text: Google, PRP, and the Stem Cell Wild West Chris Centeno, MD / September 9, 2019 By
  
  This week Google announced that it would shut down all stem cell and PRP AdWords advertising. This seems to have been at the behest of the bench scientist research organization ISSCR. So is this a good thing or a bad thing or a little of both?
  
  The Stem Cell Wild West
  
  As you know, I am and have been a staunch critic of the out of control expansion of stem cell clinics. Most of this has been fueled by unethical birth tissue vendors convincing physicians and alternative health practitioners who should know better that they are selling vials of millions of live and vital stem cells. The gasoline thrown on the out of control stem cell bonfire has been marketing groups used to selling financial services or timeshares who have now begun helping these unscrupulous clinics sell stem cell therapies. This has created an insane number of clinics offering magic stem cell therapies that claim to cure everything from ALS to knee arthritis to aging.
  
  The ISSCR
  
  The ISSCR is a bench scientist organization that got going shortly after the Bush embryonic stem cell ban. They have been instrumental in educating the press and pitching stories that are critical of physicians offering stem cells. Given the out of control nature of the Stem Cell Wild West these past few years, this hasn’t been all bad. However, the problem is that the ISSCR leadership can’t seem to separate good actors from bad actors in this space. Hence, the ISSCR approach has been to throw the baby out with the proverbial bathwater. Meaning, ignore what the clinical literature is saying about which cell-based therapies work or don’t work and throw everybody under the bus. This has created a really weird dilemma. where you have university orthopedics departments who are using platelet-rich plasma and stem cell therapies every day while you have bench scientists on the other side of campus throwing their academic colleagues to the wolves.
  
  Google and Stem Cells
  
  Google began forming a policy on stem cell ads back in September of 2017 when we began to get word that some clinics were having their AdWords accounts suspended for using that term. AdWords are the advertisements that you see above and below your search results. However, the policy seemed to be very inconsistently applied. This past week, Google announced that it would get rid of all such ads including those for platelet-rich plasma, as of October 1st as these are considered investigational care. It also announced that the ISSCR had played a big role in why it’s instituting this new policy.
  
  So has Google thrown the baby out with the bathwater here or is this smart public policy? We can figure that out with a quick literature review on platelet-rich plasma, one of the targets of the advertising ban. Let’s dig in.
  
  What is the Science Supporting the Use of PRP?
  
  PRP stands for platelet-rich plasma, which means taking blood from the patient and concentrating their platelets in their plasma (1). This is not a new concept. In fact, the early publications on PRP appear about 20 years ago in the dental literature (2).
  
  What is the evidence-base that PRP is effective for orthopedic conditions? Let’s focus on knee osteoarthritis as there are many published randomized controlled trials. A 2018 meta-analysis looked at seven published studies of 908 patients (3). All studies demonstrated that PRP worked for knee OA and all but two showed it was superior to standard treatment of hyaluronic acid (knee gel injections). A 2017 overview of systematic reviews of PRP injections used to treat knee OA found 4 systematic reviews with a low risk of bias and concluded that PRP was an effective treatment option for knee arthritis.
  
  So in summary, we have many randomized controlled trials that support the use of PRP to treat knee OA. The systematic reviews of all of that research support that using this treatment is state of the art medicine supported by solid science. How then could Google conclude otherwise? Who were they listening to?
  
  University Inc.
  
  I suspect that Google like many in the technology world didn’t understand that the university scientists whose opinions it sought to make this decision were, in fact, representing business interests of their own. This is understandable, as we all have a sense that university professors are a bit like the priests of the 21st century, toiling in threadbare academic monasteries for the betterment of all mankind. However, every since the Bayh-Dole act of 1980, all of that changed (5). This allowed universities to use public funds to create for-profit ventures from their discoveries. While this has advanced the commercial applications of research discoveries and likely saved many lives, it has also made many universities very rich and turned them into business interests no different in principle from IBM or Google itself.
  
  Why would these university bench scientists be threatened by PRP? PRP shots are cheap and they work. If you’re a university who holds a patent on a knee osteoarthritis treatment using a stem or other cells and you’re trying to commercialize that through FDA approval, that treatment will cost thousands to tens of thousands of dollars. What happens to the viability of your product if a $200 PRP kit is far cheaper and gets the same results? United Healthcare won’t pay for your expensive new therapy, hence your business plan was just blown up.
  
  Fixing Google and Orthobiologics
  
  So how can this be fixed? I suspect that we will see professional organizations get involved to produce a multi-disciplinary statement to get Google to amend these policies. Meaning, that Google will need to make sure that it listens to many stakeholders and not just one. Google will also need to do a better job of balancing public policy decisions looking at harm vs. benefit.
  
  The Good/Bad News?
  
  If there is a bright spot in this whole mess it’s that many bad actor stem cell clinics will have their digital advertising reach curtailed. However, that will be balanced by patients who could have accessed safe and effective therapies like PRP with a fraction of the risk of surgery who will no longer know about these therapies. That will cause unintended harm through increased complications from overly aggressive and unnecessary surgical care. Not to mention dramatically increased cost for the medical care system.
  
  Andy Ittleman, a regulatory attorney quoted in the Washington Post article linked above said it best:
  
  “It puts Google in the position of being a quasi regulator, taking on quite a significant amount of jurisdiction,” Ittleman said. “They’re painting the industry with a broad brush and companies with legitimate arguments are going to be collateral damage.”
  
  The upshot? I hope Google can get this right. It has an opportunity to help clean up the Stem cell Wild West, but also a responsibility to balance harm with benefit. Right now, just like the ISSCR, it seems to have thrown the baby out with the bathwater.
  
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  References:
  
  (1) Wu PI, Diaz R, Borg-Stein J. Platelet-Rich Plasma. Phys Med Rehabil Clin N Am. 2016 Nov;27(4):825-853. doi: 10.1016/j.pmr.2016.06.002.
  
  (2) Kassolis JD, Rosen PS, Reynolds MA. Alveolar ridge and sinus augmentation utilizing platelet-rich plasma in combination with freeze-dried bone allograft: case series. J Periodontol. 2000 Oct;71(10):1654-61. DOI: 10.1902/jop.2000.71.10.1654
  
  (3) Di Y, Han C, Zhao L, Ren Y. Is local platelet-rich plasma injection clinically superior to hyaluronic acid for treatment of knee osteoarthritis? A systematic review of randomized controlled trials. Arthritis Res Ther. 2018;20(1):128. Published 2018 Jun 19. doi:10.1186/s13075-018-1621-0
  
  (4) Xing D, Wang B, Zhang W, Yang Z, Hou, Chen Y, Lin J. Intra-articular platelet-rich plasma injections for knee osteoarthritis: An overview of systematic reviews and risk of bias considerations. Int J Rheum Dis. 2017 Nov;20(11):1612-1630. doi: 10.1111/1756-185X.13233.
  
  (5) 94 Stat. 3015; United States Statutes at Large, Volume 94, 96th Congress, 2nd Session; Government Patent Policy Act of 1980; A bill entitled: “to amend the patent and trademark laws”; An act to amend the patent and trademark laws; Public Law 96-517 https://uslaw.link/citation/stat/94/3015
  
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