Ethics in Medicine

Ongoing Controversies in Prostate Cancer Diagnosis and Treatment

Kristen Sparrow • September 23, 2010

I covered some of the controversies over prostate cancer screening in previous posts. Prostate cancer is a condition that should get a bit more scrutiny when it comes to the risk/benefit ratio of treatment. This should apply on an individual basis and on a public health basis.
These are the links to my previous posts covering some of the issues with PSA testing.

This New York Times article reviewing a new book about prostate cancer is poignant because it is written by a journalist who has had first hand experience with prostate cancer. I’m linking to the article almost in full because it is so important.

A Rush to Operating Rooms That Alters Men’s Lives
August 30, 2010
“As I scuffed through the stations of the prostate-cancer cross these past two years, I sometimes wondered whether I wasn’t a dupe caught up in a Robin Cook medical thriller.
Sure, the biopsy (so I was told) showed that my prostate was cancerous. And after it was removed, the pathology report revealed that the cancer was unexpectedly aggressive, thrusting me from the relative comforts of Stage 1 to the deep woods of Stage 3.

But at least on the surface, the cancer itself never did any damage. It was the treatments that razed me — the surgery, radiation and hormones producing a catalog of miseries that included impotence, incontinence and hot flashes. And a small voice kept whispering: What if this is all a lie? A dark conspiracy of the global medical-industrial complex?
And now comes “Invasion of the Prostate Snatchers,” by Ralph H. Blum and Dr. Mark Scholz, effectively confirming my whimsical paranoia.
Mr. Blum, a cultural anthropologist and writer, has lived with prostate cancer for 20 years without radical treatment, and Dr. Scholz is an oncologist who has treated the disease exclusively since 1995.
Their book, written tag-team style, is a provocative and frank look at the bewildering world of prostate cancer, from the current state of the multibillion-dollar industry to the range of available treatments.
About 200,000 cases of prostate cancer are diagnosed each year in the United States, and the authors say nearly all of them are overtreated. Most men, they persuasively argue, would be better served having their cancer managed as a chronic condition.
Why? Because most prostate cancers are lackadaisical — the fourth-class mail of their kind. The authors say “active surveillance” is an effective initial treatment for most men.
They add that only about 1 in 7 men with newly diagnosed prostate cancer are at risk for a serious form of the disease. “Out of 50,000 radical prostatectomies performed every year in the United States alone,” Dr. Scholz writes, “more than 40,000 are unnecessary. In other words, the vast majority of men with prostate cancer would have lived just as long without any operation at all. Most did not need to have their sexuality cut out.”
Yet radical prostatectomy is still the treatment recommended most often, even though a recent study in The New England Journal of Medicine suggested that it extended the lives of just 1 patient in 48...”
” In my experience, doctors play down punishing side effects like incontinence, impotence and shrinking of the penis. Those are just words when you hear them, but beyond language when you go through them.”..
The author goes on to explain that he had a rare aggressive cancer that wouldn’t have been detected short of surgery, so he was an anomaly. The article goes on.
“So yes, prostate cancer is a dark and mysterious country, and Mr. Blum and Dr. Scholz are good, levelheaded guides through these thickets. And in telling men to slow up and take a deep breath after they learn they have prostate cancer, they provide an invaluable service. I wish I had had this book back in 2008.
But all of this raises one last stark question: Was my life worth the 47 other prostatectomies that probably didn’t have to be performed?

This writer in asking this last question poses a conundrum that most patients would never even
consider asking when their own life is at stake. And I commend the author for raising the trade off. These are the types of issues that should concern public health officials, urologists and patients. They certainly interest me in the spirit of “first doing no harm.” Risk. Benefit. Think hard about it!