Leave your prostate alone

Yet more evidence that way to many men are getting unneeded (and often quite harmful!) surgery for prostate cancer:

A new study shows that prostate cancer surgery, which often leaves men impotent or incontinent, does not appear to save the lives of men with early-stage disease, who account for most cases, and many of these men would do just as well to choose no treatment at all.

The findings were based on the largest-ever clinical trial comparing surgical removal of the prostate with a strategy known as “watchful waiting.” They add to growing concerns that prostate cancer detection and treatment efforts over the past 25 years, particularly in the United States, have been woefully misguided, rendering millions of men impotent, incontinent and saddled with fear about a disease that was unlikely ever to kill them in the first place. About 100,000 to 120,000 radical prostatectomy surgeries are performed in the United States each year.

“I think this is game-changing,” said Dr. Leonard Marks, a professor of urology at the University of California, Los Angeles, who was not involved in the study. “What this study does is call attention to the fact that there are a lot of prostate cancers that are diagnosed today that are not dangerous.”

Obviously, in some cases you are saving lives, but more often than not, you are just leaving men saddled with really unpleasant conditions for no gain.   Surgeons want to cut (yes, I realize this is a simplification, but it does speak to a broader truth) and many, many people are not comfortable with the idea of not treating their cancer.  It’s a bad combination.

Prostate cancer death panel

Really interesting story in the Post yesterday about Medicare considering whether to continue reimbursing for a Prostate Cancer treatment that costs $93,000 to extend life an average of 4 months (from an average of 21 months to 25).  That strikes me (and I would think most people) as a horrible waste of money.   Of course, one might feel different if this was you or a loved one, but the truth is the resources we have to spend on health care are not unlimited (though we certainly act like they are).  One of the reasons Medicare is busting our budget is because it does cover hugely expensive treatments that provide only the most modest increase in life span.   If we ever hope to control medical costs in this country, it means that we need to start taking steps to not reimburse $100,000+ treatments that result in amazingly marginal increases in life span (there’s many that are a lot worse than this).

Despite the protests of the pharmaceuticals, I have a feeling that if Medicare stopped reimbursing, they’d find a way for it to still be profitable for them at dramatically less money.  Here’s the part that resonated with me:

“To charge $90,000 for four months, which comes out to $270,00 for a year of life, I think that’s too expensive,” said Tito Fojo of the National Cancer Institute. “A lot of people will say, ‘It’s my $100,000, and it’s my four months.’ Absolutely: A day is worth $1 million to some people. Unfortunately, we can’t afford it as a society.”

Others agreed, especially given the modest benefit.

“I’d like to think cost doesn’t need to come up when it’s a slam dunk,” said H. Gilbert Welch of the Dartmouth Institute for Health Policy and Clinical Practice. “But when it’s a close call like this, it certainly has to be a factor. That’s $100,000 Medicare can’t spend elsewhere.”

Either you are going to draw some lines based on price, or your not.  If your not willing to, we are quite simply going to bankrupt this county on health care spending.   And, if we are going to draw some lines, this one seems pretty good to me.

 

 

On cancer “survivors”

Not to belittle for a moment anybody who’s had cancer and successfully gone through treatment, but the seeming overuse of the term “survivor” has always bothered me.  The other day I was watching a college basketball game and the announcers mentioned all the men they knew that were prostate cancer “survivors.”  Now, as I’ve written about many times, whether you have treatment or not, the substantial majority of men with a prostate cancer diagnosis would not die of the disease even if they received no treatment.  Now, how exactly do you survive something that wouldn’t have killed you anyway?  I was looking for another article on Slate– which I’ll save for a future post– and I came across this excellent piece on the trouble with “survivor” from a couple years back.  It’s by an oncologist who is a breast cancer “survivor.”

The National Cancer Institute defines a “cancer survivor” as someone who’s had a malignant tumor and remains alive. This holds whether you’re thriving after a single intervention, like surgical excision of a small tumor, or struggling for years with metastatic illness. The American Cancer Societyreports that nearly 12 million Americans are living today after a cancer diagnosis; each of us is a “survivor.”…

I can’t help but wrestle with the expression. The Latin roots—super and vīvere—support a straightforward meaning: that a person has outlived another. As an oncologist, I’m not convinced of this label’s accuracy, at least as it applies to a woman living after breast cancer; this, like some lymphomas and other tumors, can recur years, even decades after treatment ends. What’s more, I worry the “survivor” lingo might cause harm: Just as the term can support or reflect upon a patient’s courage and tenacity, it might alienate or wound someone who knows she can’t alter the course of her disease…

At a deeper level, what’s wrong is that the expression connotes strength or heroism. Today, survivor feeds into the concept of cancer as some sort of contest of harsh ordeals. Best sellers like Dr. David Servan-Schreiber’s Anticancer: A New Way of Life push the impression that survival implies you’ve done something right. The fault’s in the converse: If you don’t lick your tumor, you’ve failed. Maybe you chose the wrong treatment plan, ate the wrong foods, exercised too little or too much, or weren’t sufficiently optimistic. But cancer is not a mystic life challenge or game. It’s a disease, or really a set of complex diseases, that’s common, feared, and widely misunderstood…

Only a cynic would dismiss all the tangible, big-money support for research and the information and practical assistance offered by the survivor community’s enthusiasm. But the true heroes in this—those deserving of pink ribbons and medals, if they’re to be given—are those who struggle longest and hardest, who will never truly be “survivors” in the commonly accepted sense of the word.

It’s not the same for people like me, who move on with their lives after a discrete, albeit sometimes harrowing episode of illness. I’m an oncologist; I know I’ve done nothing in particular to deserve these eight years since my diagnosis. I lucked out, nothing more. And sure, I’m uncertain about my future. But who isn’t?

Good stuff.  I think on some level these issues bothered me (in addition to what I raised above) without me really realizing what it is about the term that’s always rubbed me wrong.  And for those who have survived an ordeal with cancer– good for you, most definitely.  I just think there are some real downsides to the term and that, in some case, it paints a false picture as well.

Cancer and optimism bias

Read a really interesting piece about stage IV cancer in the Times earlier this week.  Basic gist: (sadly) a huge number of patients really don’t appreciate how bad or how incurable their cancer is.  Very much hit home with my mom’s stage IV diagnosis over 3 years ago.  The essay is specifically about a study of lung and colon cancers, but I’m sure much of it applied to these advanced cancers more broadly:

 Most patients with these so-called stage 4 cancers who choose to undergo chemotherapy seem to believe, incorrectly, that the drugs could render them cancer-free.

That is the finding of a recent national study of nearly 1,200 patients with advanced cancers of the lung or colon. Overall, 69 percent of those with stage 4 lung cancer and 81 percent of those with stage 4 colon cancer failed to understand “that chemotherapy was not at all likely to cure their cancer,” Dr. Jane C. Weeks, an oncology researcher at the Dana-Farber Cancer Institute in Boston, and colleagues reported in The New England Journal of Medicine.

When patients do not understand the limitations of such treatment, their consent to undergo it is not truly informed, the authors concluded.

This is not to say that chemotherapy is pointless when cancer is far advanced. Various drugs, some with limited toxicity, can be used as palliatives, perhaps shrinking tumors temporarily to relieve symptoms, slowing the cancer’s growth and prolonging the lives of some patients.

But aggressive chemotherapy when death is but weeks or months in the offing can seriously compromise the quality of patients’ remaining time and may delay their preparations for the end of life, to the detriment of both patients and their families.

“If you think chemotherapy will cure you, you’re less open to end-of-life discussions,” Dr. Weeks said in an interview.

Yep, yep, yep.  And definitely part of the problem is oncologists who just want to treat, treat, treat.  Now, in my mom’s case the chemo really helped in some ways as the cancer had spread to her spine and was causing great pain, but it certainly seemed to me that she had a way over-optimistic sense of being “cured.”  Now, in truth, my mom was easily among the most optimistic people I’ve ever known (definitely to a flaw), but I also feel like the medical professionals could have certainly done a better job here.

Anyway, just a couple of days later, there was a very interesting piece about the huge overdiagnosis of breast cancer.  The latest study is just strong confirmation, but the basic point that breast cancer screening leads to many, many diagnoses that actually do nothing to save women’s lives.  Ironically, my mom was well aware of the futility of breast cancer screening which led her to be skeptical of the annual pap smear which probably would have saved her life.  Anyway, on the breast cancer issue:

After correcting for underlying trends and the use of hormone replacement therapy, we found that the introduction of screening has been associated with about 1.5 million additional women receiving a diagnosis of early stage breast cancer.

That would be a good thing if it meant that 1.5 million fewer women had gotten a diagnosis of late-stage breast cancer. Then we could say that screening had advanced the time of diagnosis and provided the opportunity of reduced mortality for 1.5 million women.

But instead, we found that there were only around 0.1 million fewer women with a diagnosis of late-stage breast cancer. This discrepancy means there was a lot of overdiagnosis: more than a million women who were told they had early stage cancer — most of whom underwent surgery, chemotherapy or radiation — for a “cancer” that was never going to make them sick. Although it’s impossible to know which women these are, that’s some pretty serious harm.

But even more damaging is what these data suggest about the benefit of screening. If it does not advance the time of diagnosis of late-stage cancer, it won’t reduce mortality. In fact, we found no change in the number of women with life-threatening metastatic breast cancer.

Wow.  That’s a lot of needlessly diagnosed breast cancer and a lot of harm.  What do to differently?

What should be done? First and foremost, tell the truth: woman really do have a choice. While no one can dismiss the possibility that screening may help a tiny number of women, there’s no doubt that it leads many, many more to be treated for breast cancer unnecessarily. Women have to decide for themselves about the benefit and harms.

But health care providers can also do better. They can look less hard for tiny cancers and precancers and put more effort into differentiating between consequential and inconsequential cancers. We must redesign screening protocols to reduce overdiagnosis or stop population-wide screening completely. Screening could be targeted instead to those at the highest risk of dying from breast cancer — women with strong family histories or genetic predispositions to the disease. These are the women who are most likely to benefit and least likely to be overdiagnosed.

The more we learn, the more it seems that breast cancer resembles the over-diagnosed and over-treated prostate cancer (though, clearly, it is on average a much more serious disease).  Clearly, our medical system needs to do much better.  And it can, if we get smarter about it.

The end of the PSA as we know it?

So many men have really suffered from counter-productive prostate cancer screenings via the PSA.  The medical community has finally come around on this.  I long ago decided there was no PSA in my future unless the test were radically improved.  Here’s the latest:

Men should no longer receive a routine blood test to check for prostate cancer because the test does more harm than good, a top-level government task force has concluded.

The recommendation from the U.S. Preventive Services Task Force runs counter to some two decades of medical practice in which many primary care physicians routinely gave the prostate specific-antigen, or PSA, test to healthy middle-age men.

But after reviewing all available scientific evidence, the task force concluded that routine PSA screening will help save the life of just 1 in 1,000 men who get the test.  [emphasis mine] At the same time, the test steers many more men who would never die of prostate cancer toward unnecessary surgery, radiation, and chemotherapy, the task force concluded.

How’s this for a cost/benefit?

But after reviewing all available scientific evidence, the task force concluded that routine PSA screening will help save the life of just 1 in 1,000 men who get the test. At the same time, the test steers many more men who would never die of prostate cancer toward unnecessary surgery, radiation, and chemotherapy, the task force concluded.

An absolutely classic case of overtreatment creating far more harm than good.  It’s a shame that it took so long and caused suffering for so many men, but it’s nice to see that medicine can actually make a dramatic course correction on something like this.

Just Say No to PSA

So, the US Preventive Services Task Force recently released a recommendation that we stop using the PSA test to screen for prostate cancer in most cases.  I wrote way back when in a mini-post:

1) We so over-screen for Prostate cancer.  Unless things really change, no PSA test for me.  The costs so clearly outweigh the benefits but everyone is irrationally (though understandably) afraid of cancer.

Glad to see the medical establishment has now come to the same conclusion (of course, Republicans can now argue that this is about “death panels”).   I wanted to write something about this, but didn’t come across any articles that really grabbed my attention.  Alas, yesterday, I found this fabulous piece from a recent NYT magazine that really lays it all out.  Among other authors, it is by Shannon Brownlee, who wrote the terrific book, Overtreated: How Too Much Medicine is Making us Sicker and Poorer (I gave it 3 1/2 of 4 stars back when I read it).  Anyway, I think this extended analogy/metaphor from the piece makes the case brilliantly:

“Imagine you are one of 100 men in a room,” he says. “Seventeen of you will be diagnosed with prostate cancer, and three are destined to die from it. But nobody knows which ones.” Now imagine there is a man wearing a white coat on the other side of the door. In his hand are 17 pills, one of which will save the life of one of the men with prostate cancer. “You’d probably want to invite him into the room to deliver the pill, wouldn’t you?” Newman says.

Statistics for the effects of P.S.A. testing are often represented this way — only in terms of possible benefit. But Newman says that to completely convey the P.S.A. screening story, you have to extend the metaphor. After handing out the pills, the man in the white coat randomly shoots one of the 17 men dead. Then he shoots 10 more in the groin, leaving them impotent or incontinent.

Wow– that’s a pretty obvious and stark choice.  And it represents quite well the actual consequences of PSA treatment and screening as currently used.  Furthermore, there’s the opportunity cost of being so wedded to an approach that is so ineffective:

For Brawley, the greatest tragedy of P.S.A. screening is that it has been a distraction from making greater progress in reducing deaths with the one clear helpful thing: distinguishing between the prostate tumors that really need to come out and those that are better left alone. Instead, new types of P.S.A. screening are being promoted.

If you are a man over 40 and you are reading this, there’s quite a decent chance you actually have cancer in your prostate:

The current thinking is that about 30 percent of men in their 40s have prostate cancer, 40 percent of men in their 50s and so on, right up to 70 percent of men in their 80s. Yet only 3 percent of all men die from the disease. In other words, far more men die with prostate cancer than from it, and only a tiny fraction of prostate cancers ever cause symptoms, much less death.

Just accept it.  There’s a very small chance it will actually kill you.

Grow hair and prevent cancer

I’ve become quite a fan of the NPR Health Blog “Shots.”  This entry today about finasteride (Propecia)  caught my attention:

A generic drug called finasteride reduces the risk of prostate cancer by 25 percent, according to a 2003 study of 18,000 men.

But doctors apparently don’t believe it, misunderstand the findings, or just don’t know about it…

When researchers asked them why, half said they didn’t know the drug could prevent prostate cancer. And more than half said they were worried that men taking finasteride had a higher risk of developing more aggressive tumors.

That second concern arises from the first results of that 2003 study, called the Prostate Cancer Prevention Trial. It seemed to show that finasteride, which blocks the cancer-stimulating effects of testosterone, lowered the overall rate of prostate cancer by 25 percent but increased the risk of more dangerous tumors by 27 percent.

But in 2008, the researchers refuted from that finding, after looking more closely at the data along with biopsies of the tumors that occurred during the study. The new analysis showed finasteride didn’t really raise the risk of high-grade tumors, it just makes tests for tumor grade more sensitive.

Couple of things.  It’s hard for doctors to keep up on all the latest information (though they really should do a better job of it).  In this case, not keeping up may very well be costing men their lives, or at least other unpleasant consequences of prostate cancer.  All the more reason patients really need to learn all they can do be the best advocates for themselves.  If you ever have a doctor who resents you educating yourself on-line (what are you supposed to do, go to a medical school library?) you should find another doctor.  Also, wow, Propecia, like a wonder drug.  There’s got to be some downside to this (actually, here they are, and they really are minimal– that is unless you’re part of the extra .5% with erectile dysfunction or decreased libido).

PSA: You need more vitamin D

Seriously.  Nice article in the Times sums this up.  I listened to a podcast on this a while ago and was intrigued to learn that the current RDA standard were based on not incurring a crippling disease from Vitamin D deficiency, rather than determining a level which is truly healthy.  At my last physical I was quite surprised to learn I was just barely in the healthy range after making a concerted effort to get more Vitamin D (despite my very imperfect physique, I started jogging topless in the summer just to get the extra rays).  Anyway, here’s a bit from the article:

While studies continue to refine optimal blood levels and recommended dietary amounts, the fact remains that a huge part of the population — from robust newborns to the frail elderly, and many others in between — are deficient in this essential nutrient…

Studies indicate that the effects of a vitamin D deficiencyinclude an elevated risk of developing (and dying from) cancers of the colon, breast and prostate; high blood pressure and cardiovascular disease; osteoarthritis; and immune-system abnormalities that can result in infections and autoimmune disorders like multiple sclerosis, Type 1 diabetes and rheumatoid arthritis.

Most people in the modern world have lifestyles that prevent them from acquiring the levels of vitamin D that evolution intended us to have. The sun’s ultraviolet-B rays absorbed through the skin are the body’s main source of this nutrient. Early humans evolved near the equator, where sun exposure is intense year round, and minimally clothed people spent most of the day outdoors…

Dr. Michael Holick of Boston University, a leading expert on vitamin D and author of “The Vitamin D Solution” (Hudson Street Press, 2010), said in an interview, “We want everyone to be above 30 nanograms per milliliter, but currently in the United States, Caucasians average 18 to 22 nanograms and African-Americans average 13 to 15 nanograms.”

Vitamin D supplements are very affordable– think about it.  The Greene family is getting them.

Mega quick hits

I've been a bad blogger.  I've got a ton of tabs saved up I've been meaning to blog about and have not done so.  In the list of at least clearing this out, here goes…

1) We so over-screen for Prostate cancer.  Unless things really change, no PSA test for me.  The costs so clearly outweigh the benefits but everyone is irrationally (though understandably) afraid of cancer.  

2) A really important and not fully appreciated point is how much politicians actually shape public opinion.  Yglesias has a great post on how Republicans so consciously and successfully managed to shape opinion on health care. 

3) For all those idiots complaining about how evil, unconstitutional, and liberal the individual mandate is, you might want to mention that the idea basically comes from the Heritage Foundation.  This post from Ezra Klein very much speaks to this point as well. 

4) Charles Blow to tea partiers: "You may want “your country back,” but you can’t have it."  I.e., Uneducated whites are an ever-shrinking part of the population.

5) I've said it before, I'll surely play it again.  I really don't have a big problem with a pro-market philosophy.  I've got a real problem with being pro-business.  The Republican party (and sadly, the Democrats to a considerable degree) are decidedly in this latter category.  Ezra explains. 

6) For a young woman selling her eggs, an increase of 100 points on the SAT is worth about $2300 in the value of her eggs. 

7) Interesting story about the lobbyist working for Catholic Bishops who did his damnedest to bring down health care.  

8) At Census time, prisoners are counted as residents of the county in which they are imprisoned.  It's not fair. 

Mammograms– who needs them?

So, a couple of weeks ago I meant to blog about Mammograms in response to this recent study:

Last month, Dr. Otis Brawley, the American Cancer Society’s chief medical officer, told The New York Times that the medical profession had exaggerated the benefits of cancer screening, and that if a woman refused mammography, “I would not think badly of her, but I would like her to get it.”…

But the statement also said mammography can “miss cancers that need
treatment, and in some cases finds disease that does not need
treatment.” In other words, the test may lead to some women being
treated, and being exposed to serious side effects, for cancers that
would not have killed them. Some researchers estimate that as many as
one-third of cancers picked up by screening would not be fatal even if
left untreated. But right now, nobody knows which ones.

Interesting, but the articles is from a few weeks ago and I never did anything.  However, now we have news that a federal panel is actual recommending that most women in their 40's no longer have routine mammograms:

 Women in their 40s should stop routinely having annual mammograms and
older women should cut back to one scheduled exam every other year, an
influential federal task force has concluded, challenging the use of
one of the most common medical tests.

"We're not saying women shouldn't get screened. Screening does saves
lives," said Diana B. Petitti, vice chairman of the U.S. Preventive
Services Task Force, which released the recommendations Monday in a
paper being published in Tuesday's Annals of Internal Medicine. "But we
are recommending against routine screening. There are important and
serious negatives or harms that need to be considered carefully." 

Obviously, for an announcement like this, there's been evidence for years that mammograms are not quite the magic bullet they are often portrayed to be.  Clearly, they are important and play a major role in preventing breast cancer, but it seems that this role should be more targeted than current use.  Alas, my mom was well aware of these studies questioning the efficacy of mammograms.  Unfortunately, she drew the conclusion that all such regular testing, e.g., pap smears, was unnecessary.  When she told me she might have uterine cancer and I asked about regular gynecological testing (which she did not have) she specifically mentioned the evidence for the limits of mammograms.  Okay, then, I'm not sure what my broad conclusion should be here.  I think it is good that doctors realize the limits of their screening tests and apply them more appropriately, but I hope too many people don't take these recommendations too far and ignore needed and effective medical tests.