The Great Prostate Debate: “We” Versus “Me”

Richard Reece

Posted 10/12/11 on MedInnovation Blog

The public demands certainties but there are no certainties.

H.L. Mencken (1880-1956)

The government, representing “We, The People,” is responsible for spending the public’s money intelligently based fact. The individual citizen, “Me, The Person,” is responsible for preserving his/her health based on what he/she perceives to be in his best interest.

With PSA screening for prostate cancer, these responsibilities conflict because the screening may do more harm than good. Prostate cancer is a common, slow moving cancer. Five times more men with it than from it, and the side effects of biopsy and treatment can be devastating.

Hence, the great prostate debate – whether to screen routinely for prostate cancer with PSA testing, and whether to biopsy and treat patients with marginally elevated levels.

The debate raises other issues as well,

Medicine as a rational science,
versus sometimes irrational individual choice.

Statistical objectivity,
versus human subjectivity.

Minimalist clinical mindsets,
versus maximalist clinical behaviors.

Supposedly impersonal statistics,
pitted against very human logistics.

Cancer as a perceived death warrant,
Or cancer just another chronic disease of aging.

In the October 9 issue of the New York Times Magazine,
Daniel J. Leviter, professor of Psychology at McGill University, in a review of The Medical Mind, distills the essence of the prostate controversy with these words,

“Prostate cancer is slow moving.
More people die with it than from it.
For every 48 prostate surgery procedures,
Only one patient benefits –
The other 47 patients would have lived
just as long without it.
Moreover, the 47 who didn’t need
The surgery are often left with side effects –
Incontinence, impotence, and loss of sexual desire.
The likeliness of one is these side effects is over 50 percent-
27 or the 47 will have at least one.
This means a patient is 24 more times to experience the side effect than the cure.”

On the other hand, and there is always another side in any great debate, many doctors insist PSA screening is of great benefit, ans saves many lives. Those on the other side include urologists who treat patients with elevated PSAs, patients relieved of the anxiety of no longer harboring a malignancy, and oncologists who have witnessed malignancies caught before they spread or while in the early stages.

Richard Reece MD is an author and retired pathologist, writing at MedInnovation Blog. His latest book, Health Reform Maze: A Blueprint for Physician Practices, came out in August.

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