Well, you might not have noticed that my blogs were missing for the last three months but anyways, its good to be back. I was having a little time off blogs and social media as I was transitioning in my career but now I am back. Sometimes, it is very difficult to manage time for things that you must do versus things you enjoy doing, especially when these two don’t intersect. For me, these last few months the things I had to do were all bureaucratic while I couldn’t find the time for things I enjoy doing like writing these blogs. But now that we are back, let’s recap what has happened in the oncology world in the year 2019 so far. I can’t cover all of them, but will try to summarise the major events in oncology.
Hundred Foxes’ Howl versus One LION’s Roar
In my country, there is a saying that goes somewhat like the roar of one lion will scare hundreds of howling foxes away. In medicine, I guess, it translates as one good RCT trumps the results from hundreds of observational studies. For patients with advanced ovarian cancer, primary surgery to achieve complete resection is the most important treatment and prognostic factor. However, what to do with the lymph nodes is a question that has troubled the oncology community for a long time. Logically, it makes sense to remove the lymph nodes too because they are the sanctuary sites for cancer cells. However, lymph node dissection carries high morbidity. Although multiple observational studies suggested a survival benefit with lymph node dissection, the LION trial, now published in the NEJM, shows that for women with macroscopic complete resection of primary tumour, lymph node dissection increases morbidity (postoperative complications) and post-operative mortality rates but doesn’t improve survival. I am glad that this trial was carried out and these results will now save many women with ovarian cancer worldwide from unnecessary harmful procedures, but I am also sad that we didn’t answer this question until now and thus, many patients suffered unnecessarily. I hope this LION’s roar scares us from jumping to conclusions based on logic or observational data alone and without RCT evidence in future. Another lesson here is the importance of public funds in supporting RCTs like these.
I was diagnosed with aggressive but localized prostate cancer at a major Dutch academic hospital. My parameters were PSA 29 or 31, Gleason sum 4 + 4, and stage T2c. Fortunately, there were no detectable distant metastases. The specialist drew a simple image of my urinary tract and told me I was excluded from brachytherapy, which I had never heard of before, because of the size of my prostate. I had to choose between external beam radiotherapy (EBRT) and radical prostatectomy (RP). How on Earth could I choose rationally while knowing so little about prostate cancer? However, I had studied maths and physics and could learn necessary medical science about my condition.
The Dutch healthcare system was privatized in 2006 by a special arrangement between the Health Ministry and the private insurers. This was the first healthcare privatisation in the European Union (EU). The effect of privatisation was, in my opinion, mixed. By the time I was diagnosed I already had much to distrust about the privatisation.
I sought a second opinion in Uppsala Sweden, where I had spent a lot of time as an academic visitor. Its Akademiska Sjukhuset (The Academic Hospital) has an excellent oncology division. I consulted two specialists.
The general practice of oncology seems to come in waves of disease. One week every breast cancer patient is in trouble, another sees multiple new cases of lymphoma or leukemia, the next it as if someone is giving away lung cancer (or perhaps cigarettes) and then three patients with pancreatic cancer end up in the ICU. This week a portion of the 240,000 yearly USA cases of prostate cancer walked in our door. The rush of cases served as a reminder that when it comes to this illness, we have a long way to go.
First, Allen. He is 73 years old and has prostate cancer in one out of twelve biopsies. The cancer has a Gleason’s Score of 6 (a measure of aggressiveness of the cancer tissue: more then 7 is particularly bad), which means it is not fast growing. We recommended that given the small amount of slow growing cancer, Allen should be watched without treatment (“Active Surveillance”). What Allen found so difficult about this recommendation is that his son was diagnosed with prostate cancer just one month ago and his son, who is 49, has a Gleason’s 8 Prostate Cancer on both sides of the prostate, and is scheduled for robotic surgery. More than having cancer, Allen is hurt by the feeling it should have been him.
Then there was Robert and Mike. Robert was in the office at 10:00am for evaluation of his newly diagnosed prostate cancer, PSA blood test 32 (high), Gleason’s 7, with evidence of invasion through the capsule of the prostate gland. Fortunately, because prostate cancer likes to spread to bone, his bone scan is normal. Despite Robert’s relatively young age (66), the surgeon recommends external beam radiation therapy (RT) instead of operating. What is bizarre and makes my head spin, was that at1:00pm, in the same exam room, in the same chair, I saw Mike. He has recurrence of prostate cancer, previously treated with surgery. Now Mike needs RT. Although Robert and Mike do not know that the other has cancer, they have worked together in the same small company for 28 years, and consider each other friends. Continue reading…
Readers know that I am skeptical of medical practices that defy logic, or as we say in the business, evidence. Among the most controversial issues that beguile all of us (patients and docs) is this business about the PSA test.
A loyal reader sent me a doctor-written column with the provocative headline “My Patient, Killed by The New York Times.”
First, keep in mind that the website that posted this, Mediaite, is all about the media covering (really fawning and dishing) itself. The purpose of this story, with its provocative headline, sad outcome, and mea culpa tone, is to generate “buzz.”
Then understand that this is a story of one patient who made an informed decision to forego PSA testing, based on the fact that he was an intelligent person without symptoms who’d read the literature (or at least responsible press coverage of said evidence). He did not want to open the Pandora’s Box (literally: crapshoot) that is PSA screening.
Yes, he wound up with advanced prostate cancer and subsequently died. Had he had his prostate removed or radiation to ablate his cancer, and wound up with horrible side effects (impotence, incontinence) would he value the trade-off?
I offer you the counter-anecdote of Ted, who in a discussion with me, insisted that he get a PSA test because his heroes Joe Torre and Norman Schwarzkopf told him to. When it came back at 4.10 ng/dL (threshold 4.00), he went for biopsy (what else to do?) which showed low grade, gland-confined prostate cancer. Fearful of the “C” word, he couldn’t live with the idea of doing nothing (“watchful waiting”) about his cancer. So he chose external beam radiation, with the hope that it would be less damaging than radical surgery.
My father, Foster Hill, has stage III prostate cancer.
At 69 years old, he is a quiet man who was often told in his younger days that he resembled Muhammad Ali. He immigrated in his twenties to Canada from the small Caribbean nation of Antigua to look for opportunities beyond sugar cane and the tourism trade.
My father became a chemical technician for well-known oil refineries, while staying true to his real passion in life – playing organ music. Every Sunday, as he has since I can first remember, he plays the largest church organ in Sarnia, near Lake Huron, where he lives with my mother.
Like many men of his generation, he has always been wary for the medical system. For decades he avoided the test, known as PSA, that screens for prostate cancer. In September of this year, driven by pain he could no longer ignore, he went to his doctor who discovered a rock-hard prostate gland. The diagnosis, stage III prostate cancer, means that the cancer has already begun to spread, but is still potentially treatable.
Now retired, his long hours practicing the organ are punctuated with doctor visits to receive Lupron hormone therapy. The good news? The therapy is working. For now.
We don’t know what lies ahead. The first round of Lupron therapy is often effective, but a significant number of patients later develop a resistance to the drug.
The battle against my father’s cancer has only just begun.
This is where Big Data in healthcare can become a true lifesaver. Typically, in medicine, we know only what works for the majority of patients, not what will work for an individual. However, with enough data from enough people – we are talking hundreds of thousands, and sometimes, even millions of patients – we can apply analytics to build predictive models to discover which interventions will work. For the last twelve years, it has been my job to make that happen.
As CEO and founder of GNS Healthcare, I oversee a team of mathematicians, biologists, and data scientists as they crunch and decode healthcare data to unlock the mysteries of what treatment will work for specific patients.
My father’s cancer has given these efforts a new urgency and has raised a new question: Can I use Big Data to save my father’s life?
Dr. Timothy Wilt, a member of the United States Preventive Services Task Force, stood in front of the American Urological Association audience and explained why the task force could not recommend that men undergo routine PSA screening. At most, he explained, the test had been shown to benefit one out of 1000 men. Meanwhile, the test would cause hundreds of men to experience anxiety, and scores of them to experience impotence and incontinence from unnecessary treatments.
Twenty minutes later, I stood behind the same podium and asked the audience members to raise their hands if they disagreed with the task force’s conclusion. Ninety percent expressed their skepticism. What happened in the time between Wilt’s presentation and mine reveals a great deal about why experts cannot agree whether screening tests, like the PSA in middle-age men or mammograms in 40-year-old women, bring more benefit than harm, and about what psychological forces impede our ability, as a society, to figure out what basic bundle of healthcare services all insurance companies ought to pay for.
Wilt’s presentation was a model of scientific clarity. He explained that only two randomized clinical trials were conducted with enough scientific rigor to provide useful estimates of whether the PSA test saves lives. One trial showed no benefit and the other revealed the one in 1000 number which the task force took as the best case scenario. Wilt was followed on stage by Ruth Etzioni, a biostatistician at the Fred Hutchinson Cancer Research Center in Seattle. Etzioni presented a statistical model suggesting that the PSA test benefited many more than one in 1000 men.
There’s something compelling about the personal narrative that vast mountains of quantitative data cannot rival. Anecdotes are, quite simply, powerful. They tap into our shared humanity, making something seem somehow more real by putting a face on it. This is why, if you follow politics for very long, you will find numerous cases of policymakers championing issues that have touched their own lives in some way. For example, Senator X doesn’t care about issue Y, until they discover that their son or daughter is affected by it. Then, almost overnight, they seem to care more about issue Y than almost anything else. Such a shift is completely understandable, but often out of proportion to the true scale of the issue in society.
In health policy, the personal narrative can also be very powerful. In fact, the journal Health Affairs routinely runs a “Narrative Matters” section that puts a face on the health care issues of the day. It is absolutely critical that health policymakers, health services researchers, and others, not lose sight of the fact that their work and the subsequent decisions it informs, are based on real people. However, it is equally critical for objectivity to be maintained, and narrative can threaten our work in this regard.
The numbers are stark. According to the United States Preventive Services Task Force, for every man whose death from prostate cancer is prevented through PSA screening, 40 become impotent or suffer incontinence problems, two have heart attacks and one a blood clot. Then there’s the psychological harm of a “false positive” test result, which is 80 percent of all “positive” tests. They lead to unnecessary worry, follow-up biopsies, physical discomfort and even harm. Final grade: D.
Three men close to me have been diagnosed with prostate cancer late in life. Each was around 70. My dad, already in throes of advancing Alzheimer’s disease, did what the doctor ordered (actually, I suspect my mom told my dad to do what the doctor ordered). He had surgery. And for the last six years of his life, which until his final three months was at home, she cleaned up after him because of his incontinence. My neighbor made the same choice. He quietly admitted to me one day that he suffers from similar symptoms, but he is grateful because he believes his life was saved by the operation. And my friend Arnie? I’ve written about him in this space before. He was diagnosed at 70, and being a psychiatrist with a strong sense of his own sexual being, understood the potential tradeoffs. He decided to forgo treatment. He died a few years ago at 90. I never learned the cause.
So what does it mean that PSA testing gets a D rating?
On April 17th, 81-year-old Warren Buffett told investors that he had very early prostate cancer. The Washington Post headline read: “Warren Buffett Has Prostate Cancer that is Not Remotely Life Threatening.’” Within hours, news accounts said that the story unfolded after discovering a high PSA in a routine appointment. Next, he had a prostate biopsy. A few hours later, news accounts said that Buffett decided to get radiation therapy for prostate cancer. What’s wrong with this picture?
10. He’s an icon who other men will follow, and there is limited (or no) evidence of benefit of aggressive treatment in men as old as Buffett. At 81, his life expectancy is 7.41 years, shy of the 10-year life expectancy mark doctors look for when they recommend aggressive treatment for prostate cancer.
9. Although Buffett can afford whatever care he so desires, it would cost a fortune if tons of men in his age group went for active treatment and there would be little yield and plenty of side effects.
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.