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Background to this article begins in
Upfront March
1999

Upfront
ACS's Gabriel Feldman Questions Prostate Awareness Stamp Message

 June 6, 1999. Arrival of the Prostate Cancer Awareness stamp  reminds us  that we promised an in-depth look at evidence on early detection. For starters we suggest you read the JAMA's editorial on the stamp. Along with contrasting opinions from Dr. Gerald Chodak and Dr. William Catalona you'll see some comments from Dr. Gabriel Feldman, who heads ACS's prostate cancer division. 
       Under Dr. Feldman, ACS is becoming one of the leading US wafflers on prostate cancer testing. This is especially worrisome because Feldman's bailiwick (as of March 1998) includes his seat on the Board of the National Prostate Cancer Coalition (NPCC).
         Judging from Dr. Feldman's remarks in May 5 Journal of the American Medical Association (JAMA),  he puts very little trust in in men as health care consumers who can learn to make informed decisions about prostate cancer.
        Dr. Feldman says the ACS wants "balance" between extremes - one way of defining regular checkups and tests as extreme. "On the other hand," Feldman says, "we don't want physicians not to offer the test, because it may save men's lives, and we think it would be inappropriate at this time to vitiate the right of the patient to have a test that may save his life."
        Inappropriate at this time -- say what? Might some other time be appropriate to lose the right to find out if you have cancer? Maybe patients will need to use the Freedom of Information Act to find out their own health status. Of course that's not what was meant; but it reveals how murky and evasive ACS's  position on prostate cancer continues to be.
      Compare this with ACS's partnership in the Walgreen's paper roses mammography campaign, or their support for breast cancer awareness badges for Girl Scouts! Why, in contrast, this failure to figure out how to talk to American men as adults?
      Feldman says that in prostate cancer "we don't have the evidence we have in breast or colon cancer," and "until we do we cannot substitute our judgment and be paternalistic by screening men without their knowledge ...." Does this make sense? No. Patients will never want doctors to screen them without their consent. It is scaremongering rhetoric to jump like this from not having as much evidence as everyone would wish, to specters of forcing or tricking men into tests they do not want.
      Does Dr. Feldman really believe that men can't fathom the fact that some prostate cancers are more virulent than others? That surgical removal of the prostate is much harder than cutting a lump from the breast or removing a cancerous mole or even a piece of the colon? And that the individual needs what's best for him, not the treatment-flavor of the month? Is anyone denying how important it is for urologists and radiation oncologists to be honest about rates of impotence and incontinence and, above all, risks of extra-capsular disease and rates of recurrence?
        On the contrary, since the introduction of the PSA test, patients have flooded E-mail lists and support group meetings with demands for honest, accurate information and have cried out for long-overdue money for research to get sufficient evidence on which to base sound treatment decisions and stamp out poor care.
      According to the JAMA article, Dr. Feldman "stressed that the ACS guidelines are for providers, not patients." The guidelines "are intended to help busy physicians address a complex issue," Feldman said. What about helping men who might have prostate cancer to catch their busy physicans' full attention? For example the 18 men with prostate cancer in Massachusetts whose biopsies were misread? Not to mention men among the 43 million Americans who have no health insurance.
      After decades of well-aimed propaganda urging people to check for signs of cancer, sophisticated, popular screening campaigns are underway for breast cancer and now also for colon cancer and melanoma. Suddenly prostate cancer is in no-man's land. As though the ACS's biggest task re: the second commonest fatal cancer in men is to implant skepticism and even anxiety about the process of being tested.
     Early detection is in a different league these days. In our lifetimes, it's gone from feeling for lumps to blood tests and genetic testing. Knowledge brings agonizing decisions, which indeed cannot be left to paternalism on the part of physicians. What's needed as always is more knowledge -- a sincere dialogue on the part of physicians with men at risk and with those who have gone through the treatment decision process. Forthright discussions with men themselves.  If ACS is not focused on fighting for prostate cancer patients, why support it?

Dr. Gabriel Feldman M.D. is the national director of prostate and colorectal cancer control at the American Cancer Society.

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ACS says on their site and in their literature: "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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