My father, who celebrated his 79th birthday yesterday, is many things: eccentric, nearly deaf (though he attributes this to my mom being a “low talker”), hilarious, crotchety, and a true mensch. But he’s neither incontinent nor impotent.
It might have been otherwise. Like most men over 50, he began having yearly PSAs checked about 20 years ago, and, in the late-1990s, one came back in the 8 ng/mL range (normal is below 4). The usual stuff ensued: a transrectal ultrasound, multiple biopsies, and a small focus of prostate cancer with a lowish Gleason score. So now what?
Although a local urologist recommended surgery, he received second (and third and fourth – courtesy of “my son, the doctor”) opinions from three superb academic urologists – Peter Carroll of UCSF, Peter Scardino at Memorial Sloan-Kettering, and later, Mark Soloway of the University of Miami. All three told him the same thing: there is no evidence that surgery or radiation improves outcomes in this situation, the treatments can cause substantial morbidity (including incontinence and impotence), and there’s a decent chance that without screening, you would have lived with this till you were 90, when the indolent cancer would have been discovered at autopsy. They all recommended that his approach to the cancer be “watch and wait.”
But each of them, at one time or another, told me something like, “I give this advice to all the men in your dad’s situation, and 90% of them end up getting surgery or XRT. Sometimes, it’s because the clinical situation changes. But far more often, it’s because they just can’t stand the waiting – and the peer pressure – any longer.”
My dad’s a pretty tough cookie, and he decided to wait. Despite a couple of scares through the years, he has held out. And a recent re-biopsy, 11 years after the original, found no evidence of cancer.
I am proud of him for waiting, particularly in the face of all the well-meaning advice he received from the tennis court and cocktail party crowds: “Murray, how can you stand it?” “Did you hear about the new radiation machine they just got at the hospital?” “Mur, you hear about Joe – he’s dying of prostate cancer. How can you let yours just sit there!”?
It does seem like plain-old common sense that a program of screening for a tumor, finding it early, and treating it aggressively would be the right thing to do. After all, this is CANCER we’re talking about!
Well, this commonsensical approach is probably wrong. This week’s New England Journal includes the two most rigorous studies to date addressing the value of PSA screening. One, a European study, found that PSA screening led to little benefit; one person in 50 in whom cancer was found through screening was apparently cured through early treatment (an absolute reduction of 7 prostate cancer deaths for every 10,000 men screened). Unfortunately, this small benefit came at the cost of significant treatment-related morbidity (and even mortality) for the other 49 patients.
And the American study found that, after 7 years of follow-up, the unscreened group had a 13% lower mortality rate than the screened group, with not a whiff of benefit.
The accompanying editorial by Michael Barry of Mass General summed things up this way:
Serial PSA screening has at best a modest effect on prostate-cancer mortality during the first decade of follow-up. This benefit comes at the cost of substantial overdiagnosis and overtreatment. It is important to remember that the key question is not whether PSA screening is effective but whether it does more good than harm.
Remember our recent discussion about comparative effectiveness? The question I raised was whether we were mature enough to act on data like these. Let’s say that the two additional huge PSA screening trials currently in progress confirm the findings of this week’s American study: no benefit. Will payers have the guts and Kevlar to stop paying for PSA screening? And even if they do, the issue is far more complex than simply withholding payment for PSA testing: the cost of the PSA assay (about $100) is trivia compared with the cost of follow-up testing, biopsies, and ultimately of treatments such as surgery and radiation therapy. Even if one envisioned a system in which insurers didn’t cover PSA testing, it is hard to imagine one in which they wouldn’t cover subsequent costs of diagnosis and therapy.
Returning to the present, I see these NEJM studies as a triumph of science over common sense. Common sense tells us that PSA screening should be effective, and early observational studies and mortality trends over the past 15 years hinted at benefit. But like estrogen before it (and rapid response teams, for that matter), not everything that should work does, an argument for applying scientific methods, particularly when the test or treatment at issue is morbid or expensive.
A tip of the hat to Gil Welch, the Dartmouth internist / epidemiologist who has been a lone voice in the woods for the past decade, arguing that PSA screening (and perhaps screening for other cancers) might lead to more harm than benefit. He has pointed out, for example, that PSA screening could generate apparent improvements in 5-year survival for prostate cancer through lead-time bias (patients would die at the same time as they would have without screening, but the earlier diagnosis makes it appear that they lived longer). And in his superb 2006 book, Should I Be Tested for Cancer?: Maybe Not and Here’s Why, he wrote:
I object to the emerging mindset that patients should be persuaded, frightened, and coerced into undergoing [mammography, PSA tests, fecal occult blood testing]. There is today a certain “medical correctness” about screening – making patients feel guilty if they choose not to pursue testing. This is wrong.
Turning more specifically to PSA screening and prostate cancer, Welch added,
… In the final analysis, most of these one million extra cases of prostate cancer [diagnosed through PSA screening] represent nothing more than pseudodisease: disease that would never progress enough to cause symptoms—or flat-out would never progress at all… I should be clear that none of this should be interpreted as saying that PSA testing will never work. In fact, while many men may have been hurt by the ensuing treatment, a few others may have been helped. And it is possible that the PSA test can be modified such that it finds much less cancer and therefore makes much more sense. But right now we need to be clearer about the primary effect of the way it has been used so far: it has been making men sick.
A heartfelt thanks to my dad’s urologists, who gave him what proved to be sage advice when all of the pressures – social, psychological, and financial – might have steered them toward more aggressive recommendations.
So happy birthday, dad. So glad that you’re well, and that all the plumbing still works.