Prostate Cancer and The New York Times

An article in the New York Times of August 30, 2010 discusses the diagnosis of prostate cancer through the lens of a new book entitled "Invasion of the Prostate Snatchers" by Ralph Blum (a cultural anthropologist) and Dr. Mark Sholtz (an oncologist). http://well.blogs.nytimes.com/2010/08/30/a-rush-to-operating-rooms-that-alters-mens-lives/?emc=eta1

The scene depicted is not pretty. The gist is that the vast majority of patients with prostate cancer are over treated, that 80% of the surgery done for the disease is unnecessary and that a large motive for treatment is financial remuneration. Radical prostatectomy, the commonest surgical treatment is said to lengthen the life expectancy of one in forty-eight patients.

As a disclaimer, I have not read this book but the picture presented here deserves analysis. Some background studies--
Random autopsies show a rate of unexpected cancer of the prostate in about 30% of men in the groups around 45, 55 and 65 years of age. It trends higher in the age of 75 and higher in the 80's.
PSA, a protein made in the prostate at a predictable rate, rises in situations where blood vessels are increased in number, fragility and porousness and, for one or more of these reasons, shows up elevated in some prostate cancers.
The diagnosis of prostate cancer has historically been made on physical examination where the disease is found as a hard lump on the prostate. The prostate, when the exam is normal but the PSA is elevated between 4 and 10, has a positive biopsy in about 30% of cases.
PSA elevation generally precedes clinically detectable prostate cancer by 5 to 7 years. In clinically detectable disease, life expectancy without treatment in men under about 70 is less than those with treatment over ten years; in men over 70 the life expectancy is about the same.

Clearly, 30% of men under the age of 70 are not dying of prostate cancer but if the disease that progresses to clinical findings can be identified in these men, that should help. A big problem is this group cannot be identified. PSA is generally seen as evidence of tumor activity but that may not be so. Biopsy of men with elevated PSA may find a disease that was sleeping and will sleep on. Some evidence of aggressiveness is often assumed from the Gleason Number, a rather subjective grading of the tumor tissue's histological deviation from the norm, and further hints of presumed behavior can be gleaned from volume of disease in the biopsy and multiplicity of sites of involvement, again generalities. Youth with the diagnosis is a negative.

There is nothing written in stone here: This is a disease of context, indeed many diseases are. Chicken pox is annoying in children, fatal in the elderly. A heart attack might pass unnoticed in an older man where the younger man is struck dead. Who survived the Black Death and why? Current medical thought sees prostate cancer as a mosaic, a collection of tendencies, clinical leanings and statistics from which decisions have to be made.

And it is hard. But articles like this make it harder. And presumed scientists often do not help. Last year a study showed up from Europe that looked at two groups of men, those in whom PSA studies were done and those who did not have the studies. Using this information as a proxy for prostate cancer and the value of finding it early with PSA testing, the scientists followed the two groups for up to seven years and found no significant difference in survival rate. Their conclusion: PSA testing--early detection of prostate cancer--was of no value. But PSA elevation precedes clinical disease by 5 to 7 years and clinical disease takes a while to kill. How was this study meaningful over such a short time frame? It wasn't. And the scientists knew it. Why, then, did they publish it? Why, indeed.

How the authors of this book determined that 80% of surgery was unnecessary is not clear from the article but it will be wonderful to learn. This difficult mosaic, which so many struggle with, will finally be made clear. At least I hope it will be--although I am not sure where these insights have been hiding. I hope this is not just another financial enterprise created to take advantage of the classical American under education in science, preoccupation with conspiracies, slavish devotion to sensationalism and confusion of disrespect with independence.