In our journey around the sun, we have reached the shortest day of the year, which, although my brother-in-law informs me is not to be feared…”the sun shall return”… is still not a bad time for reflection. This was a year when I said goodbye to one of my oldest patients, a retired physician with whom I had coffee or breakfast every Wednesday for over 20 years. He came to my lab or office, and in the last years, I went to his home. We measured our lives to some extent by those intervals, sharing stories of our families, our medical training, and of course solving the world’s problems. One thing we did not do was obsess about his PSA. Indeed, for the most part we ignored it.
I cannot count the number of times I have thought to myself (and occasionally commented aloud) “If it were not for the PSA, you would no doubt be out there playing golf, skiing, biking, taking a grandchild to the park, or just enjoying life.” Far too many of my patients let their PSA control their lives. Living from one PSA to the next is a bad way to mark the passing of time.
In a lovely essay in this week’s New Yorker, Alan Burdick discusses “how time became psychological.” He quotes Plato: “The instant, this strange nature, is something inserted between motion and rest, and it is in no time at all.” And he proposes that Augustine, writing in the year 397, “plucked time from the realm of physics and placed it squarely in what we now call psychology. ‘In you, my mind, I measure time’…To consider this present is to glimpse the soul, Augustine argued.”
The PSA clock, for many physicians and patients, is dehumanizing. It is a technical artifact of modern medicine, one so sensitive that it provides a second hand when we should be looking at the hour hand, the calendar, or the seasons. Imagine if your cardiologist could measure the thickening of your coronary artery year by year in microns as plaque builds up. Would you want that test? Would it change how you lived if you knew for certain that you will die from a stroke in 8 years?
This is not to say that we can’t use the PSA to guide treatment or make decisions. A younger person with aggressive prostate cancer who must fight with every tool available may well benefit from close observation of the PSA. On the other hand, in Dr. Walsh’s series of men (reported by Pound) who had rising PSA after surgery, it was 8 years on average before anything was revealed on a bone scan or CT scan, and another 5 years before they died. Did these men benefit from the PSA’s? To be sure, treatment options have changed in the 17 years since that series was reported, but we need perspective. Another of my physician patients (a thoracic surgeon) had his prostate removed and never checked his PSA again. About 9 years later, he presented with bone metastases, and is now doing well on androgen ablation. He doesn’t come in for PSA’s. He is in his early 80’s and enjoying his life. I suspect I will see him when he develops new symptoms, and then we can discuss his alternatives. I hope that won’t be for many years, and indeed, that is entirely possible.
So on this winter solstice you might pause to consider all of your blessings and turn off the PSA clock in your mind. 47 years ago today (on the longest night of the year), I got married. Two careers, three kids, four grandchildren later, I don’t look at my PSA. Rather, I try to enjoy my Time in a Bottle. If you are in a contemplative mood as this year ends, click on that link and enjoy the holidays! Good wishes and glad tidings to you and yours in the coming year.