Friday, December 16, 2011

PSA testing

There have been a number of articles on the validity of the PSA test. Last Year, a Dr. Gifford Jones, a gynecologist practicing in Toronto, wrote an article published on the web site titled “Seven Things to Know About Prostate Cancer”. What makes a gynecologist an expert on a make urologic issue, I’m not sure, but that surely allows me, as a board certified medical specialist, to respond.


First of all, it was not Disraeli, who remarked, “there are three kinds of lies, lies, damn lies and statistics”, it is actually popularized by Mark Twain. No evidence of the quote can be found in any of Disraeli’s works and the first known appearance of this saying appeared years after Disraeli’s death. In this article Dr. Jones referenced an article from the New England Journal of Medicine that had just reported a European study that showed that this blood test cut the death rate of this disease by 20 percent. But then goes on to editorialize “But this impressive figure refers to a relative reduction in deaths” (Emphasis added). He continues on to quote figures that of those that received the PSA test, 261 died, compared to the 383 who received routine care. He then states; “A difference of 102 deaths out of 162,000 men isn’t as impressive”. I beg to differ, especially if your one of the 102 patients or a family member of one of those who didn’t die! The next paragraph is even more egregious, it states as a result of the PSA test 1,410 men have to be screened (by the PSA test), from that 48 of these men are treated, to prevent one prostate cancer death. The implication here is if you test 1,410 men, this will result in an additional 48 men being diagnosed with and treated for prostate cancer but 47 of those men will still be cured of their disease. That seems like you are saving the lives of 47 men out of every 1,410 who are tested. Now who’s playing with numbers? There are numerous problems here. First if all, if a patient has advanced cancer and dies, normally the cause of death listed on the certificate of death as cancer. Rarely does cancer kill the patient, it is normally complications of that cancer or the treatments used to keep them comfortable that kills them. Ultimately all of us die of cardiac arrest.


Dr. Jones’ treatment information is questionable at best. Radium seeds have NEVER been used for prostate cancer, the choices are Iodine, or Palladium and more recently Cesium has been introduced. Current protocols call for Radical Prostatectomy, External Beam Radiation or Radioactive Seeds, and/or Hormone therapy are the three primary treatment modalities. It is reasonable well understood by most physicians, which treatments are the most appropriate depending on the age of the patient and the diagnostic indicators. There are “newer” therapies, Cryosurgery, Hyperthermia, etc, etc, but the three above mentioned are still considered the primary options.


This is where Dr. Jones and I sort of agree. Marilyn Von Savant was once asked, is medicine an art or a science? Her response was “it was a science performed by artists”. Like most things, as long as humans are involved there is always some variability, in this case it is in determining how malignant the tumor is. But Dr. Gleason developed a method of grading the “aggressiveness” of prostate cancer. It has become a reliable indicator of aggressiveness of the disease and is used (along with the PSA) a one of the primary diagnostic indicators in determining which form of treatment is the most appropriate. Ironically, the late Dr. Whitmore, “a world authority on prostate cancer” allegedly died from metastatic prostate cancer. When a colleague of my partner asked what him what his PSA was, he responded, he didn’t believe in the PSA test!


“First, do no harm”. When you inject a patient, you do harm, it must, every young child cries when receiving a shot. Medicine should be looked at as a cost vs. benefit approach (when I say cost I don’t mean financial, although that seems to be entering into it more and more).


The one question left out of all these responses is quality of life. I’ve watched many men get worse and worse due to the progression of their prostate cancer eventually succumbing to it. When prostate cancer advances it spreads to local organs which are the bladder and colon/rectum, eventually metastasizing to the bones. It is a miserable/painful demise.


Yes, urinary incontinence is a side effect of treatment, typically but not limited to a radical prostatectomy. A rectal fistula can occur from radiation therapy if not done properly. All of these complication are almost certain if you decide not to be treated, eventually the cancer will spread from the prostate to the bladder and rectum causing these and all sorts of other complications, unless you die before they occur.


Ok, I was wrong when I said there was only one thing I agreed with Dr. Jones about, I partially agree with this point too, if you are confused about prostate cancer, get as much information as possible before treatment. There are lots of good websites that have good information on treatment options. I too cast a wary eye on statistics, but this is not a pattern of statistics.

The question, I assume, is, should you get a PSA test? My answer is unequivocally, YES!

1 comment:

  1. I hate to be pessimistic, but the fact of the matter is prostate cancer screeming is motivated by ignorance and greed.

    Ignorance in the basic fact cancer treatment is considered successful only in longevity. In fact, increasing life span has little import in prostate cancer. Quality and avoidance of complications are the real goals.

    Greed in the face of huge expenditures in healthcare cost of a baby boom generation. It is considered more cost effective to let us older men quietly slip away in order to save money for the younger generation. It is always cheaper in oncology to pay for Hospice than effective treatment. Easier to swallow if it's not you or your Father.

    We need to experiment with truth rather than confusion. We would all benefit.