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This article is from
Upfront
March 1999
Upfront
ABC News Prostate Cancer Report
by
Tony Eiranova
March 4, 1999 After watching the ABC Nightly News report on prostate cancer I believe the following points should be addressed:
1. Mass screening vs. offering the test to selected individuals
Mass screening evokes images of people being hauled off the street and given the PSA test, much in the way that some advocate mass screening for AIDS. Or it implies that everyone receiving medical care or routine physicals should be actually given the PSA test.
No one in the prostate cancer survivor community advocates that. To talk about mass screening in the introductory paragraph of the ABC News report is a red herring designed to immediately raise all sort of red flags in the viewer's mind about huge increases in health care costs, the right to privacy, etc.
The second paragraph of the news report is factually wrong. The American Cancer Society does indeed still recommend that men over 50 get annual PSA and DRE tests. It is semantics whether this constitutes "widespread testing" or "mass screening". Even though Dr. Feldman properly states that "We cannot make blanket recommendations for mass screenings for prostate cancer based on what we know in 1999", the fact is that the ACS recommends that the test be offered and it should be up to the individual, after proper counseling, to take it or reject it. This is not mass screening any more than that the current recommendations for mammography.
In fact, the next to last paragraph actually seems to contradict Dr. Feldman. If, as stated there, "the American Cancer Society says every man should learn the facts and decide for himself", shouldn't the facts be made available by, at least, making people aware of the test? Don't "the facts" need to be ferreted out by actually doing the PSA test (and/or the biopsy if so desired by the patient)?
2. "Prostate Cancer doesn't fit the formula"
There is a fallacy in Mr. McKenzie's argument which has gone unnoticed. The fact is that the two elements in the left of the "formula" are not independent of each other. There are indeed effective treatments for prostate cancer but their effectiviness is very much related to the stage at which the cancer is diagnosed. I will grant that no treatment is guaranteed to produce a cure in 100% of the cases, even with early detection, but the same applies to breast cancer for which early detection in the form of periodic mammograms on asymptomatic individuals is also recommended (again, not as mass screening but as a recommendation directed to selected individuals).
Even more importantly, the fact that the effectiviness of treatments is unquestionably higher in the early stages must lead to the conclusion that, although early detection cannot guarantee cure, the chance for cure is significantly increased by treating at an early stage. Therefore early detection plus available treatments must also lead to a better chance (although not a certainty) of longer life.
In addition, the notion that men would rather not know whether they harbor a possibly fatal cancer seems paternalistic at best and callous at worst, if economically dictated. As Dr. Brawley says in the ABC News report, "they don't need to know they have prostate cancer and they don't need the treatment." Who is he to decide that anyone at risk does not need to know that he might harbor a possibly lethal disease and that, if he does, he doesn't need treatment? What about those who have a virulent form of the cancer?
The over 50 male population need not be protected from knowledge about their health risks any more than anyone needs to be protected from knowledge about smoking health risks. They are quite able to decide for themselves on matters that are literally life and death, and a horrible death at that, questions.
The fact that is often overlooked is that the PSA test does not produce a simple positive/negative result. Much information regarding the possible lethality of the cancer resides in the sequential history of PSA measurements, as well as in their absolute values when they are outside the "grey zone" between 4.0 and 10.0. Not all abnormal PSA tests need to result in biopsies. There are other tests available (such as the free/total PSA ratio) to help decide whether to biopsy or not.
Even a positive biopsy result need not necessarily lead to immediate treatment. Much information regarding the aggressiveness of the cancer, and therefore the appropriateness of immediate treatment, is available from the pathologist's report. Perhaps, the policy makers should actually survey the populations at risk (those over 50, African-Americans, those with family histories of prostate cancer, etc.) And ask them directly whether they would prefer to have the information that might help them in choosing their fate or whether they would rather remain ignorant and, thus, forfeit the chance (even if not 100%) of cure or long term remission.
3. Treatment risks
Mr. McKenzie says that radiation and surgery "carry the risk of impotence and incontinence and at least a 30 percent risk that the cancer will grow back". Even if that was true, doesn't that mean that they also confer a 70% chance of "cure"? Why would a reasonable patient want to disregard these odds after doing his own private cost/benefits tradeoff based on his individual values?
And we are only talking about those cases where the informed patient, together with his doctor(s), has decided that he better get his cancer treated because the diagnostic information indicates a likely clinically significant tumor. Even with testing, treatment risks will still be avoided by all those others who decide that based on the diagnosis data their cancer is not likely to bother them, or that, if it is likely to do so, they, nonetheless, prefer not to take the treatment and live with the consequences.
Isn't making informed decisions what being a responsible adult is all about? Why would we want Drs. Feldman and Brawley make these decisions for us? Shouldn't the medical doctors just present the options and take care of the technicalities of the treatments while leaving the decision making to those patients who are willing and able to decide for themselves? Tony Eiranova is a regular contributor to The Prostate Problems Mailing List
Related stories
The ABC News Report online
Gabriel Feldman, PSA Screening & Sound Bites
Jim Fulks Gives ABC 2 Thumbs Down
Ralph Valle: Replying to Regush
Can the Prostate Test Be Hazardous to Your Health? at Science/Health scetion of The New York Times on the Web
You might also be interested in a New York Times health section article on how to become an active cancer patient: Don't Take Your Medicine Like A Man by Robert Lypsite.
ACS says on their site
"The American Cancer Society recommends that both prostate-specific antigen (PSA) blood test and digital rectal examination (DRE) should be offered annually, beginning at age 50 years, to men who have at least a 10-year life expectancy, and to younger men who are at high risk."
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