More on the “no free ride” reality

This post is on the same theme that I blogged on some months ago. Last week’s NEJM had a sobering article on the side effects of treatment for prostate cancer. A picture is worth a thousand words, so here is the one on urinary issues:

Screen Shot 2013-02-06 at 7.40.38 PM


And here is the one on sexual function:

Screen Shot 2013-02-06 at 7.47.08 PMThis study reflects the outcome among 1655 men with early prostate cancer, 1164 of whom were treated with surgery and 491 of whom received radiotherapy. ~60% of these men had Gleason scores of 2-4 and it could be argued did not need any treatment for their cancer at all. The scoring has migrated over time, so we can assume that they would now mostly be in the Gleason 6 category. ~70% had PSA scores <10.

So it brings us back to the old question: If we find low grade cancer, should it be treated….and even more perplexing, should we have found it in the first place if we aren’t going to treat it anyway?  Please see my thoughts on screening elsewhere in this blog. Have a nice week. I will be at the ASCO GU meeting next week.



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2 responses to “More on the “no free ride” reality

  1. Joe

    Michael, forgive me for being a cracked record. Concerning both questions in your conclusion, what is wrong with giving the patients the best information, including what you report above, and letting them decide?

    • Dear Joe,
      I can imagine some answers to your question that would satisfy me. For example – imagine a simple blood test that is 100% accurate in determining who has a prostate cancer that is destined to progress and kill someone versus a cancer that will never harm that person. We could all agree that the problem would be solved. Short of that, here are some realities:
      1) There are no patients I have encountered who don’t feel either that (a) the screening test saved their life OR (b) that if they had only been screened earlier their life might have been saved. VERY few men who have gone through the treatment (which this article and many others clearly show is damaging on many levels) want to admit that the price they paid may not have been “worth it”.
      2) “Giving the patients the best information” is a hypothetical that is not achievable. By this I mean that to really understand the nuances of overdiagnosis and overtreatment requires a serious investment of time. This simply does not happen in screening clinics run by hospitals or practices. It doesn’t happen in the busy internal medicine or family practice office in a 15 minute “wellness” clinic visit looking at blood pressure, cholesterol, obesity and the intervals for colonoscopy, recommendations for shingles vaccine, pneumococcal vaccines and whether you have had your flu shot this year. And it certainly doesn’t happen in the urologist’s office who has been sent a patient with a slightly elevated PSA “for biopsy”. No urologist I know would be comfortable from a medical-legal perspective in not doing a biopsy after being referred such a patient unless he/she had compelling evidence that the patient has a non-cancer reason like prostatitis for the elevation. And it remains a HORRIBLE thing to find out you have cancer, especially if it is a low grade cancer that your doctor says “you can just watch”. Some have suggested we stop calling Gleason 3+3 “cancer” at all given its innocuous behavior in the vast majority of patients. I won’t even go into the complex issues surrounding the fact that 20-40% of patients who have surgery in such situations are upgraded or upstaged.
      So yes, I think there is a lot of information, much of which I have tried to bring out in this blog, which could help men make “informed” decisions. I seriously doubt that even 1/100 men who get screened will ever see the details that I have outlined or that you present. At best they can be given either a 5 page consent form that attempts to condense the information that they won’t read/understand or they can accept their physician’s bias or that of the USPSTF “D” rating for screening and just forgo the tests.

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