The Gold Standard: Research-Based Treatment

"Medicine is a science of uncertainty and an art of probability."
-- Sir William Osler

Several times each year, every physician must sort through the claims for a new "technology," "drug," "device," "regimen," or "technique." Some innovations become wildly popular, while others disappear without a trace. Over the past few years, we have been learning about the potential value of Positron Emission Tomography (PET) scans for cancer patients and two recent experiences with PET scanning led me to reflect on how we incorporate new approaches into practice.

Not long ago, a longstanding cancer survivor developed a new tumor. As part of his evaluation, a PET scan showed an unexpected distribution of possible metastases. Because the pattern was very unusual, we sampled three areas where we could neither see nor feel anything worrisome. Surprisingly, all of the samples demonstrated nodules of cancer. Our treatment plan was significantly altered because of the sensitivity of the PET scan.

A few weeks later, another patient who had recently finished cancer treatment brought a PET scan to his appointment. The study showed worrisome areas in his throat and his neck. Despite a relatively normal examination, we decided to take him to surgery for biopsies and a nodal dissection. This time, however, none of the samples or nodes contained cancer.

As clinicians, we want to "trust our instincts." Most of us have a great aversion to making treatment decisions based solely on a lab test or imaging study; however, refusing to trust the technology might be just as harmful as blindly ignoring an improbable clinical finding. The dilemma becomes even more difficult as the innovations become more and more expensive and invasive.

Clinical research holds the key to solving these types of dilemmas since only well-conducted trials can test the claims and the hype. A "good idea" should become a "gold standard" only after rigorous testing. Too often, however, we find ourselves pulled along in the currents that drive medicine, learning only in retrospect what worked and what did not. We can do better.

Bruce H. Campbell, MD, FACS
Professor of Otolaryngology and Communication Sciences
Chief, Division of Head and Neck Oncology
Interim Director, Froedtert & The Medical College of Wisconsin Cancer Center

"Reflections" is a collection of essays by the health professionals of the Medical College of Wisconsin.