We discuss his general feelings about what he considers overscreening in medicine. I have my speech prepared:
“It would seem to me, Dr. Bach,” I say, “that part of my medical knowledge about myself should include whether or not I have cancer.”
“I understand that,” he says. “I really do. But screening in general is a very, very inefficient enterprise. You have to understand the math. I don’t even have to talk about prostate cancer. Take breast cancer. You have to screen about 1,000 women between [the ages of] 40 and 50 for 10 years to prevent one breast cancer death. That’s a very, very inefficient thing to do.
“Now, for prostate cancer, if you look at the trials—and this was with people with worse prostate cancer than you had—the difference in prostate mortality between those who were screened and those who weren’t was about 4 percent. Everything in health care is about probability.” (You also have to understand that “everything in health care” is about different interpretations of studies, which is the case here.)
“I understand that,” I say. “But isn’t there a difference between overtesting and overtreatment? Whether or not I get treated might be a difficult decision. But whether or not I have cancer seems to be something an individual should know.”
“Why?” asks Dr. Bach.
That stops me for a moment. “Well, for the same reason you want to know if you have a cold,” I answer. (I’m a really skilled debater.)
“Well, I don’t necessarily want useless knowledge,” Dr. Bach says. “Do you want to know what software your broker is using to manage your stocks?”
“I’d have to say that’s not the same thing,” I answer.
He thinks about that. “I guess I agree it’s not the same thing. But what you’d want to know about your broker is things that affect your planning, your financial future. You don’t need to know everything.”
Dr. Bach says that some screening interventions are worthwhile. “We found out that if you take a tongue depressor and scrape off cells from a woman’s cervix, it is a very accurate screen for cervical cancer. Cervical cancer death rates have dropped, like, 90 percent. We all but got rid of it. It’s fantastic. But other screening tests just don’t work as well.”
Dr. Bach does say that family history matters. Yet though his own father—Fritz Bach, MD, a celebrated physician and researcher who helped develop techniques that enable people to better survive organ and bone marrow transplants—had prostate cancer, Peter does not agonize about getting a PSA test. “My father had radiation and recovered just fine from prostate cancer,” he says. “He died of a heart attack. It [the PSA test] is just something I don’t worry about too much. Once every 10 years I get my cholesterol checked. I get my blood pressure checked every once in a while. And maybe I could stand to lose a few pounds. But I don’t need a doctor to tell me that.”
His position is that medical science errs by vast commission and almost never by omission. And he’s sticking with that opinion. But he doesn’t want me to feel depressed about having had surgery.
“Look, that idea of getting something early, stopping it in its tracks, being aggressive,” says Dr. Bach, “is very potent logic. The problem is, it’s not biology.
“But I’ll give you this much: Think of it as a seat belt analogy. I assume you wear a seat belt, and I have been wearing one ever since I started driving even though I haven’t had an accident in 20 years. So apparently I’m over–seat belting. But of course I’m not.”
“So what I did when I had surgery,” I tell Dr. Bach, “is the urological equivalent of over–seat belting.”
“A good way to put it,” he says.
Keith Van Arsdalen, MD
My Friend and Urologist
“You were too young and too healthy for active surveillance.”
During the two years that Keith and I intersected as fraternity brothers at Muhlenberg College four decades ago, the subject of urology, needless to say, never came up. Neither did most serious subjects unless you consider the fate of our intramural football team, which was in fact quite serious. Everyone knew that Keith would become a doctor, and a good one, but there was not much chatter about specialties.
“I didn’t know myself what field I wanted to get into,” says Keith. “I had a couple of rotations [at the Medical College of Virginia] that I didn’t like, but when I got to urology I was with a bunch of guys who were really fun. We really hit it off. At first, it had as much to do with that as anything. But as I got further in to it, the field turned out to be fascinating. There were so many aspects to it.”
Keith came to Penn to do research on the relationship between spinal cord injury and voiding dysfunction. Gradually, he branched out into the general area of urodynamics and then he became an expert in stones. (We were interested in Stones in college, although they were the Rolling variety.) Through it all, though, Keith was never far from prostate cancer.
And he says that what he sees these days compared to what he saw 30 years ago has convinced him that PSA screening is a good thing.
“We used to have our own ward here, maybe 35 beds, and at least half of them, sometimes the entire ward, consisted of older men with metastatic prostate cancer,” says Keith. “They were going to die. They were here with these huge prostate cancers that kept them from urinating, with bone pain, with all sorts of problems.
“But when someone comes in these days and presents with those symptoms, we say, ‘Oh, my God.’ Because we just don’t see them anymore. So when people say we shouldn’t do any screening, I say that while statistics might show we haven’t altered life expectancy dramatically, we also don’t have a ward full of people with metastatic disease.
“Why? Because the cancer is being found earlier. And there is no other conclusion I can reach except that it’s the PSA test that made that difference. So for me it’s still worthwhile doing the screening. The mortality might not be different. But the morbidity certainly is.”
Having said that, Keith does concede that he looked at me differently in 2011 than he would’ve in 1981 or even 2001. Although he crossed active surveillance off my list of reasonable options back in September 2011, he says he is comfortable with it in certain circumstances.
“I had a patient in here this week,” says Keith. “He’s 69. He’s got 1 core with 20 percent cancer out of 14 cores. He’s a Gleason 6. Negative bone scan. PSA of 4.2 and a list of medical problems a foot long.
“If it were me, I would choose active surveillance in that case. At the very least—or I should say at the most—I would choose radiation. Why should he have a radical procedure with all the attendant risk—even just the anesthesia—for a cancer that probably won’t kill him and he has so many other problems?
“But no matter what I say, he wants a radical prostatectomy. He wants the robot. It’s his choice and I can’t talk him out of it. What a doctor must do is present the options in the most realistic way possible. But it’s up to the patient to decide.”
So, I ask him, why didn’t he favor active surveillance for me?
He thinks about that for a moment and answers this way:
“A doctor must develop a sense of how he’s going to counsel patients. I can’t counsel you differently because I know you. So you develop parameters that fit most people.
“None of this is simple, so I’m not going to say it’s simple. But I thought you were too young to do active surveillance. I felt that sooner or later you would have to be treated for prostate cancer.
“Can I say that with certainty? No. At this point, there is no other test we can do that looks at the characteristics of the cancer and says definitively that this will be the type that will kick into gear and metastasize. I wish we could determine that.”
I tell him the anecdote of one doctor waving my report in the air and scoffing about the low level of cancer. (See Aaron Katz, MD.) Keith responds, “Let’s say you were 55. It would not be unreasonable to say, ‘Okay, I’m going to take five years of watching, buy those five ye
ars when I don’t have potency or incontinence issues, and maybe get treated when I’m 60.’ To that, I would probably say fine.
“At the same time I don’t think it’s an unreasonable assumption that the cancer is going to grow. It wasn’t 2 percent de novo. [You gotta love a urologist with a Latin background.] It started at half a percent, then 1 percent, then 2, then 3. Maybe it started when you were 40 and it took 20 years to get there. Now, in another 20 years maybe it wouldn’t have grown. But maybe it would have.
“So given that uncertainty, I felt comfortable advising intervention. And it would’ve been the same for any patient with your parameters.”
John Christodouleas, MD
Radiation Oncologist, Penn Medicine
“We need to change the culture surrounding the PSA.”
Had I chosen radiation, I would’ve chosen Dr. C., whose name I have shortened throughout this book to both save me the extra characters and reduce the chances of errant typing. Radiation oncologists sometimes remain outside the tight circle of prostate treatment decisions since they generally are not urologists, the first doctors whom prostate patients see. At Penn, though, Dr. C. seems to be part of the team, and he keeps up with every development in prostate cancer treatment.
He is not a prostate agnostic, as Dr. Blaivas is, but neither is he a standard-bearer for PSA screening. And he is certainly more willing than many to embrace active surveillance.
“The data is getting stronger and stronger that you probably don’t need to do anything for a very large percentage of patients,” says Dr. C. “Look, I was trained in the Hopkins tradition and influenced by Bal Carter. They have the age of 65 as the line. That is very conservative, and there is more and more data to suggest that any man with low-risk prostate cancer is very unlikely to develop problems. So I would say over the last 10 years I’ve gotten more and more comfortable with active surveillance.”
“You mean for patients like myself?” I ask.
“Yes, like you,” says Dr. C., who, if you’ll recall, had my records and did examine me.
“Do you agree with the USPSTF recommendations against the PSA test?” I ask him.
“I wouldn’t say I agree with them,” says Dr. C., “but I would say that the rationale they used—to try to limit overtreatment—is correct. Yes, we’ve identified the problem, which is: Lots of people die of prostate cancer. But is the solution lots of PSA screening? That’s a more difficult question.
“If I told you that getting PSA screening increases your chance of living six months longer by 3 percent, is it worth screening every man in this country? I’m not saying I know the answer to that question. I’m just saying that it’s very reasonable to ask.
“Now, throwing away PSA screening entirely is throwing the baby out with the bathwater. But if we were able to develop a culture of not overinterpreting the PSA, then maybe we could have our cake and eat it, too. People have skin cancers all the time, and they don’t start rewriting their wills. The doctor says, ‘Ah, it’s a little skin cancer.’ That happens all the time.
“But that view of being able to preserve the PSA but change the culture around it? Many people think that’s naïve. You can’t have something that a lot of men die of and try to explain that 97 percent, maybe higher, don’t die of it. It’s hard for patients not to get scared, particularly when you have a health care system that is driven by action.”
Aaron Katz, MD
Chairman of Urology, Winthrop-University Hospital
“You take away biopsies . . . you’ll go back to the day when the main thing urologists are doing is treating clap.”
We are at a Japanese restaurant in Garden City, Long Island, across the street from Winthrop-University Hospital, and Dr. Katz will have the sushi, as he does three times a week.
Dr. Katz is not a completely unconventional urologist. He opposes the USPSTF recommendations about PSAs and typically orders screening for his patients because he considers it a helpful diagnostic tool. He does operate for prostate cancer, with his intervention specialty being cryotherapy (see Chapter 12).
But he also has an alternative medicine bent, which he prefers to label “integrative medicine.” Before he came to Winthrop, he was the director of the Center for Holistic Urology at Columbia University Medical Center. The general philosophy there involved combining diet, herbal medicines, lifestyle changes, and stress management with more conventional treatments to figure out what was best for the patient. That specialty began when he studied with Robert Atkins, MD—yes, that Dr. Atkins. To be clear, Dr. Katz tells me he is not an advocate of the Atkins praise-the-protein-and-pass-the-pork-chop diet. But he does advocate, as did Dr. Atkins, the concept of integrating other factors into traditional treatment.
“There is no section of the AUA [American Urological Association] just on integrative medicine,” says Dr. Katz. “There is a board of doctors interested in alternative medicine, and I have started my own Society of Integrative Urology, the SIU. I’m hoping to gain greater acceptance by the AUA and urologists.”
Dr. Katz’s most celebrated patient is media personality Don Imus, who has elected to deal with his prostate cancer with diet, herbal medicine, and supplements. Dr. Katz has appeared on Imus’s morning simulcast show (full disclosure: so have I, though to talk about basketball, not the prostate) to discuss alternative prostate cancer treatments.
“When I go and talk around the country,” says Dr. Katz, “I can’t believe the number who want more information about this. When we did a survey, [we found that more than] 70 percent of urologists would use more of these treatments if they knew more. There has to be an education process surrounding this.”
The direction of our conversation leads me to believe that, were he my urologist, he would not have advised intervention, whether surgical or radiological (though he may have suggested cryo).
“Okay, you had a PSA under 10, right?” he says.
“Well under 10,” I say.
“You do not have a family history of prostate cancer?”
“Colon cancer.”
“Doesn’t matter. You’re not African American, obviously.”
“Obviously,” I say.
“You had a slow-rising PSA and a biopsy that showed a Gleason 6. What did your MRI show?”
“That the cancer was contained in the gland,” I answer.
He looks at me and spreads his hands. He has made his opinion clear. I told him that I was leaning in that direction when I got the word from Dr. Carter at Hopkins that I would be too young for his study.
“Well, that doesn’t mean that active surveillance is wrong for a guy who’s 62 years old or even 45 years old,” answers Dr. Katz. “It just means that Bal Carter decided to cut it off there because he doesn’t want to start saying, ‘At Hopkins, we don’t do anything at age 50.’ It’s a little more tolerable, a little more acceptable, not to do anything at age 65.”
Then I show Dr. Katz my postsurgical pathology report. He studies it for a moment and cups both his hands around his mouth as if to shout to the entire restaurant.
“Oh, my God! Gland involvement, 2 percent. Let’s operate on this guy. He has cancer! Get him into surgery right away!”
It’s a light moment. I laugh. He laughs.
“The actual pathology said ‘between 2 and 10 percent,’ ” I say. “But I guess you believe I made the wrong decision.”
“I never go back in time,” says Dr. Katz. “I only go forward with my patients. You thought about what you were getting done and, fortunately, it sounds like you hit the trifecta. Your PSA is zero, right? You are continent, right? And you are potent enough for intercourse without Viagra or Cialis, right?”
“Well, all of those except maybe, kind of, sort of, the last one,” I say. “But I’m working on it.”
“Okay. You made the decision that you considered right for you, so therefore it’s right for you. You saw the right surgeon. You’re moving on. You’re writing a book, which is in some ways cathartic.
&nbs
p; “I hope I’m not coming across as negative. There’s a lot of good doctors out there. Great urologists, great surgeons. And some men have aggressive prostate cancer. Men need to be treated. Men die of the disease, men with Gleasons of 8 and 9, high PSAs, MRIs showing cancer outside the prostate.
“But for the majority of men whose PSAs went from 3 to 4, small area of cancer, Gleason 6? Those men should be strongly offered—I don’t care what age—the idea of watching and waiting. Because why take a 45-year-old guy and subject him to surgery when even in the best of hands that guy could lose his erections forever? Yeah, you may have ‘cured’ him, so to speak. But he may never have normal sexual relations again and will never experience ejaculation.”
One of Dr. Katz’s ideas is to change the Gleason system, perhaps to not even allow Gleason 6s to appear on the scale and to give a new name to cancers such as mine.
“Right away guys in your position think of the friend who died of pancreatic cancer,” says Dr. Katz. “Or my son who had an aggressive leukemia and whose life was on the line.” (His son has recovered.)
So what should we call it?
“Call it ‘atypical’ or ‘preneoplastic,’ ” Dr. Katz suggests. “Anything but ‘cancer.’ Because in one sense you don’t really have prostate cancer. You have some abnormal cells in your prostate, and the risk of it getting out of the prostate is extremely low.”
Dr. Katz’s final target is Dr. Catalona, whom he refers to, pejoratively, as “Mr. PSA.”
“If you talk to Bill Catalona, he’ll say everybody needs a PSA, everybody needs a biopsy, everybody needs a prostatectomy,” says Dr. Katz. “And you know what? The AUA loves this guy. All he wants to do is biopsy and operate, biopsy and operate. So the AUA makes money. It’s business. Cancer is big business. You take away biopsies, you take away a lot of prostate cancer, and—whoa!—next thing you know you’ll go back to the day when the main thing urologists are doing is treating clap.”
The Prostate Monologues Page 12