Study Type – Therapy (prevalence)
Level of Evidence 2b
Study Type – Therapy (prevalence)
Level of Evidence 2b
• Many experts consider that media coverage, marketing and/or direct-to-consumer advertising, particularly Internet-based forms, are fundamental to the widespread adoption of robotic-assisted prostatectomy (RARP). However, this has not been explored previously.
• The primary objective of the present study was to delineate the role of media coverage and marketing of RARP on the Internet, whereas the secondary goal focused on website quality with respect to the presentation of prostatectomy.
• Website content was evaluated for direct-to-consumer advertising after the retrieval of the first 50 websites using Google and Yahoo for each of the terms: ‘robotic prostatectomy, laparoscopic prostatectomy (LP) and open radical prostatectomy (ORP)’.
• A linear regression analysis was performed for the annual number of Internet news hits over the last decade for each procedure. Website quality assessment was performed using WHO Honesty on the Internet (HON) code principles.
• Of the retrieved sites, the proportion containing direct-to-consumer advertising for RARP vs LP vs ORP using Google was 64% vs 14% vs 0%, respectively (P < 0.001) and, using Yahoo, 80% vs 16% vs 0%, respectively (P < 0.001).
• In a linear regression analysis, the r2 values for news hits for each year over the last 10 years were 0.89, 0.74 and 0.76 for RARP, LP and ORP, respectively.
• Website quality assessment found that a minority of the websites were accredited with HONcode principles, with no difference between procedure types (P > 0.05).
• Media coverage and marketing of RARP on the Internet is more widespread compared to LP and ORP.
• Disturbingly, the quality of websites using any technique for prostatectomy was of poor quality when using principles of honest information presenting and such findings need to be discussed with respect to obtaining informed consent from patients.
Honesty on the Internet
minimally invasive surgeries
open radical prostatectomy
Subsequent to the introduction of robotic-assisted radical prostatectomy (RARP) for the surgical treatment of clinically localized prostate cancer in 2000 , and despite a great deal of controversy regarding its outcome and cost effectiveness compared to traditional forms of treatment , there has been a major shift toward this type of surgery. In 2001, ≈250 procedures were preformed in the USA, whereas this number has increased substantially to ≈50 000 in 2007 .
This shift reflects a major commitment made by urologists (of whom most are at different stages of their career) in terms of acquiring this new technology and changing from the open technique. Consumers (i.e. patients) and urologists appear to have embraced this technology, and have been at least partially influenced by the early results obtained from centres of excellence reporting acceptable oncological control, continence and potency rates, which appear to be better than those previously reported with open surgery . Factors such as better vision (i.e. three-dimensional), superior and precise instrumentation and surgeon comfort were also noted as contributing forces . Other important factors considered to have played a major role with respect to the wide adaptation of RARP are media coverage and marketing/direct-to-consumer advertising, either by the manufacturer of the robot used in RARP (da Vinci Surgical System; Intuitive Surgical, Inc., Sunnyvale, CA, USA) or by the hospital/surgeons offering the procedure [5–10]. However, this role has yet to be explored in detail.
Overlying this is the ease of access to information, primarily available on the Internet, which was shown to be the most important resource of added information when patients and their family seek out supplementary knowledge [11,12]. This does not always lead to good quality information being disseminated because a recent multilingual study of urological oncology websites found that only a minority follow basic principles of honest health information presentation . Specifically regarding RARP, there is little data available and only one study supporting poor quality sexual function data after comparing RARP with open radical prostatectomy (ORP) on the Internet . The end result is that patients may be misled because they confuse information with knowledge and understanding . An even more extreme outcome is that patients choosing RARP appear to report less satisfaction than those having open surgery after RARP, with patients being more regretful and dissatisfied, possibly because of higher expectations of an ‘innovative’ procedure, which is largely driven by the hype surrounding the procedure .
Against this background, the present study aimed to quantify the role of media coverage and marketing of RARP on the Internet. A secondary objective was to assess the quality of websites that present RARP to consumers.
Based on the evidence that Google and Yahoo represent the two most common search engines, accounting for over 80% of searches performed [17,18], we performed an online search of (Google at http://www.google.com; Yahoo at http://www.yahoo.com) using the terms ‘robotic prostatectomy’ (RARP), ‘laparoscopic prostatectomy’ (LP), and ‘open prostatectomy’ (ORP). Furthermore, as a result of the observation that patients rarely access more than the first page of search results (typically ten results) , we assessed the first 50 websites (i.e. the first five pages) yielded by each search and classified them based on the main type of content into ‘News’, ‘Scientific’ or ‘Patients’ Educational/Informational’. The proportions of websites that contain direct-to-consumer advertising of the procedure were compared between the three types of surgeries.
Each of the terms ‘robotic prostatectomy’, ‘laparoscopic prostatectomy’ and ‘open radical prostatectomy’ were used separately to search (GoogleNews at http://www.news.google.com)  and, for each search, the number of news results per year over the last decade was noted, which is a function provided by the search engine.
A linear regression analysis was performed to assess whether there is a linear trend between the number of news hits and the time period subsequent to the year 2000 for each procedure; r2 and P-values were used to compare these trends.
The websites evaluated as described above were sequentially screened for quality as defined by the World Health Organization as the Honesty on the Internet (HON)
Foundation. This was done by applying HON principles through the HONcode toolbar function (available at http://www.hon.ch) for use on any personal computer, which activates or ‘lights up’ a toolbar if a website is accredited. The HON function has been used and assessed in several studies and was thus considered to be a valid and high calibre tool . We compared the percentages of websites that are accredited by HONcode for each type of procedure (i.e. ORP, LP and RARP).
All statistics were performed using SPSS, version 17 (SPSS Inc., Chicago, IL, USA). Chi-squared analysis was performed for categorical variables and linear regression analysis was performed to determine whether there is a linear trend between the number of news hits and the time period subsequent to the year 2000 for each procedure; r2 and P-values were used to compare these trends. P < 0.05 was considered statistically significant.
Table 1 summarizes the classification of the first fifty websites yielded by each search based on their content. Using Google, out of the first fifty websites yielded by each search; 32 (64%) websites contained direct-to-consumer advertising of RARP when searching ‘robotic prostatectomy’ compared to seven (14%) websites that has direct-to-consumer advertising of LP when searching ‘laparoscopic prostatectomy’ and none for RP when searching ‘open radical prostatectomy’ (P < 0.001) (Fig. 1). When using Yahoo, out of the first 50 websites yielded by each search; 40 (80%) websites contained direct-to-consumer advertising of RARP when searching ‘robotic prostatectomy’ compared to eight (16%) websites that had direct-to-consumer advertising of LP when searching ‘laparoscopic prostatectomy’ and none for RP when searching ‘open radical prostatectomy’ (P < 0.001) (Fig. 1).
|News, n (%)||1 (2)||5 (10)||0 (0)|
|Scientific, n (%)||10 (20)||25 (50)||24 (48)|
|Educational/informational, n (%)||39 (78)||20 (40)||26 (52)|
|News, n (%)||0 (0)||2 (4)||2 (4)|
|Scientific, n (%)||9 (18)||13 (26)||5 (10)|
|Educational/informational, n (%)||41 (82)||35 (70)||43 (86)|
In the year 2000, there were only 13 news hits for the term ‘robotic prostatectomy’ in Google News, whereas this increased to 173 in 2009. In a linear regression analysis, the relationship between the number of news hits in each year over the last 10 years for RARP, LP and ORP is shown in Fig. 2, with r2 values of 0.89, 0.74 and 0.76, respectively. When the three slopes were compared, the trend for RARP was statistically more significant than LP and ORP, with P-values of 0.03, 0.67 and 0.91, respectively.
As shown in Table 2, in terms of website quality assessment of the first 50 websites yielded using Google, those accredited by the HONcode toolbar comprised seven (14%) for RARP, eight (16%) for LP and nine (18%) for ORP (P= 0.88). Using Yahoo, out of the first 50 websites yielded by each search, the accredited ones comprised five (10%) for RARP, eight (16%) for LP and 13 (26%) for ORP (P= 0.24).
|Accredited, n (%)||7 (14)||8 (16)||9 (18)||0.88|
|Accredited, n (%)||5 (10)||8 (16)||13 (26)||0.24|
Society has a major role in the delivery of health care. Davis and colleagues described the societal forces that impact the health professions and the delivery of health care and summarized it as the ‘movement of consumerism in health care’. They concluded that this ‘movement:’ is fed by the rising education levels of the patients, relentless media coverage of health issues, proliferation of direct-to-consumer advertising, systems of ‘tiering’ of benefits and increased rationing of access (either by denying the choice of health care provider or by a system of queuing to obtain desired care).
Furthermore, urologists must be aware of the impact of consumerism on health care and should critically appraise the information that is provided to news outlets, as well as that made available on websites. Certainly, an assessment of quality by adhering to principles such as those of the WHO HON comprises one mechanism for assisting patients and others who are being provided with balanced information. We know from a previous study of urological oncology Internet quality  that the number of websites available for assessment is in the millions to tens of millions for each disease but that HON accreditation is available but is only utilized by around 30% of prostate cancer websites.
Many experts in the field of urology consider that both marketing (either by the manufacturer of the robot or by the hospital/surgeons offering the procedure) and media coverage have played a major role in the wide adaptations of RARP [5–10], despite the minimal data available to support this assertion. The only analysis of RARP on the Internet and the information it provides was by carried out by Mulhall et al., who focused on sexual function and, to a lesser extent, on continence post procedure, where it was shown that Internet sites advertise RARP with the promise of better potency and urinary continence rates (usually without presenting any data).
In the present study, we were able to expand upon this initial finding and comprehensively quantified the role played by the key factors of marketing and media coverage by evaluating one of the main sources of information used by patients and their families in the 21st Century (i.e. the Internet) [17,18]. Direct-to-consumer advertising refers to the marketing of diagnostic or therapeutic tools directly to patients instead of health care professionals . Subsequent to its legislation in the USA in 1997, there has been more spending on direct-to-consumer advertising from pharmaceutical companies and medical device manufacturing companies and such spending was shown to lead to an increase in the use of drugs and medical services . With regard to RARP, 64–80% of the top hits in the most commonly used search engines (i.e. Google and Yahoo’) were manufacturers, surgeons or hospital websites advertising the procedure directly to patients, which reflects the major role played by direct-to-consumer advertising in this area compared to the other surgical treatment options (i.e. LP and ORP).
The results of the present study also show that there is a significant increase in the media coverage of RARP subsequent to its introduction, as is evident by the greater number of hits obtained when searching for news about ‘robotic prostatectomy’ (via http://www.news.google.com). This shows that the introduction of RARP has resulted in massive media coverage over the last decade and we consider this also to be a major contributor to the movement of consumerism in this area. The data obtained in the present study also support the assumption made by Murphy et al. that patients are attracted by often unsubstantiated posts on commercial and health provider websites claiming that RARP is minimally invasive and that outcomes are superior to other approaches [8,24].
There are few studies linking RARP to the level of education. In two cross-sectional studies, Tseng et al. in 402 patients and Schroeck et al. in 400 patients found no association between the level of education and the rate of receiving RARP vs the traditional ORP. However, in a larger population-based study including 8837 patients, Hu et al. showed a significant sociodemographic and geographic variation with respect to the use of minimally invasive surgeries (MIS) vs ORP. Living in areas of higher socioeconomic status based on education and income was associated with greater receipt of MIS vs ORP. Hu et al. concluded that the variation probably resulted from ‘the highly successful RARP marketing campaign disseminated via the Internet, radio, and print media channels likely to be frequented by men of higher socioeconomic status’.
In the context of RARP, an increased rationing of access comprises another factor that may have fed the movement of consumerism. An interesting explanation given by Hu et al. in terms of their finding of a significant increase in receiving MIS among white and Asian men and in patients living in areas of higher socioeconomic status, based on the education and income, compared to black and Hispanic men and patients living in areas of lower socioeconomic status, is that: ‘black and Hispanic men with lower socioeconomic status may not have access to networks or surgeons that offer the procedure (i.e. MIS)’. However, another study showing no correlation between the patient income and the likelihood of receiving RARP  may represent a challenge to these findings.
The quality of websites that present RARP to consumers (as assessed in the present study using the HONcode) remains poor because only 10–14% of websites presenting the procedure to patients were accredited, and this is no different for LP and ORP. These results are in keeping with the recent findings reported by Lawrentschuk et al. in a multilingual study of urological oncology websites, where it was shown that only minorities follow basic principles of honest health information presentation. Clearly, physicians, their hospitals and the input that they provide to such websites needs to be of a higher standard and to be based on data rather than assumptions or marketing by external agencies.
It stands to reason that newer procedures will generate more interest in the lay media and press, and this partly explains some of the findings of the present study. However, the hype surrounding a procedure or drug may be mixed with the hype known to influence researchers and clinicians as a result of cross-pollination between different public media and the scientific literature . Regarding RARP, there have been some recent negative reports particularly regarding an honest assessment of the pitfalls of the procedure by Murphy et al., as well as a comprehensive cost analysis highlighting the inequity of the procedure compared to traditional open surgery . Importantly, a large administrative data outcomes analysis found that open surgery had better results , althuogh the methodology of this analysis and the presence of the learning curve may explain the differences. In any case, the results of the present study have only fueled the debate and reaffirm what many people feel, namely that it is probably not the type of approach but rather the surgical expertise that is important.
Sultan Alkhateeb and Nathan Lawrentschuk perform open and robotic prostate surgery.