Prostate Politics

If you had cancer, wouldn’t want to know?

That’s the Siren’s call of cancer screening: don’t you want to know?

Last week, the US Preventive Services Task Force released its recommendations on screening for prostate cancer using the PSA test. After a review of the scientific literature, the Task Force found that there was no good reason for men to be routinely tested. This stance echoes that of the American Cancer Society, which made the same recommendation a year ago.

The American Urological Association objected strenuously. Urologists, of course, are the principal medical people responsible for screening for and treating prostate cancer. The chief medical officer for the American Cancer Society took a swipe by saying “If your income is dependent on you not understanding something, it is very easy not to understand something”—referring to urologists’ failure to acknowledge the validity of the Task Force’s evaluation and conclusions. Urologists were deeply offended: “We will not allow patients to die, which is what will happen if this recommendation is accepted.”

The Prostate Cancer Foundation—its motto is “Accelerating the world’s most promising research”—was less testy than the urologists, but it didn’t like the recommendations either. They want to wait for the urologists to set guidelines, they want to continue with using the PSA test, and they want more research into early detection.

The politics goes something like this…

The government agency—whose members don’t have any glaring conflict of interest in continuing PSA tests or not—claims there’s no good science to continue screening using PSA.

The professionals and patient organizations who have an interest in keeping the early detection bandwagon going want the screening to continue.

The American Cancer Society—friend to the cancer industry—seems an odd ball until you realize that their interest is in redirecting attention away from an increasingly suspect screening technology, use of which might increase patient misery and as a consequence cause doubts about the wisdom of early detection.

But here’s the problem. Neither a PSA test nor any other method of early detection actually discovers cancer. Even biopsies. What these methods discover is signs that cancer is present. And then activities referred to as treatments are undertaken intended to eliminate the cancer that is the alleged cause of the signs such as elevated PSA or a positive result from a pathology lab—in this case “positive” meaning “yes, it’s cancer.”

“Wait!” you say. “A biopsy is an examination of cells taken from a suspect prostate by a trained pathologist who, using his or her professional judgment, concludes that some or all of the cells are characteristic of cancer cells and therefore indicate that cancer is present in the man’s prostate.”

The problem is false positives: the PSA or the biopsy indicates cancer when there is, in fact, none. The consequence is the suspect prostate is poisoned with chemotherapy or blasted with radiation or, most commonly, surgically removed. The man often becomes impotent or incontinent or both—not to mention the psychological stress of having cancer and the physiological stress of being treated. When the early detection is a false positive, all that happens to remove something that wasn’t there in the first place.

And the earlier a biopsy is performed, the more likely it is that it will be a false positive.

So the deeper politics are that everyone in this particular drama is agreed that early detection is a good thing. What they disagree about is whether PSA tests help or hurt in that campaign.

This is for a condition that most agree is something a man is more likely to die with than to die of. Nevertheless, panic is the rule of the day. “Don’t you want to know?” is the rule of the day.

But what is it exactly that a man “knows” when the test comes back positive, whatever that test might be?

This is a still-greater depth of prostate politics. What a man knows when the test comes back positive is that a bunch of people he believes to be experts have said that something is wrong and action needs to be taken. He is in no position to critically examine the basis for those expert conclusions. The institutional force behind those people bears down upon him: why ask whether you’ve got prostate cancer if you’re not ready to act?

Yet it is perfectly rational to say, “No thanks” to the seductive call of “Don’t you want to know?” One important reason is that, properly supported, your immune system routinely takes care of cancerous cells that pop up. Another is that you will avoid a significant amount of stress and misery. And yet another is that, in the absence of overt symptoms, a good case can be made for leaving well enough alone.

At the deepest level of prostate politics is the misdirection caused by “Don’t you want to know?” and its companion “Don’t you want to do something about it?”

The agency is called the US Preventive Services Task Force. Preventive. Yet here they are passing judgment on the effectiveness of a test intended to get men into treatment. Shouldn’t it be attending to actual prevention? Why aren’t they featuring tests for men’s testosterone, which protects the prostate? Or why not feature tests for exposure to toxins that promote cancer? Or even better still, why not feature prostate protective foods?

The answer, of course, is that it doesn’t give medical institutions anything to do because these are all things you can do for yourself.