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.
As Senate and House Committee versions of health reform move toward unified legislation and floor votes, the most complex political challenge is how to resolve the “public option” controversy. While one would have thought weightier issues such as the shape of Medicare reform, the taxation required to support coverage subsidies, or the presence or absence of mandates would have been pivotal in this debate, the seemingly peripheral issue of a Medicare-like “public option” might be the hill on which health reform dies.
