Shedding New Light on Lasers for Medical Use : Euphoria Over the Beam’s Potential Dimmed by Concerns About Marketing
The bright, warm red light beam swirls through the glass fiber tube carrying it from the laser generator in another room, spilling onto the hand of UC Irvine researcher Michael Berns, who observes that there is persuasive--if not final--evidence the laser may help cure cancer.
It is a heady, gee-whiz kind of thing, perfect for the evening news on television--not coincidentally where such magic light beams have repeatedly starred. But with the stardom there are now starting to come questions--not necessarily about the laser itself but about the means being used to market and promote it.
Dye Laser
This little demonstration of a device called a dye laser occurs in an outpatient operating room inside the new $7-million Beckman Laser Institute on the Irvine campus. It is a facility just opened this June but it has already established itself as one of the three most important centers in the country for research on how these futuristic light beams can play a role in medicine and surgery.
There are green argon lasers that can vaporize warts on the skin--a point Berns unintentionally emphasizes by accidentally inflicting a minor burn on his hand during a demonstration. And there are invisible carbon dioxide lasers capable of extraordinarily precise incisions in their role as a so-called “light scalpel.”
Something called a YAG laser (an acronym drawn from its full name, neodymium:yttrium-aluminum-garnet) can play a role in cataract surgery and a wide variety of other eye operations.
Fascination for Public
They’re captivating, these lasers, and since the first such beam of light was shot in a laboratory in about 1960, they have emerged as a fascination for the public. They act as speed-of-light pipelines for millions of telephone conversations and they may eventually be able to shoot guided missiles from space. They have certainly revolutionized some branches of medical care and they may revolutionize others.
This kind of publicity has been good for lasers, Berns thinks, but it also has been the basis for growing concern that lasers are being oversold and perhaps overused by doctors and hospitals eager to cash in on the laser’s value as a marketing gimmick.
The dermatologist who advertises he will use a laser (cost of machine: $20,000) to remove a simple wart from the hand, for instance, may not tell a patient that the wart can be removed at least as effectively by three other less expensive and more conventional means. One of them is the cheap, pedestrian, disposable $3 metal scalpel.
Sitting in his office at the institute, Berns chuckled at a question about lasers and warts, using his own son as an example of how patients have come to equate the laser with cure. “He’s having a plantar’s wart taken off his foot,” Berns said of the boy. “They’re using cryosurgery (a now comparatively old-fashioned process in which a wart is frozen under controlled circumstances). But he (the youngster) says to me, ‘Dad, why can’t it be done with a laser?’ ”
The laser has become the treatment of choice for warts at some body sites--most notably in the ano-genital area. And even for routine wart removal, the laser has its adherents who, like Harvard Medical School’s Dr. Kenneth Arndt, a nationally known laser expert, argue that in many cases if a dermatologist or plastic surgeon has become proficient with a laser and feels more comfortable using it than other methods, there is little reason to avoid use of the laser, “as long as the charges aren’t absurd.”
Laser’s Premium Price
But like many other doctors, Arndt said he is concerned that some physicians may charge a premium for using a laser when a cheaper means of treatment would substitute. Such practices, he contended, are inexcusable.
The plastic surgeon who advertises he uses lasers to make wrinkles disappear in a “laser face lift” may not explain to patients that there is no evidence the effects are long-lasting. The practitioner offering “laser acupuncture” or touting lasers as a means to promote wound healing might not point out that acceptable proof of such effects has yet to emerge in scientific circles.
“I think those things (such claims) are bordering on fraud,” Berns said. “They represent an abuse of lasers where there is no scientific evidence the laser is having any benefit.”
So with the understandable hope engendered by the varied present-day capabilities and possibly greater future potential of lasers, there is a zapping by frustration and worry, too. If is felt by people like Berns, who is president-elect of the American Society for Laser Medicine and Surgery, and Dr. George Bohigian, an ophthalmologist at Washington University in St. Louis who headed a special American Medical Assn. panel studying the established and emerging roles for lasers--as well as their potential for abuse.
Having assembled a 14-member panel Berns called clearly weighted in the laser’s favor, the AMA Council on Scientific Affairs scrutinized the real, imagined and overstated roles of lasers in medicine and surgery, publishing a report in the Journal of the American Medical Assn. two weeks ago. The report was optimistic, emphasizing the laser’s already accepted and clearly promising uses in a cross section of medical specialties.
With the panel report, however, the journal published an editorial by Bohigian that raised questions not necessarily about the laser, but about the way doctors who use it may try to promote it. “ ‘Appropriate use’ is a fundamental question,” Bohigian wrote. “What some find disturbing to ask is, ‘Who oversees physicians who purchase lasers for use in their offices or ambulatory surgery centers?’
‘High Degree of Autonomy’
“Society has bestowed upon physicians a high degree of autonomy by what amounts to a social contract of mutual trust. How can physicians uphold their end of the compact by controlling the occasional physician who applies marginal or inappropriate use of technology to generate income?”
“I think the potential for abuse can be there,” he added in a telephone interview from his St. Louis office. “Because lasers so captivate the public attention, (a laser in a doctor’s office) can be used as a public relations tool.”
In his own specialty, Bohigian said he has already noticed a tendency for eye doctors to advertise that they perform “laser cataract surgery,” leaving patients to conclude that the laser has replaced more conventional cutting tools in the eye. In fact, Bohigian and other ophthalmologists emphasized, while certain lasers are used in cataract procedures, they play a role only in one specific phase of the operation--after the clouded lens has already been cut away.
“I think there is a problem,” Berns said. “The finger cannot be pointed at any one person or group of companies, but I have seen advertisements in the newspaper portraying the laser to the general public as something that can do everything. There are hospitals marketing lasers, essentially saying, ‘Come here. We have laser treatment.’
“This puts pressure on a physician. A patient comes in and says, ‘Hey, my friend had laser treatment. Can you do it for me?’ The physician says ‘no,’ and he loses the patient.
“There are an awful lot of good things the laser can do. But the physician should use a laser only when it’s called for and not use it when it’s not called for.”
“As physicians become more competitive, they are looking for ways of making their own practices more attractive to patients,” said Dr. Alan Wile, a UC Irvine tumor surgeon who is experimenting with new uses for the dye laser in cancer treatment. “Sometimes, just saying you have a new technology makes your method more attractive then someone who does the same procedure using something older.”
(The treatment with which Wile and Berns are experimenting involves injection of a chemical called called hematoporphyrin into the body. The chemical--for reasons not yet understood--has a tendency to collect in cancerous tissue where it can then be subjected to low-heat light bombardment with a dye laser. The laser activates a cancer-fighting property in the chemical and the tumor tissue is subsequently dissolved.)
Too, argued Dr. John Dixon, a surgeon who is director of the University of Utah School of Medicine’s Laser Institute, lasers can be just as captivating to doctors as they are to patients.
‘You Tend to Overuse’
“To a man whose only tool is a hammer, all the world looks like a nail,” Dixon said. “You tend to overuse the laser because it is there.” It is still true and is likely to remain true, he and others said, that the more conventional alternatives to lasers are better than the new-fangled gadgetry in many medical applications.
Typical of such an approach is development of a technique called laser circumcision, said Dixon, whose institute is another of the trio (Harvard Medical School is the third) of top laser centers in the country. While a laser is perfectly capable of trimming the foreskin from a penis, he said, conventional methods are at least as good and probably better. “This kind of thing,” he said, “just seems like overkill.”
But if things like the so-called laser face lift and the laser circumcision have cropped up on medicine’s fringe, even the harshest critics emphasize that mainstream medicine has developed an array of legitimate and promising possible applications more varied than perhaps the laser’s publicity might imply.
Among the current familiar ground and frontiers of laser medicine are these:
- In ophthalmology, the field that currently boasts the greatest array of accepted uses, lasers are being used to repair damage to the eye caused by diabetic retinopathy and for certain operations to treat glaucoma. Lasers make it possible to perform precise, microsurgical procedures in which damage to healthy tissue immediately adjoining diseased areas can be essentially eliminated.
Lasers are being used in cataract surgery, but in a comparatively limited way. Once a conventional knife has been used to cut away the clouded lens and a new plastic lens has been substituted, a laser can be employed to clear affected tissue farther inside the eye.
Among possible future developments is use of the laser in radial keratotomy, the controversial surgery in which a series of slits is cut in the cornea to correct extreme nearsightedness. In recent years, however, major questions have emerged about whether incisions made by scalpels heal properly or whether the structural integrity of the eye may be permanently damaged in radial keratotomy. Leading journals have recently carried a new round of reports of severe eye infection after radial keratotomy. Whether the laser can actually better accomplish the goal of radial keratotomy than present methods remains to be established.
- In dermatology and plastic surgery, lasers are being used for a variety of procedures--some controversial and some not. Among the best established applications is use of the argon laser to wipe out a type of facial birth mark common called port wine stains. Until the laser came into use, such markings required complex skin transplants and the surgery was considered difficult. Today, the laser has made removal of such markings all but routine. The laser has also shown promise in removal of tattoos.
Because the laser can simultaneously cut through tissue and cauterize severed blood vessels, minimizing bleeding, lasers also are being used for removing tumors on and around blood vessels. On the other hand, use of lasers to “weld” skin--an application once thought to have great promise in plastic surgery--has fallen into disrepute.
- In general and gastrointestinal surgery, the laser is thought to have great promise on several fronts. Techniques are now being developed by which some of the smallest blood vessels in the body may be stuck back together by use of a light beam. It may also be possible in the future to use lasers to reattach nerves--a field in which conventional techniques have had only very limited success. In many surgical fields, use of lasers in conjunction with fiberoptic devices called endoscopes--which permit a surgeon to visualize wide areas of the body through an optical scope inserted through a small incision--has already achieved widespread use.
Already Used
Carbon dioxide lasers are already used for a variety of cutting techniques in surgery of all sorts, where they provide improved control of blood loss and reduce infection. Use of lasers also is making surgery more available to some patients with blood clotting disorders. It is being used to remove large and previously inoperable tumors in the chest and abdomen.
- In neurosurgery, lasers are widely used in situations where traditional techniques have involved an unacceptable risk to damage to brain tissue and small blood vessels. The YAG laser has proven successful in the delicate process of removing tumors from the brain and spinal cord and the laser’s ability to induce rapid binding in areas where tissue has been cut have made it an invaluable addition to the field.
- In gynecology, lasers are already a treatment of choice for cervical cancer when the cancer is detected early. An area of great promise is the developing use of lasers in treatment of endometriosis. It can be used to vaporize uterine cysts and to deal with other complications of this common disease, which often robs a woman of her ability to have children.
It may eventually prove possible to clear plugged Fallopian tubes with a laser and to reconnect severed tubes with greater prospects for restoration of fertility than now exist.
- In urology, laser endoscopes are also being widely used. Lasers are being used to treat penile cancer and some bladder cancers. Lasers may eventually prove able to reattach severed ends of the vas deferens, the tubing carrying sperm away from the testicles that is deliberately cut in a vasectomy. Vasectomy reversal is currently unreliable but the laser may eventually improve now uncertain odds.
Of great potential promise is use of lasers to destroy bladder and kidney stones. A laser device may eventually replace the recently developed lithotripter, which knocks stones apart by use of ultrasonic shock waves. But here, the captivation potential of the laser also comes into play. Berns and Dr. Gerhard Fuchs of UCLA said both of their centers have received new laser devices to begin experimental stone destruction on selected human patients. Originally, a company making the devices was to locate experimental sites all over the country, but in a bid to lock up marketing of the units, the firm picked both UCLA and UC Irvine as locations for the human tests.
The experimental treatments are only now starting.
- In heart, lung and chest surgery, the laser’s most captivating and potentially revolutionary application is also one of the most controversial--and, so far, still theoretical. Involved is the promise that lasers may soon emerge as a means of removing life-threatening fatty deposits from inside arteries near the heart.
But although emergence of what has been called the “laser bypass” operation has been widely publicized, experts questioned by The Times agreed the publicity has been premature. While the laser is, indeed, capable of cutting through fatty arterial plaques, the beam used in such experiments so far also may harm the arterial wall itself--with potentially catastrophic consequences. It has also been theorized that plaques cut away by a laser inside an artery could get loose in the blood stream, traveling as embolisms to the brain where they could cause stroke or death.
The laser bypass, however, is theoretically possible, and many top doctors believe it will inevitably be developed--perhaps within as little as one or two years. “As opposed to a year ago, I am more optimistic that this will be a useful technique,” said Dr. Frank Litvack, a cardiologist at Cedars-Sinai Medical Center who wrote a medical journal editorial on the subject earlier this year. Unestablished at the moment is whether the laser will work best alone or in conjunction with the so-called balloon catheter, an accepted technique in which a balloon-like device is inflated inside the clogged vessel to force it open.
Litvack was speaking specifically about laser use in heart surgery, but what he said echoed statements of experts questioned by The Times about the broader emerging role of lasers in medicine. “I believe there have been tremendous advances and we’re moving in the right direction,” Litvack said.
“These are promising techniques, but many of them are not certainties. But if the laser is as good as we hope, it will be a great tool.”
