Here we go again. This time it’s sixty-three-year-old John Horgan, who directs the Center for Science Writings at the Stevens Institute of Technology. John doesn’t want to heed his doctor’s advice. He says he won’t get a PSA test. He explains why in his article published in Scientific American, but Horgan’s position is neither scientific nor American.
Horgan has written many articles for Scientific American about evolution, policy and ethics, physics, cognition, public health, and other topics. I suppose he is smart and well-educated in many areas. In his recent article for that publication, he explains in seventeen paragraphs why it’s a bad idea to have the much-maligned PSA test.
The implication is that others like him should also decline the allegedly dangerous test. His reasoning is flawed, but he is certainly entitled to his view, to apply it to his life, and even to share his opinion. However, it is unfortunate that many who read his article may be influenced as much by the fact that it appears in a well-reputed publication as by the article itself. Only in the tiniest of fonts will you find the obscurely-placed disclaimer that the “views expressed are those of the author(s) and are not necessarily those of Scientific American.”
Maybe in fairness they’ll publish a counterpoint—maybe even this one.
Horgan’s old news
Much of Horgan’s article is accurate, and he writes well. He provides an easily understandable, concise definition of the PSA test and the prostate. He correctly states that elevated PSA levels “can indicate cancerous cells in the prostate gland.” He points out that there are also other possible causes for an elevated PSA level, and adds that prostate cancer cells are often slow-growing and might never cause death. All true, and all old news.
To help justify his position, Horgan conveniently cites the PSA-nay-saying statements of 2012 and 2017 by the United States Preventive Services Task Force (USPSTF, a.k.a. the Task Force). However, he fails to inform his readers that this allegedly impartial panel of experts—part of the Department of Health and Human Services (HHS)—is no longer merely advisory or investigative. It has morphed from its original intent in 1984 to a full-fledged government policy-making entity. As such, its so-called recommendations are infested with political bias and hidden agendas, and cannot be regarded as objective, despite their own declaration to the contrary.
… the Cochrane Group … not only gave a thumbs-down to PSA testing, they likewise rejected DREs (digital rectal exams).
He also cites concurrence from the Cochrane Group, another self-declared impartial bunch who did a meta-study in 2013. They arrived at their conclusion based on combined data from five other studies, including trials examined by the aforementioned Task Force. As a bonus, not only did they give a thumbs-down to PSA testing, they likewise rejected DREs (digital rectal exams). At least they’re consistent.
Horgan dutifully provides additional support for his position, proving what we already know: he is by no means alone in his belief. But he doesn’t seem to give much credence or acknowledgement to the equally many with a favorable view of the value of PSA testing. His presentation and intentionally one-sided message is clear: bad things happen to men who have PSA testing for early detection of prostate cancer.
Horgan hears the numbers
John Horgan appears to be a numbers man, and he uses the New York Times as his source to support his position mathematically. Here are the statistics he passes along to his readers from the NYT:
At first glance, this certainly makes PSA testing seem worse than unnecessary, unless of course you become one of the deaths that could have been prevented. And just in case his readers missed his point, he blasts it home by saying, “you are 240-120 times more likely to misdiagnosed as a result of a positive PSA test and 80-40 times more likely to get unnecessary surgery or radiation than you are to have your life saved.” Well, who in their right mind wants to be misdiagnosed or receive unnecessary treatment, just because he had a PSA test? Not me!
Digging deeper into the math
Let’s take a breath and dig deeper into Horgan’s numbers. Even if they are accurate, the entire paragraph is critically flawed on several levels.
First and foremost, “surgery and/or radiation” is not a treatment. There is surgery. There is radiation. And there can be surgery combined with radiation beforehand or afterward. Of the 80 men treated, what is the breakdown of their actual treatment? How many of the 60 who suffered side effects from “this treatment” were surgery patients? How many had radiation? To properly interpret Horgan’s data, we need to know.
First and foremost, “surgery and/or radiation” is not a treatment. There is surgery. There is radiation.
In fact, we need more than just the number of radiation patients included. We also need a detailed breakdown of this group. Radiation is a broad category including several very specific, very different varieties. Did all those patients receive conventional photon/x-ray/IMRT radiation? Did any have brachytherapy (radioactive seed implants)? Did even one of those 80 patients receive proton beam therapy?
Does John Horgan even know about proton therapy?
Let’s be specific
There is continuing debate and research about which form of radiation therapy has the best likelihood of kicking the cancer without side effects. We can no longer lazily lump them together simply as “radiation.” Articles making this mistake are significantly devalued and misleading.
When deciding if and how we choose to be treated, specificity is mandatory. Each type of radiotherapy is a useful tool to have in our toolbox. Each has unique characteristics and risk profiles. Surgery must also be in our toolbox. However, bundling surgery with all forms of radiation into a single nonexistent composite treatment alleged to cause side effects in 60 of 80 patients is irresponsible and misleading.
Bundling surgery and all forms of radiation into one nonexistent composite treatment alleged to cause side effects in 60 of 80 patients is irresponsible and misleading.
Furthermore, Horgan has provided no evidence that 60 of 80 men treated for prostate cancer with any of these methods have noteworthy side effects. The NYT article he references also mentions but fails to identify the source of this number. It does cite a European study not even focused on side effects. But interestingly, on a related and relevant matter, the study says that “a substantial reduction in prostate cancer mortality (is) attributable to testing of PSA,” a finding Horgan doesn’t bother mentioning.
What about death?
Only one or two deaths will be prevented, Horgan says. Early detection beginning with PSA testing could save a couple lives out of the 80 treated, he adds. Not worth the risk, he concludes. No PSA test for John, he decides.
… compared to maybe (if ever) saving a few lives out of millions of air travelers by frisking old ladies at airports, preventing a couple horrible deaths out of 80 men with cancer would be a huge win.
For perspective, let’s consider gun control laws. Or airport security measures. Or traffic speed limits. Or mandatory seat belts. Or anti-drug laws. Or motorcycle helmet mandates. All were at least partly inspired by the notion that “if only one life could be saved …” then we should do it. I don’t happen to think this way, but many do, possibly including Horgan. To address them, I would argue that compared to maybe (if ever) saving a few lives out of millions of air travelers by frisking old ladies at airports, preventing a couple horrible deaths out of 80 men with cancer would be a huge win.
What about life?
There is a subset of Horgan’s sample he completely fails to identify. Consider the 10 percent—100 men—of Horgan’s thousand tested who do indeed have prostate cancer. What if none of them had been tested or diagnosed? What happens to them?
One or two would die, he says, and he accepts it as okay. But does he think all of the other 98 or 99 left untreated would live symptom-free until they die of another cause? Some certainly might, but others could sooner or later suffer the awful effects of advanced prostate cancer, even if they do not ultimately die from it. And it’s not a pretty picture.
When prostate cancer is allowed to progress, some horrible symptoms are possible. A list can be found on the WebMD website. They include the inability to urinate, difficulty starting/stopping the flow, frequency, pain or burning, and blood in urine or semen. Also on the list are erectile dysfunction, weight loss, swelling in the legs and feet, and frequent deep pain in your lower back, belly, hip, or pelvis. Shouldn’t these be included as possible “side effects” of leaving prostate cancer undiagnosed and untreated?
… others could sooner or later suffer the awful effects of advanced prostate cancer, even if they do not ultimately die from it.
I challenge John Horgan to find a man who first discovered his prostate cancer only after he began experiencing these symptoms, yet does not wish he had been diagnosed and possibly treated sooner. By the time symptoms are evident, the cancer is almost assuredly at a stage at which treatment is more challenging, cure rates are lower, cancer symptoms and treatment side effects may be all but unavoidable. What kind of life is that?
Sadly, a simple blood test might have given such a man the chance to at least consider options available only at an earlier, more manageable stage. It’s the very test John Horgan doesn’t want, despite his doctor’s recommendation.
What about me?
In Horgan’s group of 1000, I was one of the men who chose to be tested regularly. With PSA levels on the rise, I qualified as one of Horgan’s 240. I did not immediately schedule a biopsy at the first sign of a rising PSA. My excellent urologist and I waited until it became clearer something was probably going on and worth investigating further.
Ultimately, based on my PSA pattern along with many memorable DREs (digital rectal exams) and an ever so pleasant PCA3 test (click here to read how I described the PCA3 test in my book), I chose to have a biopsy. It was positive, and I thus graduated into the Horgan-100.
Even then, I was undecided how to proceed. I considered and investigated the question—not the assumption—of whether I should treat my cancer. On one hand, I knew the usually slow-growing prostate cancer might not progress significantly in my lifetime, but it could. There was potentially plenty of time for that to happen, as I was only 60 years old at the time. On the other hand, I knew treating it at my early stage would likely kick the cancer, but could result in the side effects Horgan mentioned. It was a tough call for me to make, as it is for every man in such circumstances. None of us make the decision lightly.
My research in 2010 led me to proton beam therapy. I was convinced it would give me an excellent chance of curing my cancer, while offering a low probability of incontinence, erectile dysfunction, or other side effects. I believed proton had an acceptable risk profile favoring a desirable outcome, and was a better option for me than other therapies, or doing nothing.
I believed proton had an acceptable risk profile favoring a desirable outcome, and was a better option for me than other therapies, or doing nothing.
I had made my decision. I became one of Horgan’s 80 men. Was it the right move for me? Do I really have a 75 percent chance of future disaster, as Horgan would have us believe?
Based on what I know (here’s one recent 5-year outcomes study), I doubt it. But all I can truthfully say today is, so-far, so-good. I am not one of Horgan’s allegedly unfortunate 60 men. Ask me for an update in thirty days, or thirty years.
What I do know is this: I played the cards I was dealt based on knowledge and information, and the PSA test results were part of it. For me, ignorance is never blissful. I made an informed decision.
John Horgan, of course, is off the hook. He won’t have to make that decision.
The mistaken assumption
The underlying assumption—the essence of most anti-PSA-testing arguments—is that the PSA test causes bad things to happen. It almost never does, unless you have difficulty finding a good vein for the blood draw—venipuncture. The PSA test is nothing more than another blood test telling us what’s going on in our body. It’s not even expensive.
For any line item in our routine blood profile, we can make good or bad decisions based on the results. We can start taking drugs to bring our numbers back into normal ranges. We can order more tests, some possibly dangerous or invasive. We can even ignore the lab results. But blood analysis is a routine and valuable diagnostic tool, not a gateway to inevitably disastrous consequences. Bad judgment and poor decisions can lead to disaster. Good information is not the culprit.
I’ve highlighted my next paragraph because it encapsulates my main point. Feel free to copy and share it with others:
It bears emphasizing that the PSA level is merely a clue that prostate cancer cells might exist. In the absence of a 100% definitive test, it’s a clue I and many men want. It’s information we use along with other data to reach informed decisions. Other men, including John Horgan, prefer to remain clueless, which is their privilege.
Should Horgan be tested?
I’ll bet John Horgan has a routine blood workup as part of his annual physical, and I’ll bet he wants to know the results each time. We can assume he explicitly demands exclusion of the PSA test, but should he include it?
I’m curious: If his doctor were to mistakenly include the PSA test against John’s wishes, would Horgan ask for the result to be redacted?
I say no. Why? It’s simple: If he doesn’t want the test, then … that’s it. End of discussion. No test for Johnny. But I’m curious: If his doctor were to mistakenly include the PSA test against John’s wishes, would Horgan ask for the result to be redacted?
By his example, John Horgan is encouraging men to avoid a simple inexpensive test that can provide useful information about their health. Instead, he should use his high profile position to remind them that the only direct side effect of having more information is greater knowledge. The main result of ignoring readily available information is self-imposed ignorance.
A note to John Horgan
If you happen to run into John Horgan at your local Waffle House, please give him this message from me:
John, as we both know, one in six or seven men might have or could develop prostate cancer, and I sincerely hope you do not. But if you do, I hope you don’t find out the hard way, by developing symptoms. If that should happen, I hope researchers will by then have found a risk-free way to treat or at least manage your symptoms along with your late-stage cancer. And I most certainly hope you do not become one of the men who dies of this disease, and might have been cured had it been detected earlier.
What do you think? Should John Horgan have a PSA test? Email me here—thanks!