Demythologizing the Gold Standard

We live in an age of medical specialties that “compete” for patients. In women’s health, for example, treating noncancerous growths called uterine fibroid tumors has traditionally been the territory of gynecologists. Gynecologists, like urologists, were trained in surgery so they often recommend hysterectomy (surgical removal of the uterus) as the gold standard for treating severe fibroid cases. Over ten years ago, the Wall Street Journal published an article on the reluctance of many gynecologists to tell women about a new minimally invasive treatment called UAE (uterine arterial embolization) that is performed by interventional radiologists, not gynecologists.[i] In its early days, well over half of women who had UAE had heard about it through the internet, not from their own doctors. A gynecologist, Juergen Eisermann, commented on what he described as a sad situation in terms of what his colleagues were doing to patients: “We do a disservice not to mention all the options.”

A physician who steers patients to his/her own treatment because it is the “gold standard,” and withholds information from patients about alternatives, may sincerely be trying to protect patients from an unproven treatment. When prostate cancer patients are told that radical prostatectomy is the gold standard, they may take it to mean that it is the best or perfect treatment. According to author Jurgen Claassen from Nijmegen Medical Center in The Netherlands, even many physicians have come to misinterpret the phrase. He writes, “Inspired by the Olympic Games, where the best athlete wins the gold medal, people who use ‘golden standard’ think the term denotes the best standard in the world. Not bronze, not silver, but gold. Of course, this is incorrect.”[ii] In fact, the term means that when a procedure such as prostatectomy has gained a long-term statistical track record, it can be used as a yardstick by which to measure newer treatments. This concept was borrowed from economics, in which pure gold became an international standard for measuring the value of national currencies.

Claassen points out that ALL gold standard treatments become superseded by newer treatments that either give better results, are kinder to patients, or both. When the newer treatments gather reproducible, long-term data, they in turn become a new yardstick.

In the world of prostate cancer, today’s focal laser ablation (FLA) lacks the statistical weight of radical prostatectomy. Around the world, millions of prostates have been surgically removed during the past four decades alone. This has generated an enormous accumulation of data, including discouraging statistics on the aftermath: urinary problems and impaired sexual performance. I venture to say that in the U.S., not even a thousand FLAs have been performed yet—though we’re getting close—but already awareness of this alternative treatment is growing because men and their loved ones find out about on the internet or word of mouth. This is very similar to women’s history with UAE.

Thanks to early prostate cancer detection by 3T multiparametric MRI, and the revolutionary genomic tests, I believe the day will come when focal therapy, not radical treatment, will be the new gold standard for targeting prostate tumors with little to no impact of quality of life. If so, patients will still need to keep in mind that there is no such thing as a universally perfect treatment. What’s most important is what’s best at meeting the needs of each individual patient.

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[i] “Hysterectomy Alternative Goes Unmentioned to Many Women.” Wall Street Journal p. A1, August 24, 2004. http://www.ivfmd.com/data/Wall_Street_Journal.pdf

[ii] Claassen JAHR. The gold standard: not a golden standard. BMJ?: British Medical Journal. 2005;330(7500):1121. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC557893/#__ffn_sectitle