Since when is less information a better basis for making a good decision? I am sure Ian Haines (oncologist) is well-intentioned and speaks for many when he explains why he won’t have the “cancer blood test” commonly known as a PSA test (a simple blood test measuring the amount of prostate-specific-antigen in the bloodstream). He provides four reasons you should not have the test. However, he does not speak for me or for many intelligent men I know. Although much of what he says is true, his conclusion is flawed.
Like Dr. Haines, I too have “skin in the game,” and so I feel compelled to step forward and represent the opposing team. Haines has served up an unhealthy meal of random facts seasoned with his personal fears, all blended together with questionable logic. Let’s throw it up against the wall and see if it sticks.
Imperfect Does Not Mean Worthless
… in light of the fact that there are precious few prostate cancer testing tools at all, should we toss out the ones we do have merely because they are imperfect?Haines’ first reason to avoid the PSA test is that “PSA is a poor testing tool.” He explains why, and I’m willing to concede that PSA is indeed an imperfect diagnostic tool for prostate cancer. But like many imperfect things in life, it still has value. Especially in light of the fact that there are precious few prostate cancer testing tools at all, should we toss out the ones we do have merely because they are imperfect? PSA testing provides one of very few clues about the possibility of prostate cancer. It seems that Haines is more comfortable being clueless than having an imperfect clue to consider.
Early Treatment Can Help
Next, Haines points out—again correctly—that prostate cancer is different than other cancers. The relevant difference is that “in the majority of cases, prostate cancer … does not pose any threat to the patient’s natural life span.” Well, that’s wonderful news unless you are in the not-insignificant minority. The Mayo Clinic says, “Early treatment can help catch the cancer before it becomes life-threatening …” Well, yes! Isn’t that a legitimate goal? Now, how do we get there without a few clues, imperfect or otherwise?
The third reason Dr. Haines offers is that “surgery won’t always cure you.” True. But aside from failing to even mention any other treatment options for prostate cancer—and there are many, including proton radiation which I had in 2011—why is this man so obsessed with guarantees and perfection, or the lack thereof?
… why is this man so obsessed with guarantees and perfection, or the lack thereof?Just for fun, let’s go along with surgery as the only treatment apparently worth mentioning. In a very confusing and mystifying paragraph he says that radical surgery (i.e., removal of the prostate) “cures” six in seven cases. The quotation marks are his, indicating, I suppose, “not really” cured. He goes on to explain that most of those six “did not require treatment.” This bizarre remark is left dangling for his readers to ponder as to what that means. Did they not require treatment because in the Haines Crystal Ball he saw them dying of something else before their cancer would have done them in? Or were they tricked by the super-salesman-surgeon into needlessly going under the knife? Maybe in post-op Haines heard the surgeons say something like, “Darn, really didn’t need to do that one!” Beats me.
As for the other “one in seven” not in the above group, the ones with “dangerous cancers requiring cure,” well, sadly, most “will not be helped by the treatment,” he says. So what is Haines suggesting by implication? If you’re one of his six not needing treatment, wait in blissful ignorance until you’ve become the unfortunate seventh for whom it’s usually too late? What kind of logic is that?
What especially troubles me about Haines’ six-in-seven or one-in-seven is that he makes no comment regarding men not in his “most” groups. We must assume that they did require treatment and very possibly were helped. But too bad for them; they were in the Haines-Minorities.
Life is Risky; PSA Tests are Not
Dr. Ian Haines’ fourth and final reason for not having a PSA test is perhaps the most revealing one. He once again accurately states that “one in six men will be diagnosed with prostate cancer” and that their “lives will be profoundly changed.” Right on, Ian. Then the curtain rises, and he presents a laundry list of his personal fears.
Here is a summarized list of what Ian Haines fears and explicitly does not want: anxiety, depression, relationship changes, impotence, urinary incontinence, or the 1-2% risk of infections caused by prostate biopsies. Fair enough. I did not and still don’t want those, either. Surprisingly, after listing these horrors, Haines does not actually blame them on or tie them to PSA testing. He just jumps ahead to his flawed conclusion, hoping we will join him in blindly regarding the PSA test as a Pandora’s Box of Prostate Peril that should be left locked to protect us.
PSA Tests are Not Omnipotent
The PSA test result is nothing more and nothing less than a clue about the possible existence of prostate cancer. Where is the harm in letting each man decide …Haines’ “bottom line” and biggest fear is having his life “ruled by a regular blood test like PSA that has no advantage.” No advantage? The advantage is simple and obvious: it provides information. The PSA test does not cause any of the Haines Hit List of Horrors. The PSA test is benign. It is not cancer. It is not a biopsy. It is not surgery. It does not rule lives. It is merely information that is easily obtained along with your cholesterol levels and other possibly useful data about your health.
The PSA test result is nothing more and nothing less than a clue about the possible existence of prostate cancer or other prostate-related conditions. Where is the harm in letting each man decide whether he wants that clue, and how to utilize the imperfect information it provides? We live with imperfection every day. We make decisions of all kinds based on less than ideal data. If a man does not want that information, that’s fine with me. If I played golf I would still be happy to hit the links with a man who doesn’t want a PSA test. That is, as long as he does not presume to tell me whether I should have one, and whether I can use the information as I see fit.
For some, ignorance is bliss. For others, information is empowering.Before he offers his four reasons, Haines sets the stage for his editorial by mentioning that “only” 3% of men die because of prostate cancer. The American Cancer Society reports that prostate cancer is the second leading cause of cancer death in American men, and predicts that over 29,000 men will die of prostate cancer in 2014. That might be 3% of men, and it might be some other percent—I really don’t care. I just don’t want to be one of them, and if I am to do my best to stay out of that group I need information.
For some, ignorance is bliss. For others, information is empowering. When it comes to having the PSA test, I would not presume to tell any man including Ian Haines whether he would be most comfortable in the former group or the latter.
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Sure glad he wasn’t my doctor. My urologist makes a good part of his income – probably – from doing surgeries. Yet he recommended proton therapy. Here is a doctor worth having as opposed to one who wants to throw the baby (PSA testing) out with the bathwater. (Baby wasn’t clean enough)
Excellent piece. My own feelings after reading the USPSTF report on PSA testing:
A group of government-appointed “experts” (their fields of practice and expertise include behavioral health, family medicine, geriatrics, internal medicine, pediatrics, obstetrics and gynecology, and nursing) held forth on PSA testing and prostate cancer (PCa). Note the lack of “oncology” or “urology” as a specialty in their credentials. Their line of reasoning:
1) PCa treatment (apparently only surgery was considered) itself is not a certain cure, and in fact may itself be dangerous, with nasty side effects, including death.
1a) Therefore, PCa should not be treated unless it’s an aggressive tumor certain to be fatal during the expected lifetime of the patient.
2) PSA is not a 100% reliable predictor of aggressive PCa requiring treatment.
2a) Therefore, the PSA test should not be routinely used for screening.
2c) Unfortunately, we don’t have a better test.
Like Ron, my PSA history showed I possibly had PCa. It may well be that I could have waited watchfully (with apprehension building to mild terror, probably) for the rest of my life until some MD said, “Congratulations! We’re now pretty certain that this is going to kill you, so let’s whack it out. The odds are that you’ll be incontinent and/or impotent, at least for a few years, but WTH — you’ll be alive, maybe! Unless, of course, it comes back, which is likely, since we’ve waited so long.”
Instead, my biopsy showed it was an early-stage (i.e., treatable) tumor, and proton beam therapy seems to have cured it (now 5 years post treatment) with no side effects during treatment (other than spending (arguably) the best two months of my life with a bunch of affable guys) and negligible side effects after treatment, which have mostly gone away.
Another example of the government helping us.
Yes, I agree with you Ron. For two years my elevated PSA appeared to respond to the antibiotic Cipro, and I did not have a biopsy. After all, I was told, that meant I had a very low probability of cancer. The third year I did have a biopsy, the results came back with a Gleason score of 9 (out of 10) and high risk prognosis.
Luckily I was able to get to UFHPTI and qualify for their high risk program.
In my opinion there is NO excuse for intentional ignorance.
FX, I really like your phrase “intentional ignorance,” a.k.a. “head in the sand syndrome.”
Rico Masi–Thanks for helping educate the average guy. most of us that came down with PC really didn’t know which way to go. I remember my Dr. at Sloan Kettering in N.Y. told me to go home (Green Cove Springs, Florida) and go on the internet, and read all you can about PC. I had some help from my urologist, he sent me to a surgeon and a oncologist. I also informed some close friends. Well, one of those close friends told me about Proton therapy. The rest is history. Thanks Ron, keep up the good fight, education is still a great thing.
Thanks, Rico. We all do what we can to help the next guy. I think it’s irresponsible to tell that next guy that he’ll make better decisions with less information, i.e., no PSA data. So I had to speak up. I appreciate you sharing your thoughts here, too. Your support adds strength to my comments.
Mike, thanks for pulling back the curtain even further. Regardless of what anyone (government, oncologists, Uncle Joe) says, the PSA test is what it is: just a test providing information. It is hard to imagine a catastrophe resulting from a test, but easy enough to imagine the consequences of life-changing decisions made (or evaded) in ignorance.
I recently learned, from John Mulhull,a Sloan Kettering doc speaking at the PC Conference that a low testosterone level, can result in a low PSA because cancer needs testosterone to produce PSA. So along with a PSA test I think knowing your testosterone level makes sense. It may be the reason why aggressive disease, as determined by a high Gleason score, may not always go hand in hand with a high PSA. Just a thought although somewhat unrelated to this conversation.
Ron, testosterone definitely seems to be part of the picture. In fact, the game plan for hormone therapy is essentially to inhibit testosterone production to stop cancer growth. Little by little, as we learn how all the pieces of the complicated prostate cancer puzzle fit together, maybe someone will figure out how to fix it for good!