Shattering myths, offering medical advice, and advocating for patients

Two Harvard nurses explain how they care for men with prostate cancer and erectile dysfunction — and their families

When it comes to prostate problems, men turn to internists, urologists, and other specialists for reliable information about the disorder and treatment. But as any longtime patient will tell you, the help they receive from nurses is just as valuable. Nurses act as advisors and educators, dispelling myths and helping overwhelmed patients sort through treatment options. They help patients and their families cope with devastating diagnoses, as well as therapies that can erode quality of life. And nurses are often the first — and last — ones to see a patient during a doctor’s visit, meaning that they’re likely to handle some big issues as well as the small questions that the patient forgot to ask the doctor.

Recognizing that nurses and doctors approach medicine from differing though complementary viewpoints, Harvard Health Publications editors invited two nurses who practice with Harvard-affiliated physicians to talk about the role they play in caring for patients with prostate cancer and erectile dysfunction (ED), conditions that are often related. The nurses are

• Kevin Flinn, R.N., who treats men with erectile dysfunction and other conditions at Men’s Health Boston. He has worked there for the past nine years and has over 15 years of experience in sexual medicine. He lectures on the diagnosis and treatment of ED.

• Mary-Ellen Morrissey, R.N., who sees prostate cancer patients at Boston’s Beth Israel Deaconess Medical Center. Her nursing career has spanned 25 years; for the last 10 years she has been the center’s research nurse for genitourinary oncology.

Marc B. Garnick, M.D., moderated the discussion, which covered a wide range of topics.

The nurse–patient relationship

POPD: You see patients with every stage of prostate cancer. What are their most common questions? What do they share with you?

MORRISSEY: What they share and worry about is often related to where they are in the course of the disease. In the early stages of disease, they often wonder about the complications of treatment and what’s important to them, such as maintaining erectile function. Over all, I think the most common thing they want to know is whether they are going to die. After that, the next biggest concern is whether the treatment that we’re giving them is going to work — and for how long.

How do you respond to these questions and concerns?

MORRISSEY: I explain that whatever we’re doing, we wouldn’t be trying it if we didn’t think it would help. I’m optimistic. I’ll say, “Well, we’re going to try this, and if this doesn’t work, then we’ll move on to something else.” If patients see that you haven’t given up hope, then they’re willing to try anything that you have to offer. They want to hear that we’re not giving up on them, so they shouldn’t give up on themselves.

Do these conversations take place with the spouse or partner in the room?

MORRISSEY: Often, but a lot of times the men don’t want the spouse or partner in the room because they don’t want to hurt their feelings. If they have been in the room together, at the end of the appointment, the patient will say, “Oh, can I just talk to the doctor for a few minutes?” Sometimes, they want to be apart, such as when the subject of death comes up. They’ll talk about it with the physician or nurse, but they don’t want to have that conversation with their partner or spouse in the room. I think they are afraid of how their loved one will react.

How do you counsel them?

MORRISSEY: Well, the conversation usually turns back to the treatment and whether it will work. If a patient is just starting hormones, they’ll want to know how many people I’ve treated, so I’ll try to quantify it by saying, “I give 10 injections a day.” That reassures them that the treatment they are getting is something someone else has had and that it works. If they are just starting chemotherapy, they want to know how other people on chemotherapy are doing. When I tell them that the others are doing well, it gives them hope.

Do you think patients share concerns with you that they don’t share with their physician?

MORRISSEY: With the physician, I think patients feel that they have to be stoic. With me, I think they let their guard down. They’ll say, “Okay, tell me like it really is.” Perhaps that’s because I have more of a casual rapport with them. With the physicians, they worry about the scientific information they are going to be told. It’s more formal. With me, they can open up a little bit more, like they’re talking to a friend. They know that I’m going to be their advocate no matter what choice they make. They know I’ll be helping them through it, and that they can follow up with phone calls later if they have questions. It’s just a more relaxed relationship than they have with the physician.

Do you find the same thing is true in your practice, Kevin, even though you’re not dealing with life-or-death issues?

FLINN: Absolutely. Even though the issues aren’t life-or-death, sexual function affects quality of life. Often, the patient will say to me, “I’m so happy you’re here and that you’re spending the time with me to work through the treatment options.”

There are other practices where patients only see a physician, who probably has a limited amount of time. He or she usually doesn’t have enough time to fully educate the patient about the treatment that he’s receiving. For a man who needs injections to get an erection, a physician might say, “You just take the needle, put it here, and inject it,” and hand the patient a prescription. Unfortunately, that does a big disservice to the patient because the patient is now turned off by the treatment.

If a prosthetic, or penile implant, is indicated, they might feel that the doctor just wants to do surgery. As a nurse, I can walk them through the different treatments. If they need surgery, they’ll come to realize why. They’ll see that it’s the best option because other treatments haven’t worked. They know that I’m giving them time, that I’m on their side and will advocate for them, and that they were counseled properly throughout the process.

What could doctors do to improve their relationships with patients?

FLINN: I am fortunate that I work with a physician who’s very sensitive to these issues. But in general, I think that the prostate cancer oncologist, surgeon, or whoever the specialist is needs to be as up-front as possible about the potential complications of treatment. If a patient is going to have a radical prostatectomy, the surgeon needs to spell out what percentage of his or her patients experience erectile dysfunction after surgery. True, we have treatments for erectile dysfunction that we can turn to once the cancer has been addressed. But I don’t think the physicians always tell patients that they should expect to have ED and that it can be treated. Often, I think patients are misled or just not told. They’ll say to me, “I’m impotent now, and the doctor didn’t really discuss this with me beforehand.”

MORRISSEY: I think patients like knowing that the physicians are in it for the long haul and won’t give up on them. It comforts patients to know that their health care providers will always be there for them. They also want compassion. Sometimes, patients say to me, “Gosh, the doctor wasn’t very compassionate.” They want to know that their doctor really cares about them and will stick with them no matter what treatment they choose.

ED evaluation and treatment

How does your practice work, Kevin? Do patients start by seeing a doctor and then see you once a treatment has been chosen?

FLINN: Most of the patients who come to our practice are referred. There are some patients who find us on their own, but most are referred.

Most patients will see me first, during a nurse visit, before they see the doctor. The reason we do that is to initiate some testing to better understand what’s going on physiologically and why the patient might have ED. Patients fill out a questionnaire about their general health, so we know about other conditions they have and what medications they’re taking. I then talk with them about their sexual history.

Do you use the International Index of Erectile Function, or IIEF, survey?

FLINN: If a patient is part of a study, we will use the IIEF [see Table 1]; if you are going to publish data, you need to use a statistically validated questionnaire. But generally, when a patient comes in, we do our own individualized sexual history interview. We ask questions like: Are your erections hard enough for vaginal penetration? What percentage of the time do you have an erection that can penetrate? How long do your erections last?

Table 1: The IIEF questionnaire explained The original IIEF questionnaire includes 15 questions to assess erectile function, orgasm ability, sexual desire, satisfaction with sexual intercourse, and overall satisfaction. An abridged version of the questionnaire, called the IIEF-5, evaluates erectile function and satisfaction with five questions (below). Totaling the point value of each answer yields a final score that indicates the severity of ED: severe (5 to 7 points); moderate (8 to 11 points); mild to moderate (12 to 16 points); mild (17 to 21 points); and no ED (22 to 25 points). Because the answers to some questions are subjective, clinicians also rely upon the medical history, physical exam, and lab tests to diagnose and treat ED.
Over the past six months:	1	2	3	4	5
How do you rate your confidence that you could get and keep an erection?	Very low	Low	Moderate	High	Very high
When you had erections with sexual stimulation, how often were your erections hard enough for penetration?	Almost never or never	A few times (much less than half the time)	Sometimes (about half the time)	Most times (much more than half the time)	Almost always or always
During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?	Almost never or never	A few times (much less than half the time)	Sometimes (about half the time)	Most times (much more than half the time)	Almost always or always
During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?	Extremely difficult	Very difficult	Difficult	Slightly difficult	Not difficult
When you attempted sexual intercourse, how often was it satisfactory for you?	Almost never or never	A few times (much less than half the time)	Sometimes (about half the time)	Most times (much more than half the time)	Almost always or always
SOURCES: Rosen RC, et al. Development and Evaluation of an Abridged, 5-Item Version of the International Index of Erectile Function (IIEF-5) as a Diagnostic Tool for Erectile Dysfunction. International Journal of Impotence Research 1999;11:319–26. PMID: 10637462. Rosen RC, et al. The International Index of Erectile Function (IIEF): A Multidimensional Scale for Assessment of Erectile Dysfunction. Urology 1997;49:822–30. PMID: 9187685.

Do you tailor your interview based on whether the patient has ED related to prostate cancer or not?

FLINN: Yes. If a patient has been treated for prostate cancer, I ask about the treatment: Was it a nerve-sparing prostatectomy? Was it radiation? What kind? I also ask about his potency before treatment. I need to understand what kind of function he had to determine what caused the erectile dysfunction. It could be caused by treatment for prostate cancer, but as you know, men start to develop ED issues as they age. So he may have already been experiencing some level of erectile dysfunction before he was treated for prostate cancer.

How do you evaluate patients? What kinds of testing do you do?

FLINN: The initial test is a nocturnal penile tumescence [NPT] test. The patient takes home a device that looks like a small computer monitor. It has two loops that slip over the penis like a blood pressure cuff. He puts it on for two nights while he sleeps, and it records his nocturnal erections. It’s not painful. [See “NPT monitoring.”]

From the targeted sexual history, we’ll know if the problem has come on gradually, if erection quality is poor during masturbation when they aren’t with a partner, and such. That helps us screen for psychological versus physiological causes. The nocturnal penile tumescence test tells us if the erections at night are strong and sustained. If so, we know that the physical ability is there and that there might be a psychological cause. What we generally see is that the rigidity and erection quality at night fall below levels considered normal. If someone has 20% or 30% rigidity on his nighttime test, we know that the problem is more severe than if it’s 50% or 60%. This also tells us what his baseline level of function is.

NPT monitoring During this test, a recording unit collects data on the number and duration of nocturnal erections, the change in the circumference of the penis, and penile rigidity. The measurements are made by two loops: one at the base of the penis and the other at the tip. Rigidity above 70% constitutes a nonbuckling erection; below 40% represents a flaccid penis. During eight hours of sleep, three to six erections lasting 10 to 15 minutes each, on average, is considered normal, though definitions of “normal” vary.

How do people react to having this test?

FLINN: Well, patients with ED have often already gone to their primary care doctor. They may have tried Viagra [sildenafil] or one of the other PDE-5 inhibitors. If the drugs are working and the patient is satisfied, he really doesn’t need to see a specialist. But if the drugs haven’t worked and the patient just feels like he is being thrown a pill, he wants an in-depth evaluation. So when patients come to us, they feel like someone’s really attempting to understand what’s causing their ED. They want to know what’s going on, too, so most patients are enthusiastic and want to do to the test. They want to know how much of the problem is physical and how much is psychological.

What other tests do patients have?

FLINN: At that first visit, I might also do a very simple screening test called biothesiometry, which is a test for sensitivity. You place a device that vibrates on different parts of the patient’s penis, and he reports when he feels the vibration. Some men have decreased sensation in the penis, and this test picks that up.

Men with diabetes, for example?

FLINN: Yes, exactly. Other patients may have back problems that have a neurological component to them. Men who have a very low testosterone level often seem to have diminished sensation in the penis, too.

Getting back to the other tests, I also do what’s called a penile brachial index to compare the penile systolic blood pressure to the brachial systolic blood pressure. To do this, I use a miniature blood pressure cuff, which goes on the penis, and a Doppler probe to check blood flow. It’s not the most accurate method of screening, but if the number falls below 0.7, that’s an indication of a vascular component. For some patients, a more sophisticated test — penile ultrasound — can better evaluate blood flow in the arteries.

We would also do a complete endocrine screening for all of their hormones — luteinizing hormone [LH], follicle-stimulating hormone [FSH], estradiol, testosterone, free testosterone, and prolactin. We also test for SHBG, which stands for sex hormone–binding globulin. As men get older, the SHBG level rises and can deactivate the total testosterone.

How do you get patients to relax when you are discussing such personal information with them?

FLINN: When a patient first comes in, you really need to utilize some basic counseling skills and take into consideration that erectile dysfunction is a very sensitive issue. It can affect the marriage or other relationship, and it can affect the patient psychologically. I try to create an environment where the patient feels comfortable sharing information about his private, sexual life with me. Most primary care physicians don’t have the time to go into that, but because this is the nature of our practice, I give the patient a full hour.

After the tests and evaluation are done, the patient comes back to see the physician for a comprehensive urological consultation, examination, and treatment plan. My role is then to educate the patient about the various options and institute therapy.

What sort of therapy?

FLINN: Usually, the next step after PDE-5 inhibitors is a urethral suppository treatment called MUSE. [MUSE stands for medicated urethral system for erection.] The patient uses an applicator to insert the little suppository, which can induce an erection, into the urethra. After that, we might try penile injections containing drugs that make blood vessels dilate [see Figure 1]. We use alprostadil, papaverine, and phentolamine. These medicines are fairly powerful and can induce erections within five or 10 minutes, erections that can sometimes last an hour or two before they subside. Men inject the drug into the corpus cavernosum, which is the side of the penis. Obviously, that’s more invasive, so if that’s the next step, I need to counsel the patient and present it in a nonthreatening, appealing way so that he’s not overwhelmed by the idea.

Vacuum erection devices are another therapy. They are mechanical devices that work by negative pressure to cause an erection, but I would say they are probably the least popular of the options.

Figure 1: Injection therapy Using a small needle (about half an inch long, the same size as those used to inject insulin), a man can inject one or more prescription medications into the penis. The injected drugs relax the smooth muscle tissue of the penis, allowing blood to flow into erectile tissue.

Do you find it difficult to get a patient to try injection therapy?

FLINN: Well, if a patient comes in and tells you right away he is needle-phobic, that he just can’t imagine himself injecting his penis, it can be challenging to overcome those objections. But sometimes, the fears can be overcome. I know the injections sound painful, but they’re not, because you use a very fine needle. So I try to get the patient to inject himself in the office in private. If he sees that it’s not particularly painful and that it gives him a reasonable erection quickly, he’ll probably reconsider that option.

Do your patients talk with you about erectile dysfunction, Mary-Ellen?

MORRISSEY: Patients who are treating their prostate cancer with hormones will often ask, “Is there anything that I can take that will help with the erectile dysfunction?” If they have finished hormone therapy, they ask, “How quickly will things get better?” Once their testosterone level goes back up, their erections will return, but that can take awhile, and sometimes they aren’t willing to wait. They’ll ask me if there are any drugs or other treatments that will help.

What percentage of patients, both men who have been treated for prostate cancer and those who haven’t, respond to oral medications?

FLINN: In general, a low percentage of my patients respond to oral agents like PDE-5 inhibitors.* Probably 70% to 75% respond to an injected vasodilator. The other 25% to 30% will need to consider using a vacuum erection device or consider a surgical prosthetic if they want to be sexually active.

*Editor’s note: Studies report that PDE-5 inhibitors are generally effective in about 60% to 70% of men with ED, but individual results vary.

Do you think that the low rate of response you see to oral medications is due to the fact that the patients who come to you have already tried and failed to get results from sildenafil or another medication?

FLINN: Yes. About 80% to 85% of my patients have already tried Viagra [sildenafil], Cialis [tadalafil], or Levitra [vardenafil] before I see them. They know that an oral agent is not likely the answer for them, and they understand that they need to be open to other options.

Deciding on treatment for prostate cancer

How do you counsel someone who has recently been diagnosed with prostate cancer and is trying to sort through the multitude of possible treatment options?

MORRISSEY: A lot of times, patients will pull me aside after having seen the doctor and say, “Okay, tell me what I’m supposed to do.” Of course, I can’t tell them what to do. They have to sit down with their spouse or partner, meet with physicians, and make their own decision. But I do remind them that they have to figure out what sort of treatment is going to fit with their lifestyle. We also talk about side effects — what they’re willing to live with and what they aren’t. Weighing the pros and cons in that way can help them make treatment decisions.

Are most patients happy with their treatment choice after the fact?

MORRISSEY: I think that younger patients seem to do better, at least emotionally, when they choose surgery. When they hear that they have cancer, younger men more often say, “Oh my gosh, just take it out.” If they eventually decide to take hormones or undergo radiation, they often second-guess themselves later, saying “maybe I should have just had it taken out.” In my experience, older patients — meaning men in their late 60s and older — generally don’t second-guess themselves. They usually believe that whatever decision they made was the right decision.

What about patients who choose active surveillance?

MORRISSEY: Once men hear about the possible side effects of treatment, many who meet the criteria for active surveillance decide to delay treatment. But that has its own set of anxieties. It can be hard to just wait and see what happens.

Let’s talk about patients who have already had surgery or radiation and been through hormone therapy. What’s their reaction when the physician starts talking about chemotherapy?

MORRISSEY: When patients hear the word “chemotherapy,” they start thinking that they’ve exhausted all of their options. They wonder whether chemotherapy is really going to work and start thinking that they’ve reached the end of the road. I try to explain that it’s definitely not the end of the road, that there are all sorts of treatments that can still get the PSA down and keep the cancer in check. But once patients get to the chemotherapy stage, I definitely have to give them more support because they think that they’ve failed everything else and that this is the only chance they have left. That’s rarely true.

How do you address their fears? What role can a spouse or partner play?

MORRISSEY: I think the spouse is usually just as scared as the patient. They’re both frightened because, as I said, the word “chemotherapy” brings with it thoughts of nausea, vomiting, your hair falling out, and all sorts of terrible things. When I sit down and talk about the chemotherapy regimen that they’ll get and explain what the side effects are, they are often surprised to learn that they will still be able to work and do activities that they enjoy. I do a lot of teaching and put a lot of effort into getting rid of the myths that have built up around chemotherapy.

What advice can you give patients to make their management of the situation as effective and as successful as possible?

MORRISSEY: I tell patients that they have to stay positive and believe that the treatment is going to make them better, that it’s going to prolong their life, and that their quality of life won’t be stolen. I also remind them that there are other options out there, so if they can’t tolerate the treatment, we can try something else. And then I tell them what the other possible options are.

How do people respond to this sort of advice?

MORRISSEY: They’re very receptive. They are looking to me for advice, comfort, and support, and as a nurse, that’s the most important thing I can do.

Table 2: Chemotherapy for advanced prostate cancer
Drug name	Some possible side effects
docetaxel (Taxotere)	Hair loss, nausea and vomiting, drop in blood cell count
mitoxantrone (Novantrone)	Nausea and vomiting, hair loss, fatigue, drop in blood cell count
paclitaxel (Taxol)	Hair loss, fatigue, drop in blood cell count, numbness and tingling in hands and feet (usually after long-term use)
vinorelbine (Navelbine)	Nausea and vomiting, fatigue, constipation, diarrhea, tingling in hands and feet, hair loss, muscle aches, drop in white blood cells
Note: Although these drugs are routinely used for the treatment of advanced prostate cancer, paclitaxel and vinorelbine are not approved by the FDA specifically for this purpose. Mitoxantrone is approved for pain relief.

Myths about prostate cancer treatment

What are some of the myths that people have regarding chemotherapy?

MORRISSEY: People think that they are going to be very, very sick, be in excruciating pain, and be unable to work. I explain that the chemotherapy medications we use for prostate cancer do not cause a lot of nausea. We’ve come a long way with antiemetics, so if a drug does cause nausea or vomiting for some reason, we can prescribe an antiemetic. [See Table 2 for a list of commonly prescribed chemotherapy drugs and some possible side effects.]

Patients worry that chemotherapy is going to cause them a lot more pain. If they’re at the point that they need chemotherapy, they most likely have widespread metastatic disease that’s spread to the bones. That’s painful, and they don’t want to be in more pain. But it’s actually not true that chemotherapy causes more pain.

Hair loss is another myth. The chemotherapy drugs we use — docetaxel [Taxotere] is one — cause thinning of the hair, not total hair loss. Patients also worry about chemotherapy taking away from their quality of life. A lot of patients are hesitant to go on chemotherapy for fear that they’ll never get out of bed. I explain that this isn’t going to be the case.

So a man on chemotherapy for prostate cancer isn’t going to be stuck in the hospital, feeling desperately ill, tethered to machines for weeks on end?

MORRISSEY: That’s right. The most common chemotherapy medications for prostate cancer are very well tolerated.

If a patient starts chemotherapy and it doesn’t work, or it works for a while and then it stops working, can he try another drug?

MORRISSEY: Absolutely. The doctor may recommend another drug or add a second drug to the first one. In some cases, if a patient doesn’t respond or stops responding to a drug, he may qualify for a clinical trial. We have quite a few clinical trials under way for patients who have metastatic cancer.

Do similar myths exist about hormone therapy?

MORRISSEY: Yes. I’ve had patients tell me horrific stories about hormones. They’ll tell me about people who have lost all of their hair or are so tired that they don’t get out of bed for weeks. Hormone therapy certainly has side effects, but I’ve been doing this for 10 years, and I’ve never seen a patient who couldn’t get out of bed because he was taking hormones. I do a lot of teaching to dispel these myths.

Resources for patients

What resources do you recommend to patients who want more information on their condition or the possible treatments?

MORRISSEY: When patients see me initially, they’ve already done their homework. They’ve gone online and found a wide variety of sites with information on prostate cancer and hormones. But if patients ask me about clinical trials, I usually send them to www.clinicaltrials.gov.

FLINN: The American Urological Association has resources for patients that are objective and unbiased. Their Web site, www.urologyhealth.org, offers a lot of information.

MORRISSEY: I’d also recommend the American Cancer Society’s Web site, www.cancer.org. The organization is well respected and its information is reliable.

FLINN: I almost discourage patients from spending too much time on the Web for information about erectile dysfunction; it seems to confuse them more. And it can be hard for them to determine which organizations and sites are reputable.

Another resource, especially for men with prostate cancer, is a prostate cancer support group. Many men who attend those groups seem to get a lot of information and emotional support there. The big support group in Boston has a subgroup related to erectile dysfunction associated with prostate cancer. Men who attend can learn about different therapies from patients who have tried them.

I also have a list of patients who have a penile implant, or surgically implanted prosthetic, who have agreed to talk to patients considering that option. A lot of patients have a negative impression of a prosthetic because they don’t understand it. I try to explain that it doesn’t alter sensitivity or alter their ability to have an orgasm, unless their orgasm has already been affected by another treatment. But sometimes, patients really need to talk to other patients who’ve had the procedure. They want to know what the surgery was like, how well the implant is working, and how it has changed their lives.

Does that sort of informal patient network exist in your practice, Mary-Ellen?

MORRISSEY: For clinical trials, yes. We do ask patients who are taking part in a clinical trial if they would be willing to speak with other patients who are thinking about going on the same clinical trial. That helps patients who are new to the trial know what to expect.

Like Kevin, I’ve sent a lot of patients to the local support group. I think it’s great for patients to talk with other men who have gone through the same thing. Patients come back and tell me how great it is. No matter how many books you read or how many Web sites you visit, there’s nothing better than hearing from someone who’s faced the same challenges that you are facing.

Natural isn’t necessarily safe — a supplemental reminder

Any parting comments for our readers?

FLINN: One thing that we haven’t talked about is over-the-counter supplements. A lot of the patients who come to our practice for problems with erectile function want to believe that these agents are going to make an erection stronger or last longer. The problem is that these supplements aren’t regulated by the FDA. Some of them contain sildenafil, so if the patient is on nitrates, the supplement can affect his blood pressure. I think these supplements should really be discouraged. Patients waste a lot of money on them. They rarely work, and sometimes they contain potentially harmful ingredients or ingredients that will react with medications patients are already taking.

Do patients tell you that they are taking supplements? Or do you only find out after they’ve had an adverse reaction?

FLINN: We specifically ask if they are taking any over-the-counter supplements when we ask about medications. Sometimes, patients will tell me that they’ve just seen an ad for a product claiming to cure erectile dysfunction and ask if it’s something they should try. I explain that clinical trials haven’t established their efficacy. Buyer, beware.

MORRISSEY: I go through the same thing with patients who’ve been diagnosed with prostate cancer. They’ll try all sorts of different products thinking that they’re going to get better. Once treatment has started, they run into problems because the so-called herbal remedy is interacting with other medications. They think that products labeled “herbal” or “natural” aren’t harmful.

Are your patients up-front about the fact that they take supplements?

MORRISSEY: Sometimes. Other times, they might not even realize that the littlest things can cause a problem. Green tea, for example, can cause inaccurate test results of liver function in patients who are on hormones. We also had a patient whose white blood cell count was off every single time, and we couldn’t figure out why. We finally managed to find out that he was taking bee pollen supplements! So no, patients don’t always tell you what they’re taking until something shows up in the lab work.

That’s a good reminder for everyone: products labeled “natural” aren’t necessarily safe.

MORRISSEY: That’s absolutely true.