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What Would You Do, Doctor?
Editorials
What Would You Do, Doctor? WHEN presented with options and conflicting recommendations, patients frequently ask their doctor what he or she would do if faced with the same issue. Nowhere in urology is this more prevalent than in prostate cancer management and, increasingly, in decisions about the merits of prostate specific antigen (PSA) screening. What is a patient supposed to think when one learned body recommends that a PSA be obtained in all men at age 40 years and another strongly opposes PSA screening in anyone? The recommendation that a patient consider the pros and cons of screening and then make his own decision can be even more troubling. No wonder a man may simply ask the doctor to put himself in the same position and say “what would you do.” A fundamental problem with this scenario is that people make different decisions even when presented with the same information. Individual values, and tolerance of risk and reward partially govern virtually all decisions, and this surely applies to personal medical choices. What the doctor would do may not be relevant to what an individual patient may prefer. However, what is really being asked is for the physician to make an honest, empathetic recommendation, and to use his/her knowledge and experience to help unravel confusing data. This is a fair and understandable expectation but one not easily accomplished. Two recent studies published in the New England Journal of Medicine have focused increased attention on the issue of PSA screening.1,2 Reports in the lay press create the impression that doctors are learning for the first time that prostate cancer is over diagnosed and over treated but that knowledge preceded the advent of PSA testing. Multiple publications in The Journal of Urology® and elsewhere have addressed directly this very subject for decades, and have repeatedly urged the discovery of better prognostic parameters. There are multiple valid criticisms of the large, randomized studies now being reported and it seems that there is still a glass half full versus half empty perspective. Nonetheless, one striking observation from the studies is the small proportion of men who actually die of prostate 0022-5347/09/1822-0421/0 THE JOURNAL OF UROLOGY® Copyright © 2009 by AMERICAN UROLOGICAL ASSOCIATION
cancer in these trials with up to 10 years of observation. However, someone is dying of prostate cancer. In fact, about 35,000 men will die of carcinoma of the prostate in the United States this year. Whether improved screening and treatment have decreased the death rate is another subject of controversy but the substantial morbidity, mortality and societal expense of this disease are not debatable. Furthermore, virtually every urological surgeon can identify patients in his or her practice who clearly seem to be beneficiaries of screening. Consider, for example, a 53-year-old man with a Gleason 8 cancer detected because of an increased PSA but whose postoperative PSA has remained undetectable for many years. Surely this man is cured of a cancer which otherwise would likely have been fatal. The problem is that this patient is mixed in with many more who undergo treatment of a less threatening cancer with the potential for life altering quality of life compromises. Thus, we have the risk versus reward conundrum. Is it worth subjecting the majority of men to treatment to cure the minority of a cancer that would be life threatening? In the European Randomized Study of Screening for Prostate Cancer 48 was the calculated number needed to treat to cure 1 case of prostate cancer.2 Although this number may be appropriate when applied indiscriminately, clinicians likely do much better than this when selecting patients for treatment by considering known health and tumor related prognostic factors for individuals. Therefore, what ratio would be acceptable? For almost a quarter of the United States population the reward (or need) of smoking seems to outweigh the profound and proven health risks. The mental compartmentalization required for a man who presents for routine PSA screening with a pack of cigarettes in his shirt pocket is sometimes difficult to comprehend. Regardless, many people want to take advantage of prostate cancer screening and few would argue that PSA is effective in helping find cancers. The real governor of screening and treatment may best be applied once a diagnosis is made. A Vol. 182, 421-422, August 2009 Printed in U.S.A. DOI:10.1016/j.juro.2009.05.071
www.jurology.com
421
422
WHAT WOULD YOU DO, DOCTOR?
clear benefit of some of the recent attention to this subject is that more patients are willing to accept a strategy of active surveillance when appropriate. Undoubtedly, though, a diagnosis of prostate cancer can initiate a cascade of events, a so-called slippery slope, wherein treatment is performed “just to be sure.” Maybe even more important for urological surgeons than making wise recommendations about PSA screening is to help patients put a diagnosis of prostate cancer in proper perspective and not let an overdone concern about cancer lead to unnecessary treatment. With appropriate counseling and recommendation, the slope does not have to be so slippery. Most guidelines recommend, in one form or another, that the doctor discuss the pros and cons of prostate cancer screening with patients. The naivete and impracticality of this approach are that it would require virtually an entire weekend seminar for a man to be properly informed. The pressures of clin-
ical practice and patient volume do not remotely permit full discussion of pertinent issues. Nonetheless, recognition that one size does not fit all virtually mandates individualized use of prostate cancer screening. So, what would you do, doctor? It is always informative to see physician responses to confidential queries of how often they, themselves, have had a PSA drawn. Even among urologists, a surprising number do not undergo routine PSA testing. However, most remember the patients they have seen who had a scary appearing cancer cured because of screening as well as the ones who suffer and die from prostate cancer. Treatment or non-treatment decisions can be made once a cancer is found but not knowing about it in the first place surely burns bridges. Joseph A. Smith, Jr. Associate Editor
REFERENCES 1. Andriole GL, Crawford ED, Grubb RL 3rd et al: Mortality results from a randomized prostate-cancer screening trial. N Engl J Med 2009; 360: 1310. 2. Schröder FH, Hugosson J, Roobol MJ et al: Screening and prostate-cancer mortality in a randomized European study. N Engl J Med 2009; 360: 1320.
What Would You Do, Doctor? WHEN presented with options and conflicting recommendations, patients frequently ask their doctor what he or she would do if faced with the same issue. Nowhere in urology is this more prevalent than in prostate cancer management and, increasingly, in decisions about the merits of prostate specific antigen (PSA) screening. What is a patient supposed to think when one learned body recommends that a PSA be obtained in all men at age 40 years and another strongly opposes PSA screening in anyone? The recommendation that a patient consider the pros and cons of screening and then make his own decision can be even more troubling. No wonder a man may simply ask the doctor to put himself in the same position and say “what would you do.” A fundamental problem with this scenario is that people make different decisions even when presented with the same information. Individual values, and tolerance of risk and reward partially govern virtually all decisions, and this surely applies to personal medical choices. What the doctor would do may not be relevant to what an individual patient may prefer. However, what is really being asked is for the physician to make an honest, empathetic recommendation, and to use his/her knowledge and experience to help unravel confusing data. This is a fair and understandable expectation but one not easily accomplished. Two recent studies published in the New England Journal of Medicine have focused increased attention on the issue of PSA screening.1,2 Reports in the lay press create the impression that doctors are learning for the first time that prostate cancer is over diagnosed and over treated but that knowledge preceded the advent of PSA testing. Multiple publications in The Journal of Urology® and elsewhere have addressed directly this very subject for decades, and have repeatedly urged the discovery of better prognostic parameters. There are multiple valid criticisms of the large, randomized studies now being reported and it seems that there is still a glass half full versus half empty perspective. Nonetheless, one striking observation from the studies is the small proportion of men who actually die of prostate 0022-5347/09/1822-0421/0 THE JOURNAL OF UROLOGY® Copyright © 2009 by AMERICAN UROLOGICAL ASSOCIATION
cancer in these trials with up to 10 years of observation. However, someone is dying of prostate cancer. In fact, about 35,000 men will die of carcinoma of the prostate in the United States this year. Whether improved screening and treatment have decreased the death rate is another subject of controversy but the substantial morbidity, mortality and societal expense of this disease are not debatable. Furthermore, virtually every urological surgeon can identify patients in his or her practice who clearly seem to be beneficiaries of screening. Consider, for example, a 53-year-old man with a Gleason 8 cancer detected because of an increased PSA but whose postoperative PSA has remained undetectable for many years. Surely this man is cured of a cancer which otherwise would likely have been fatal. The problem is that this patient is mixed in with many more who undergo treatment of a less threatening cancer with the potential for life altering quality of life compromises. Thus, we have the risk versus reward conundrum. Is it worth subjecting the majority of men to treatment to cure the minority of a cancer that would be life threatening? In the European Randomized Study of Screening for Prostate Cancer 48 was the calculated number needed to treat to cure 1 case of prostate cancer.2 Although this number may be appropriate when applied indiscriminately, clinicians likely do much better than this when selecting patients for treatment by considering known health and tumor related prognostic factors for individuals. Therefore, what ratio would be acceptable? For almost a quarter of the United States population the reward (or need) of smoking seems to outweigh the profound and proven health risks. The mental compartmentalization required for a man who presents for routine PSA screening with a pack of cigarettes in his shirt pocket is sometimes difficult to comprehend. Regardless, many people want to take advantage of prostate cancer screening and few would argue that PSA is effective in helping find cancers. The real governor of screening and treatment may best be applied once a diagnosis is made. A Vol. 182, 421-422, August 2009 Printed in U.S.A. DOI:10.1016/j.juro.2009.05.071
www.jurology.com
421
422
WHAT WOULD YOU DO, DOCTOR?
clear benefit of some of the recent attention to this subject is that more patients are willing to accept a strategy of active surveillance when appropriate. Undoubtedly, though, a diagnosis of prostate cancer can initiate a cascade of events, a so-called slippery slope, wherein treatment is performed “just to be sure.” Maybe even more important for urological surgeons than making wise recommendations about PSA screening is to help patients put a diagnosis of prostate cancer in proper perspective and not let an overdone concern about cancer lead to unnecessary treatment. With appropriate counseling and recommendation, the slope does not have to be so slippery. Most guidelines recommend, in one form or another, that the doctor discuss the pros and cons of prostate cancer screening with patients. The naivete and impracticality of this approach are that it would require virtually an entire weekend seminar for a man to be properly informed. The pressures of clin-
ical practice and patient volume do not remotely permit full discussion of pertinent issues. Nonetheless, recognition that one size does not fit all virtually mandates individualized use of prostate cancer screening. So, what would you do, doctor? It is always informative to see physician responses to confidential queries of how often they, themselves, have had a PSA drawn. Even among urologists, a surprising number do not undergo routine PSA testing. However, most remember the patients they have seen who had a scary appearing cancer cured because of screening as well as the ones who suffer and die from prostate cancer. Treatment or non-treatment decisions can be made once a cancer is found but not knowing about it in the first place surely burns bridges. Joseph A. Smith, Jr. Associate Editor
REFERENCES 1. Andriole GL, Crawford ED, Grubb RL 3rd et al: Mortality results from a randomized prostate-cancer screening trial. N Engl J Med 2009; 360: 1310. 2. Schröder FH, Hugosson J, Roobol MJ et al: Screening and prostate-cancer mortality in a randomized European study. N Engl J Med 2009; 360: 1320.