My 2 Cents: Incontinence

As I noted yesterday, we tend to look out for own self-interests. We like to play up studies that go along w/what benefits us. But when evidence-based medicine comes out against us, we argue vehemently.

Witness the recently unpopular US Preventive Services Task Force. Nearly all the specialists were willing to brand this primary care driven group when the USPSTF came out against screening for prostate cancer. At first, the studies were considered wrong or poorly run. Then the USPSTF was wrong because there were no urologists involved in the making of the recommendations. And now, there are efforts underway to disband & disbar this group from any further interpretation of medical literature. What's really impressive & telling is the backlash as noted by Gary Schwitzer in his blog last week.

So I find it rather ironic that a study published in the New England Journal of Medicine last Thursday concluded that radical prostatectomy did not improve (reduce) all-cause, or even prostate cancer, mortality, in localized cancers, as compared to active surveillance, otherwise known as watchful waiting or observation, over a dozen years after screening. One would have expected at least some reduction in prostate cancer mortality w/radical prostatectomy; after all, you're removing a cancer, right? But this is exactly why we need science rather than assumptions.

It turns out that radical prostatectomy really offers no benefit at all, especially with regards to the gold standard, all-cause mortality, otherwise known to me as Whac-A-Mole medicine. Worse, by undergoing surgery, one risks giving up urinary continence, erectile function, and overall quality of life. Which begs the question, why screen for prostate cancer in the first place? Unless you're holding a hammer in your hand, in which case, everything tends to look like a nail. Maybe it's time to get rid of that old medical school surgery adage, a chance to cut is a chance to cure. By holding a pen, I have nothing to gain or lose when it comes to your care. Let's remember to put our patients' interests first.

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I'm often asked "what's the best medicine/treatment/surgery for x" where x equals some health condition. Too often, the answer is "they're all about the same". In this day & age of medical technology, we know what broad category of medicine to choose, but not the specific one best suited for that individual patient's genetic profile. Sure, we can swab someone's cheek for some basic ideals related to liver metabolism, but I can't tell you whether you'll respond better to fluoxetine or paroxetine.

I was reminded of this yesterday when one of my 90yo female patients admitted to some urge incontinence (as distinct from stress incontinence). We discussed the various pharmacologic options available to her as noted in a wonderful systematic review published earlier this week in the Annals of Internal Medicine. Bottom line, they all demonstrate essentially equivalent benefit w/many anticholinergic side effects.

For an avowed car lover, it's like being asked to choose between Chevy, Dodge & Ford. They all make wonderful cars but I would be hard pressed to tell you that the Corvette ZR1 is better than the SRT Viper or the Ford Mustang GT500 (of course, if any manufacturer wants to convince me, I'm open to an evaluation!).

In the end, I gave my patient the same answer that I give everyone else and repeat over & over: the best medication is the one that you can afford and are willing to take as directed with the least number of side effects that will get you the benefit/outcome that you need. Her choice? Scheduled toileting since an empty bladder can't leak!

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