Screening Controversy:
I recently answered a private email from a valuable member of the PPML
tactfully asking me to explain my lack of enthusiasm for screening.
I thought I'd share some of my response since I am sure others of you may
be puzzled by my seemingly obnoxious resisitance to general screening. I am
an advocate for informed screening, but don't see how that can be
practically accomplished in a general population which watches "Wheel of
Fortune" with a frequency which would make me puke if I dwell on it any
longer.
****************************************************************************
You, of course, mention the . . . argument FOR screening. It's a good
argument, but it doesn't look at both sides of the story. I've done plenty
of autopsies where I've made a new diagnosis of non-localized prostate
cancer, the poor stiff (who died of some other cause) blissfully ignorant
of it when he was alive. Would his life be improved if he had had this
knowledge?
>
> I get almighty tired of two things in this PCa game:
>
> 1. Those . . . who would interfere with the*right* of any of us
> to *know* if we have PCa so that we can exercise our own free will to
cope
> with it. . . .
I think any man with non-localized PCa will see the benefit of screening.
Obviously, if he had been detected early enough, he would not be dealing
with the problems he has now. But that's not the audience which screening
needs to address. Its every Joe Blow walking along Main Street oblivious to
the fact that he even HAS a prostate.
>
> 2. The idea that, if you have PCa, you are not going to have *some*
> impairment of your QOL (including terminal impairment).
FACT - Most men who have prostate cancer will never know about it, and will
die happily or not from other causes.
QUESTION - For those prostate cancers detected by screening, do we have the
necessary staging and treatment skills so that the benefits of detection
outweight the risks? And do the benefits of screening outweigh the
personal and societal costs to the rest of the population (After all,
screening is a public health issue)?
I don't know the answer to these questions as they apply to August 1997. I
am 100% sure that as we learn more about PCa, and as our technology
improves, the answer will most definitely be Yes. I'm just not sure that
we're "there" yet.
Regards,
JR Oppenheimer
Prostate Pathologist
*************************
> >On the other hand, he
> >cannot suffer decreased QOL due to various interventions if he isn't
> >diagnosed.
>
> Jonathan,
> The above that you wrote is that same tired -- and spurious -- argument
> espoused by everyone from our Dutch friend Henk down. How about the
effect
> on QOL of the PCa endgame? An endgame that can be visited upon one
without
> his knowledge or any opportunity to intervene if he is not diagnosed.
You, of course, mention the spurious argument FOR screening. It's a good
argument, but it doesn't look at both sides of the story. I've done plenty
of autopsies where I've made a new diagnosis of non-localized prostate
cancer, the poor stiff (who died of some other cause) not even knowing it
when he was alive. Would his life be improved if he had had this knowledge?
>
> I get almighty tired of two things in this PCa game:
>
> 1. Those like Tom and Henk who would interfere with the*right* of any of
us
> to *know* if we have PCa so that we can exercise our own free will to
cope
> with it. Tom particularly irks me as he has known of his cancer and has
> taken his shot at it -- a bit hypocritical to then argue against
screening,
> wouldn't you say?
I think any man with non-localized PCa will see the benefit of screening.
Obviously, if he had been detected early enough, he would not be dealing
with the problems he has now. But that's not the audience which screening
needs to address. Its every Joe Blow walking along Main Street oblivious to
the fact that he even HAS a prostate.
>
> 2. The idea that, if you have PCa, you are not going to have *some*
> impairment of your QOL (including terminal impairment).
********************
Dr. Lynes writes
> Early detection in an individual discovered to have a small prostate
cancer
> obviously benefits that person. However, statements that early detection
> and screening may not benefit are statements on the entire male
population
> as a whole, not for that individual.
I think this is the key to the debate. Men young enough to benefit from
screening are obviously helped by it. These men necessarily have prostate
cancer. Men that don't have cancer (or aren't benefitted by detection)
aren't helped and might be harmed. The first population composes a rather
small (but important and growing) part of the whole. The non-doc PPML crowd
is composed of men (or women who love them) in the first group. Public
policy tries to balance the interests of both groups.
JR Oppenheimer
FACT - Most men who have prostate cancer will never know about it, and will
die happily or not from other causes.
Warm regards,
Jonathan
*********************
> From: Charlie in San Francisco <cmullins@sirius.com>
> To: PROSTATE@MAELSTROM.STJOHNS.EDU
> Subject: Re: [PP] Anti-screening
> Date: Thursday, August 28, 1997 11:01 PM
>
> Aubrey, I think that what I can't understand is why anyone
> would NOT want to know if they have cancer.
>
> --
> Charlie in San Francisco
I can't speak for others, but I would not want to know if I had cancer, if
that knowledge would cause greater harm to my life than good. Now if such
knowledge would help me live a happier and longer life, there is no
question I want that knowledge. If it would cause me to interrupt my life,
steal time from my family to spend it in front on my computer, suffer from
treatment complications, etc. WITHOUT giving me substantial benefit, then I
don't want that knowledge. The unsolvable dilemma is that we can't decide
whether to obtain this knowledge in one's particular case before knowing
whether it is helpful or not.
I have performed several autopsies in which a man had locally invasive
prostate cancer without ever being cognizant of the fact. He died of other
causes. A diagnosis of PCa before he died (even twenty years before he
died) could not have been of benefit, and certainly would have caused him
and his family much anguish. I have also performed autopsies on men with
extensive metastatic PCa that cut them down much, much too early in life. I
am sure these folks would have benefitted from very early detection.
Hindsight is 20/20. At present I can't find the correct presciption to
correct my blurry picture of the screening controversy. Of one thing I am
certain: As we learn more about diagnosis, staging, treatment, and
espcially the natural history of the progression of PCa, we will definitely
arrive at a time (if we have not already) when screening is beneficial.
Advances are rapidly being made. I do not envy the men who were screened
last month and must now make a treatment decisions; they are truly in a
crap-shoot and all the smart docs can do is suggest as to where they place
their bets and how best to play their hand. This is a game where I'd rather
be lucky than smart.
We can do more than hope for better knowledge. We can insist that more of
our tax-monies be spent on prostate cancer research. We can reach into our
own pockets to support the National Prostate Cancer Coalition and its
constituent member organizations. We can talk with other men in our
communities about this most common deadly cancer of men. And perhaps most
importantly, we can keep in perspective that from the day of our birth, we
all have a death sentence which is delayed by four score years give or
take. What a waste not to enjoy what precious gift of the time we are
allowed. The courage of the men with advanced disease recently expressed in
this forum is proof-positive that life's trials truly can bring out what is
most magnificent in us.
JR Oppenheimer, M.D.