samadi? If so, be transparent and declare.  If not, state that to be the case.  It is hard otherwise to not be suspicious about the sudden interest in prostate cancer articles where Dr Samadi comes across to me as being featured expert in each of them..

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.