An opinion piece from today’s Boston Globe …

… is likely to stimulate some ferment among the prostate cancer advocacy community. (See the article
entitled “Does prostate screening make sense for you?“)

This article, by Drs. Woloshin and Schwatz, follows a previous academic article on which we commented in this column at the beginning of September. The basic question that the authors are trying to address is, “What is the real risk that initially localized prostate cancer (latent or otherwise) will lead to metastatic disease and death in a specific individual if it is not treated?”

This is a very reasonable question. However, we believe that it is utterly separate from the question of whether men should be screened for risk for prostate cancer. Having regular DREs and PSA tests gives the individual male some idea of his potential risk for prostate cancer. In association with his physicians, he can then determine whether he really needs a biopsy. Once he has had a biopsy (if he has one), he is still in a position to determine whether active interventional treatment, active surveillance, or watchful waiting are appropriate forms of management.

The most pervasive problems we face today are the assumptions (by many physicians and many patients) that any signal of risk is an immediate indicator for a biopsy and that any amount of tumor on biopsy is an immediate indicator for interventional treatment. Neither of these assumptions is necessarily accurate. However, it appears that (at least in the USA today) the majority of men have great difficulty with the idea that you can live perfectly well with cancer that may not need treatment.

This discussion is at the very heart of how we will think about and manage prostate cancer for years to come. Those with progressive disease are bound to have a hard time understanding this argument. Those who had localized disease and who suffered serious complications from surgical or radiotherapeutic treatment may have a whole other point of view. And then there are a few (at present) who will simply say, “I don’t know why you even would consider treatment with those numbers, given the probability of significant progression.”

Some people are better at making these “bets” than others. We will only be able to stop “going to the casino” if we can develop either a highly effective preventive medication with minimal adverse effects or a highly predictive test for prostate cancer that can tell us whether the disease is likely to become metastatic within a brief period of time. (I suppose it would be too much to hope for both!?)

3 Responses

  1. Interestingly, the article quotes a number of statistics regarding the odds of dying from prostate cancer but no numbers regarding the known harms that follow from screening: emotional issues caused by the diagnoses, complications from biopsies, or side effects of the usual treatments that follow.

    How many is a “substantial proportion of men impotent or incontinent”? Why do men always have to ask to be told those numbers?

  2. Dr. Steven Woloshin and Dr. Lisa M. Schwartz have sung off the same page for years. Given an opportunity they will speak out against screening for prostate cancer. At least they are consistent.

  3. I have been railing against the practice of performing prostate biopsy simply because there is nothing else for a doctor to do. When I went to my urologist (and I think I have a very good one), he did an ultrasound and a fairly long DRE and could conclude nothing. The only thing he could offer was the 12 sample trans-rectal biopsy. The only other option was watchful waiting which I was too frantic to do at that time. Since my father and his brother and my maternal grandfather had prostate cancer, my risk factor was higher, so perhaps it made sense.

    What I am fearful of is a new movement that is promoting the halt of testing all together. The argument is that there is little evidence of the value of the testing because we don’t know enough about CaP to decide which types of cancer are dangerous or not. As a man younger than 50, I can understand the concept, but this movement is trying to convince men that testing is not only unnecessary but dangerous to your health.

    I say “to each his own”, but all men should be encouraged to test and diagnose. There should not be a single man that dies from CaP. If you believe what you read from any side of the debate, it would seem that the only choice is to test. Whether you like it or not, testing is the only choice to get any answers today. When better, proven testing methods are available I know I will rush to use them. For now we have the 12 sample trans-rectal biopsy (which to me makes no sense at all) or the high density trans-perineal stereotactic prostate biopsy.

    If you don’t test you won’t know and if you don’t know you can die. My personal assessment is the risk of the test hurting you may be statistically higher than the risk of the disease, but the damage the test may do will not kill you.

    Here are contrary opinions to mine in the venue. The more famous authors Dr. Steven Woloshin and Dr. Lisa M. Schwartz have a long-standing position of recommending that common treatments and healthcare practices are dangerous. For instance they suggest that the risk from flu vaccine outweighs the benefit of the protection it provides. Another anti-testing stance they take is to suggest that screening for melanoma, which is drastically on the rise, is unnecessary and should be halted. But the American Cancer Society recommends regular skin screening, as does the American Academy of Dermatology, which sponsors Melanoma Mondays and free skin screening clinics that see more than 200,000 people a year. It appears to me that these doctors are simply bucking the currently common practices everywhere they can in the current healthcare industry.

    I am simply calling for a sane, middle ground. The medical establishment wants to get as much money as possible into their pockets. The answer is to test for everything. My answer is to apply a little caution and common sense and continue to take good care of yourself.

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