Read all about it... It can be awkward when a patient asks you about a report in their favourite tabloid detailing an amazing research breakthrough or a ‘cutting-edge’ new treatment / test and you don’t know what they are talking about! So this section fills you in on the facts.
Shocking treatment to perk up a man’s flagging lovelife: Can erectile dysfunction really be cured with soundwaves?
The Daily Mail – 14 September 2020
We start off this issue with a superbly written and very balanced piece in the Daily Mail. The story details extra-corporeal shockwave treatment (ESWT) for erectile dysfunction (ED). I will confess a degree of ignorance regarding this particular treatment. Certainly, I was aware of its existence, but I had not appreciated its proliferation in recent months / years. A quick ‘google’ however shows that many private companies are now offering this treatment to the public. Indeed, this story will go some way to further highlighting the existence of the treatment and raises the chances of a patient asking you about this.
This article in the Mail is thoroughly researched and gives a good, if basic, breakdown of what the treatment involves as well as a balanced summary of the evidence to support the use of the treatment.
In some more detail however (for readers of Urology News), ESWT for ED has been a concept for 10 years now. The earliest studies in the field of ‘improving bloodflow’ through ESWT were carried out on porcine myocardium and this was first trialled in ED in 2010, when a small pilot study was published in European Urology. The exact mechanism of action of ESWT remains somewhat hazy, as best as I can tell. Several studies have demonstrated increased levels of angiogenic factors within ESWT-treated tissue in animal and in vitro studies. This is thought to lead to neo-vascularisation. There have been some claims of evidence of nerve regeneration in diabetic patients and regeneration of cavernosal endothelium and smooth muscle as well. What is clear, is that there is no universal consensus on a mechanism of action.
The best summary of the evidence for ESWT for ED comes from a 2019 meta-analysis (Dong L. et al) published in American Journal of Men’s Health. This paper was an analysis of seven randomised controlled trials (RCTs), making this the first meta-analysis to provide level 1 evidence. Even with this, the total number of patients is only 522, all with vasculogenic ED and no other co-morbidities. As you might expect, the analysis is complicated by the usual difficulties of widely differing RCT methodology, treatment regimes and follow-up schedules. By and large, the most common treatment schedule was weekly treatment for around five weeks, with 1500 shocks to the penis on each visit. Each study used sham treatment in the control group. Follow-up was very variable, studies were either just four to five weeks of follow-up or 12 months (in just two studies).
Response to treatment was assessed through the change in International Index of Erectile Function (IIEF) scoring. Of note, the minimal clinically significant difference (MCID) for IIEF is thought to be four. This means that a four-point change is required to translate to a meaningful difference for patients. Of the studies using IIEF scoring, one study (with a low number of shocks) failed to cross this threshold, a further three just about cross this line, a further two show a clear improvement. Overall, the results (in terms of IIEF improvement) are statistically significant in this meta-analysis.
In conclusion, there is evidence that something appears to be happening with this treatment, but quite what remains somewhat uncertain, as well as how long the effect will last for. There is clear variation in the efficacy of the treatment between studies that is not easily explained and no evidence from this analysis at all on how it would work in patients with co-morbidities and severe issues (which are the majority of our patients). At a cost of £3000 for private treatment, it is not something I feel I could freely recommend to even wealthy patients at the current time and clearly a great deal more research is needed before the treatment could possibly become more widely used.
Prostate cancer referrals dropped by HALF during lockdown to the lowest levels for a decade as thousands of men put off seeing a doctor about the disease, charity warns
The Mail Online – 8 September 2020
Moving away from meta-analyses and statistics, this story details the news from Prostate Cancer UK that 27,000 fewer patients were seen between April and June (during the first wave of COVID-19) for investigation of possible prostate cancer than would have been expected. Clearly, we all saw this change, but the scale of the number is still surprising. The Mail, quite rightly, has flagged this so that men will hopefully seek investigation and treatment, should they need it.
I think these numbers simply raise more questions though. From my understanding, there have been huge differences across the country in availability of GP appointments and given the fairly ad-hoc nature of prostate specific antigen (PSA) testing in the community, a reduction in PSA testing will certainly lead to fewer referrals. In the particular case of prostate cancer, it remains quite likely that the men who have been significantly disadvantaged by a delay of a few months will be in the minority at least.
I suspect that your department, much like my own, has ‘tweaked’ pathways during COVID and are ready to receive and manage referrals despite circumstances. The letters on my desk however, suggest that the gulf between primary and secondary care has never been larger. I do not believe that general practitioners are terribly well informed of the ongoing circumstances which continue to impact theatre capacity in many hospitals and neither are we well informed of how local surgeries are currently managing their patients. Hopefully, this is something that can be remedied going forward.