By Anthony H. Horan, MD
The Big Scare
During my 30+ years as a board-certified urologist I’ve seen quite a bit of suffering, much of it needless, in my opinion. In my work both in private practice and with the VA in Fresno, CA. I’ve encountered many men who’ve received treatment for prostate cancer that greatly diminished their quality of life and produced horrible side effects, but did absolutely nothing to prolong their lives. These patients served as the inspiration for The Big Scare: The Business of Prostate Cancer, a book I wrote, hoping to spare men from the over-diagnoses and over-treatment for prostate cancer that’s taking place in this country every single day. I contend that screening for prostate cancer with a blood test and treating the cancer, discovered in the absence of a palpable nodule, offer no measurable good that outweighs the measurable harm. Instead, I advocate interceding before a man is falsely diagnosed with clinically significant prostate cancer.
Prostate Cancer is relatively common disease, with about 260,000 men over the age of 50 diagnosed each year. But as daunting as that number may sound, the fact is that prostate cancer is a very slow moving disease with estimates showing that 94% of the cancers detected with the routine PSA blood test would not even cause death before the age of 85. More men die in accidents than of prostate cancer. The PSA is a test I have major qualms about and objections to. The PSA test has triggered an enormous number of expensive and unnecessary prostate biopsies, which have led to treatments, a rash of radiation and radical surgery injuries, and death. After undergoing radiation, only 55% of men retain erectile function. So this is an issue that not only impacts the lives of many men, but the lives of their significant others as well.
Most of the men over 40 who are reading this blog have heard about or even had a PSA test performed. But that does not mean that it’s a reliable indicator of prostate cancer – because it is not. The PSA test should not be given without first having a long conversation with your doctor – or not given at all. Starting in 1986, just after the PSA test was introduced, many doctors, other than urologists, started buying machines in order to make a profit by doing the tests in their offices. Following this, diagnoses of prostate cancer and its treatment rate started to soar. The biopsy rate quintupled and the number of men labeled prostate cancer victims doubled between 1989 and 1992. Despite this, statistics prove that no more cancers have been discovered since the introduction of the PSA than would have been found in a random series of men the same age – whose PSA is unknown.
You can tell your doctor that you don’t want the PSA test. That’s your right. The only men who should be having the test are those who’ve already been biopsied and diagnosed for prostate cancer. That said, the PSA test is indeed useful for another far more frequent prostate problem, found in ten-times as many men as aggressive prostate cancer. Benign Prostatic Hypertrophy – better known as BPH, is a prostate condition that can create real devastation for men in their later years.
When I went to medical school at The Columbia University College of Physicians and Surgeons and also during my urology residency at the Columbia Presbyterian Hospital in New York in 1973, non-intervention was the rule. We didn’t go looking for the incidental cancers that were of no clinical significance. And if we found them, we did nothing about them. This non-treatment approach came from a Mayo Clinic study that showed a man who is diagnosed with prostate cancer had a survival curve identical to the general population of men. That was the conventional wisdom of the 1960s and it is still true today.
My credo is to treat people as citizens first and as patients second. My humanistic approach to medicine may occasionally put me at odds with my colleagues but has preserved the quality of life for a great number of men, their wives and partners. I believe that for a vast majority of men diagnosed with prostate cancer the best course of action is minimal cryosurgery or no action at all. In order to maintain a good and positive quality of life, people should stop worrying about cancer and learn to enjoy their lives. Living life to the fullest is the guiding principle by which I live my own life and the message I hope to impart to all who visit my medical practice.
Dr. Anthony H. Horan, a board-certified urologist in Delano, California. He has extensive experience in the diagnosis and treatment of adult and pediatric urological conditions. He combines clinical services and expertise with state-of-the-art therapies. He served two years in the Air Force as a general surgeon, one of them in Vietnam. After 10 years in private practice, Dr. Horan spent 15 years as a salaried urologist for the Veteran’s Administration. He has written a book The Big Scare: the Business of Prostate Cancer. Its purpose is to diminish the harm being done to our men and women by the overdiagnosis and overtreatment of prostate cancer.
Categories: Uncategorized
Das ist toll, ich hätte nie gedacht, über Nostradamus im OP
Although this is not my disease risk, allow me to jump in here. It seems to me that there exists a large group of health care providers whose financial goal it is to maintain a high level of consumer fear about most disease diagnoses, especially the C-word.
Take heart disease for example – by far the #1 killer of women in North America. Yet most women would insist that the health threat they are most fearful about is breast cancer, not heart disease, even though this year heart disease will kill six times more women than breast cancer will. As a PR professional for 35+ years, I have to say that my counterparts in breast cancer have done a fabulous job in convincing women (mistakenly!) that breast cancer is their biggest danger. It’s a world of PINK out there. The ‘industry’ of breast cancer treatment and research demands that this industry continues and thrives, even as our cure rates now approach 84%.
Ditto for prostate cancer. There is a massive growth industry in men’s fear of cancer – any cancer – particularly one as serious-sounding as prostate cancer. If it’s in the financial interests of physicians to maintain men’s current anxiety about prostate cancer, their actual mortality risk is irrelevant to the average patient. Few patients would happily wait around doing nothing, knowing that cancer cells were growing somewhere in their body, no matter how slowly or benignly.
How sad that many men may be unnecessarily undergoing the devastating, life-altering trauma of prostate treatment that not only doesn’t prolong life, but tragically impacts the day-to-day quality of that life.
Dr. Childs, I am not a urologist and don’t know all the evidence here, but I suspect you are wrong on the idea. What matters are the odds when you undergo the test or treatment. Let’s say a drug X has a higher chance of killing you (or making you worse than you were before) than curing you. And yet you meet someone who swears that X “saved my life” becaUSE he/she had a good outcome and you should take it, too.
Similarly, you meet someone who got saved from a burning car wreck, just split seconds before it bursted into flames … firemen tell him that if he had worn seatbelts, he would be dead in the burning wreck. Thus, not wearing the seatbelt saved his live. What is the recommendation? Stop wearing seatbelts?
How will the general public (and juries) be able to discuss this when even docs go for the intuitive fallacy?
There is a little bit of “right” in all the comments.
BUT, nine years ago my rectal exam was perfectly normal, but my PSA was five. So, I had a biopsy which revealed cancer in nine of the ten specimens, Gleason grade 3 + 4 = 7. I had a radical prostatectomy, but the cancer had already spread outside of the prostate capsule. I was 54 y.o. Five years later my PSA started rising so in April of this year I had radiation. Now the PSA is falling. Had I not had the PSA and later the surgery, the aggressiveness of the cancer would most likely have taken my life eventually. I am 63 now and I have been a board certified urologist for thirty years.
Yeah, we need another test, but right now the PSA is helping save lives. That is the gospel truth.
You are on the mark. Change could come from financial constraints (that will be unpleasant, and will also prevent a lot of useful medicine from happening), or from a concerted effort from within the healthcare system. But the latter appears unlikely since there is limited awareness of the problem (Upton Sinclair: “It is difficult to get a man to understand something when his salary depends upon his not understanding it”).
rbar, using a scan to avoid further medical costs to the system is ok, but I protest treating patient paranoia as I would hypochondria. But given all the drug ads we’re exposed to it’s to be expected we’ve created a super group of medical worry worts and a medical profit industry ready to bill for it.
Peter,
You do oversimplify.
Let me tell you a common occurence: Patients come to me often with the fear of a certain condition that falls into my subspecialty. In very many cases, the guidelines tell you clearly not to image (CT, MRI). However, if a patient is fearful and I don’t image, they will get it done by the PCP or some other doc. If there is a harmless incidental finding on that scan, the anxiety is big, and further inadequate action might follow. Therefore, I say: I rather order the scan myself (without having any financial incentives, although there are docs in my specialty who own MRIs) in order to avoid all the above trouble and to address the scan obsessed patient’s (that’s not a rarity) worries. Did you ever watch “Mystery diagnosis”?
Nate,
In order to have a case, you need to prove that the doc did not meet the standard of care AND that he/she suffered damage from that. I am not a urologist and don’t know the standard of care and the guidelines etc., but in the case of prostate cancer and PSA, I am not so sure if anyone could prove either.
But re. what you quoted from my earlier post, litigation is just another factor to do the max. … I can say it again and again: docs in the US have no incentive of not doing tests, but plenty of incentives (financial, fear of litigation, pt. preference) to do tests, incl. absolutely superficial or potentially harmful ones.
“as soon as reimbursement depends greatly on certain procedures, these procedures will be overused to the patient’s diasadvantage,”
rbar how in the world could a doctor today not offer a PSA and not advise aggresive treatment if something is found? If you honestly tell a patient they don’t need to treat prostate cancer because they are more likely to die of old age if that patient ever dies from anything close to prostate cancer or a condition that even appears related, even if they live to be 150 the family will sue.
Dr. Horan in your experience how do you advise a patient to forgo treatment and not end up in court?
A PSA test is not usually administered by the physician who will financially benefit from a positive test. It’s usually given by the primary care doc, right?
“(remember that the patient may want “sthg done”, too).”
Patients want all sorts of things. If they want heroin would it be ok to give them that too? My point is that docs have continually been saying here that over utilization is for law suit protection but also because the patient just wants it and will get it from someone if not from “you”, so why not give it to them, hell someone will. I call that just as much medical fraud as Medicare is seeing.
In some cases, maybe, but it often is an unconscious process (remember that the patient may want “sthg done”, too).
I think the question (fraud or not) is not too helpful. if you incentivize behavior, it will be more prevalent, be it growing corn, buying cars etc.
“We just have the wrong incentives: as soon as reimbursement depends greatly on certain procedures, these procedures will be overused to the patient’s diasadvantage”
rbar, would you consider that fraud?
“My humanistic approach to medicine” – well, medicine’s goal should be increasing lifetime and quality of life, so I guess anything else than humanistic is the wrong approach.
We just have the wrong incentives: as soon as reimbursement depends greatly on certain procedures, these procedures will be overused to the patient’s diasadvantage, be it PSA, back surgery or angioplasty. This is not only happening in the USA; Germany, for instance, has fee for service structures as well.
IMHO, physician’s should be payed in a similar manner to how judges are paid (although be subject to quality control): a guaranteed comfortable income, independent of the number of certain procedures. Yes, there may be a productivity bonus for especially hard working docs; but patients and peers should generally be happy with the doc’s communication, and the outcome parameters have to be about right.
Thanks to the editors for publishing another viewpoint after the “commercial” for robotic prostate cancer surgery a few weeks ago. As a pathologist, I can offer my opinion that this clinician’s reservations about the PSA test are on the mark. There have been many efforts to improve this test or produce variations on it to make it more useful, but none have achieved magic bullet status yet.
I believe that many PSA tests are administered as yet another manifestation of defensive medicine. I think a physician could be successfully sued for failure to offer this test to men in a given age/risk group based on some previous guidelines. This should give some pause to those who think comparative effectiveness research is going to be simple. I am in favor of such research, but it will not be simple.