Rorshach and biomarkers

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Psychology, or for that matter being able to read others’ personalities, has never been a strong suit for me. Neither was art – I still am at the stick figure stage when drawing. It turns out that Hermann Rorshach was probably good at both. The question of what you see when looking at an ink blot seems relevant to the current status of biomarkers in prostate (and others) cancer. On the one hand, some biomarkers are fabulous – for example the Philadelphia chromosome, described in 1959, was the first unique cancer marker that ultimately resulted in a specific targeted treatment, imatinib (Gleevec), dramatically improving survival for patients with chronic myelogenous leukemia. PSA, on the other hand (our “favorite”) is not so great, and as I previously noted, may give rise to the “PSA Clock” effect in which patients ruin their lives by clock watching. But, as we know, it is remarkably useful as a weather vane. When a prostate cancer patient is being followed on any sort of therapy, going down is good and going up is bad.

Thus, there have been thousands of articles attempting to either make PSA interpretation  better, or to replace it with more sensitive or more accurate predictors of prostate cancer behavior. I reviewed some of these, and the challenges here. Today, yet another article on a rather “simple” biomarker, PTEN loss, showed up among the >20 prostate related emails I receive each day. Writing in European Urology, a group of well-known prostate cancer investigators looked at immunohistochemistry (using special stains to highlight a protein in cells under a microscope slide) to evaluate loss of PTEN, a tumor suppressor gene, in prostatectomy specimens. This simple test (in this particular experiment) was as good as the commercial Prolaris test that evaluates a panel of genes related to how fast cells are dividing in predicting biochemical recurrence (PSA relapse) or prostate cancer specific mortality. With PTEN loss, the chances of having a biochemical relapse (rising PSA) or developing metastases or dying in a 10 year followup period were significantly greater than if you did not have PTEN loss. A simple, inexpensive test might replace a more complicated one.

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Here’s where Dr. Rorshach’s psychological construct comes into play at so many levels. If you are the scientist looking through the microscope, do you score a loss when there is only faint staining? Are you sure you are looking at a cancer cell and not a normal cell or  a stromal cell, or maybe even an immune cell? If you decide on giving a score to each cell, say “1+, 2+, or 3+” staining, how do you add all those up?  How many cells should you examine? All parts of the tumor, or only the most aggressive (Gleason pattern ≥ 4) And if you can figure all that out, can you teach your colleagues to look at the same specimen(s) and come up with the same answer? These are the challenges we face when we move a lab experiment into the clinic (and they are well recognized by the authors).

But…there is more! Look at the graphs. Obviously you would rather be on the upper curve with PTEN present, but how bad is it really? At 10 years, only ~10% of the men had developed metastases or died in this study. Recognize that these men were a cross section of patients, median age 59, median PSA 5.9, 64% Gleason 3+3 and another 23% Gleason 3+4 with pretty low a priori risk (did we need the PTEN test to tell us?). So the real issue is whether you would want anything different done to you if you were one of the few patients with Gleason 3+3 and PTEN loss, just because you have this new information? And what would that be?? Radiation? Hormone therapy? How much and how long? -all in the psychology of looking at those curves. Some men might want nothing more done, while others would want “the kitchen sink” thrown at them, even if they had relatively little (and unproven) to gain.

So, medicine remains as much an art as it is a science (with no offense to my mathematical statistical colleagues). As the father of American Internal Medicine, William Osler, told his students, “Common sense in matters medical is rare, and is usually in inverse ratio to the degree of education.”


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8 responses to “Rorshach and biomarkers

  1. Julius

    Very good observation and information. Thank you.

  2. john c miller

    awaiting my consult with Mayer Fishman on Thursday. Xofigo failed totally. PSA at 860. Now on Xtandi. Bone Scan will reveal ???? something. We shall see. MISS YOU DR MIKE

  3. Hey John,
    Good luck – Thinking of you!!

  4. Scott

    You offer us insight into just how far we are from having the ideal protocols for cancer treatment. You also give us a glimpse into the major frustrations scientists, doctors and patients can face in treating it. In the short term, I am hoping that at least the art part of it becomes increasingly standardized. Then again, consensus on what isn’t science may not be especially meaningful.

  5. Ed Rust

    I was dx w/pca in mid 2006. I opted for watchful waiting and researched natural supplements for help. I have received no medical treatment other than periodic psa/biopsy. My last two biopsy’s did not detect cancer. Psa’s recently have been 6-8. At 77 I am healthy and active.

  6. Dr Mark Paul McAndrew

    An “applied science”, rather than art or science. But a careful consideration of what is important for any individual patient at a particular time is an essential element of the craft of medicine. The Rorschach test, like other projective tests, are aimed to discern “unconscious” motivations. It would be better to say that we have to live with considerable epistemological ambiguity and uncertainty in the application of new findings in medicine. Take care and best wishes folks – Mark 54 yo physician, 4 months clear PSA post RP.

  7. Great comment. Among the unconscious motivations, one might list our collective denial of mortality (“Doctor, do anything/everything to keep me alive at any cost…”), and sadly, even the financial considerations for both patient and physicians. I agree that there is always uncertainty in the application of new findings, but the nature of medical science and science in general is that the uncertainty decreases with time and further studies that confirm or question initial findings. I still find it interesting how different patients respond to a statement that “you have a 15% chance of developing metastases based on this test”.

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