Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Patient Choice
- Peter Berrie (11 January 1999)
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Controversy in managing patients with prostate cancer
- Paddy O'Reilly (18 February 1999)
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Peter Berrie, none none
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The striking thing about this letter is the attitude to patient choice. "Patients would only have access to the new treatment by agreeing to abide by the protocol, which would include randomisation. Doctors would only be licensed to use the treatment within the trial and only after appropriate training. Trials could recruit much larger numbers of patients and do this more quickly than is currently the case." This gives the impression that for those paying for their medical care through the NHS, treatment is a privelige not a right; whatever patients are, they are far from being customers, and any opinions they and their physicians may have about what treatment is best for them in the light of currently available evidence should be disregarded. One has often suspected the existence of such attitudes in the NHS, but this astonishingly direct expression of them makes the best argument I have heard for a long time for private medical care! Note that we are talking RP and EBR - treatments with a considerable clinical history, not new at all, though there have been few randomised trials. The evidence of their effectiveness is unclear. Different view of it are possible. This makes things very difficult for everyone. But the solution is not to try to abolish people's right to choose what they and their doctors, rightly or wrongly, think is right for them, based on this evidence. |
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Paddy O'Reilly
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Sir, No one would deny the need for controlled prospective trials to determine best management in serious conditions such as prostate cancer. But to adopt a nihilistic approach towards available treatments because such data does not exist is to turn back the clock of progress. Proponents of evidence based medicine may claim there is no evidence that radical prostatectomy is the treatment of choice for early prostate cancer, but there is no evidence that it is not. The suggestion of Willis (BMJ1999;318:126) that patients should "only have access to a treatment by agreeing to abide by the protocol which would include randomisation" is rather arrogant, and insulting to patient and doctor. Men with a life expectancy of 10-25 years who develop prostate cancer will not allow themselves to be randomised to a "watchful waiting" group (waiting for what - disease progression? metastases?), as the early demise of the MRC PRO6 trial demonstrated. Stepping Hill Urology and the uro- oncologists at the Christie Hospital have for 12 months been conducting a prospective controlled trial to compare radical prostatectomy with radical radiotherapy. Currently 20 patients have been entered and 3 more are being processed. If funding is forthcoming the study will be opened to the North West Region urologists and others. All patients are fully counselled by a urologist, a radiation oncologist and a specialist nurse, then offered randomisation. Of the first 20 patients, only 1 agreed to be randomised, the other 19 making their own informed decision between the 2 treatments. Patients want to make up their own minds regarding their future, and they deserve to have full information about and access to all available treatments. A study comparing surgery and radiotherapy is still possible, but it is unlikely ever to be a randomised study. Paddy O'Reilly Linda Martin Gerald Collins on behalf of the CRASH Oncology Group Paddy O'Reilly Consultant Urologist Stepping Hill Urology Stepping Hill Hospital Stockport SK2 7JE |
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