Do you benefit from these surgeries? Consumer Reports says maybe not
Magazine tells patients to check out safer alternatives
Warning: Consumer Reports is telling your patients that they may not need surgery. The popular magazine recently posted an article that says there are 12 procedures that may be overperformed, and it goes as far as referring to bloodletting and lobotomy as examples of popular procedures that later proved ineffective or dangerous. (To view the article, go to www.consumerreports.org/mg/free-highlights/manage-your-health/needless_surgeries.htm.) Knee debridement and lavage also is given as an example. The article credits the Rand Corp. in Santa Monica, CA, as the research source for its list of procedures that may not be necessary.
Consumer Reports says overuse of surgeries typically occurs when surgeons don’t keep up with the research, rush to perform new approaches before their safety and effectiveness has been documented, and when they recommend a procedure that hasn’t been proven without describing other options.
"It is true that a number of medical procedures previously thought helpful have been shown to be of little or no use," says Thomas G. Stovall, MD, clinical professor of obstetrics/gynecology at the University of Tennessee, Memphis. "This generally comes about secondary to a lack of scientific information or the lack of proper study being done before a procedure is introduced."
Even with the rigid clinical studies required to approve a new drug, members of the medical community have seen instances where new or unusual side effects occur after the drug is released, he points out. "With surgical procedures and other medical devices, these controls are lacking."
Here are some of the specific procedures for which Consumer Reports issued warnings:
• Surgical weight loss. The number of people having bariatric surgery quadrupled between 1998 and 2002, the article reports. While acknowledging that the procedure appears to cause a significant amount of long-term weight loss in the severely obese, it goes on to say the operations are "highly invasive." It warns of potential complications and says that one of every 200-300 patients dies. It recommends weight-loss surgery as a "last resort" for the extremely obese, those who have weight-related medical conditions, and those who have unsuccessfully tried to lose weight with other methods.
The article mixes fact with fiction, says Neil Hutcher, MD, president of the American Society for Bariatric Surgery. "These are isolated facts taken out of context and out of the reality of the situation," he adds.
For example, there is no medical treatment for morbid obesity, Hutcher emphasizes. "I would be happy to debate anybody, anytime that bariatric surgery is the most rehabilitative treatment in modern medicine today," he says. "In one treatment, you can cure diabetes, heart disease, hypertension, obstructive sleep apnea, hyperlipidemia, control arthritis, control spastic incontinent bladder, and make the patient feel better about himself or herself."
Additionally, most patients suffering from morbid obesity are desperately ill, he says. "The trivialization of what a morbidly obese person goes through, the fact that they seek surgery — is totally misleading and not accurately represented," he says.
• Prostatectomy. While Consumer Reports acknowledges that prostatectomy appears to cut the opportunity for recurrence of prostate cancer slightly better than radiation therapy does, it goes on to warn of complications such as impotence and incontinence.
Durado Brooks, MD, MPH, director of prostate and colorectal cancer at the American Cancer Society, argues against the tone of the article. "It made it sounds as if surgeons are knowingly operating on people who do not need surgery," he says. "That is not the case."
The article is incomplete, Brooks says. "It’s not as easy as this makes it sounds to determine whether or not surgery is the best route."
Clearly, there are some men undergoing surgical removal of prostate gland or radiation treatment who will not benefit from the procedures, he says. "But selecting which men will benefit and clearly identifying those men that don’t need active treatment is a challenge," Brooks says. "We simply don’t have accurate enough testing methods to make that determination with absolutely certainly."
Men need to know their options other than surgery for addressing prostate cancer, he urges. "They need to be educating themselves about all of these options and potential complications and side effects related to treatment and making a decision based on their personal preferences," Brooks says.
&bull Hysterectomy. While hysterectomy is absolutely needed in some circumstances, less invasive treatments are appropriate in other cases, according to Consumer Reports. Hysterectomy poses unusual surgical hazards, such as reduced sexual pleasure, the magazine says. It also says conditions that most often cause pelvic pain or abnormal bleeding, such as endometriosis, can be treated less aggressively. For example, surgeons can remove just the fibroids or use endometrial ablation, it says.
Stovall offers this viewpoint: "For many patients, hysterectomy is the appropriate procedure and an answer to the patient’s problem. The patient should talk with her doctor, ask questions, and determine if there are other alternatives that she is willing to try, he says. "No single treatment or procedure is right for any patient and any time."
• Enlarged prostate procedures. Transurethral resection of the prostate (TURP) is very effective but causes infertility and retrograde ejaculation in most men, the article says. Additionally, it causes complications, including serious bleeding, in about 10% of patients, Consumer Reports says. It discusses simpler treatments for prostate enlargement but says all of them are usually unnecessary, as 30% of men usually get better without them.
J. Brantley Thrasher, MD, spokesman for the American Urological Association and chairman of the department of urology at the University of Kansas, says he doesn’t basically disagree with the points in the article. However, from before the time there were alpha-blockers and finasteride (Proscar), "TURP has been the gold standard," he says. "For every treatment that a reader sees or hears about, it has to be compared to the effectiveness of TURP."
Thrasher acknowledges that the procedure has several side effects, and he says that a thorough history and physical is critical in determining the best course of treatment. He also points out that urethral stricture has similar symptoms to an enlarged prostate and should be ruled out before surgery. "Once that’s done, I like to treat patients most of time from less invasive to more invasive, along that spectrum," he says. Most patients would rather take a pill than undergo any type of surgery, regardless of how invasive it is, Thrasher emphasizes.
• Lumbar laminectomies and cervical discectomy. Consumer Reports points out that operations for low back pain have increased from about 190,000 annually in the 1980s to more than 300,000 per year today. "Many of those operations are probably unnecessary," the magazine says. The most common cause of low back pain is a minor problem that usually goes away within about a month, the article says. Even pain from a herniated disk resolves itself within six weeks about 90% of the time, the magazine says. Additionally, the benefits from having surgery apparently are temporary most of the time, it says. It quotes one long-term study as saying that people who waited had no more back pain than those who had surgery.1
Consumer Reports says surgery should be considered only under certain conditions, such as when other treatments, such as spinal steroid injections, have failed. Stuart Weinstein, MD, president of the American Academy of Orthopedic Surgeons, takes issue with the report. "I think it’s very difficult to say that because the numbers of surgeries increased, it’s unnecessary," he says.
However, Weinstein does say that surgery is indicated only rarely in acute situations. "With back pain, there is a logical order of nonoperative therapies and diagnostics before surgery," he says.
Reference
- Weber H. Lumbar disc herniation. A controlled, prospective study with ten years of observation. Spine 1983; 8:131-40.
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