"Decisions, decisions, decisions!" This often is spoken in a mixture of ennui and smug irony for decisions such as "should I buy the Audi, the BMW or the Lexus?" But this piece is nothing like that, it is about the general confusion and questionable value of our medical establishment.
The three "decisions" are apt because the diagnosis and treatment of three major illnesses have been called into question in the past year and this is disconcerting if not alarming. If you are unfamiliar with the work of Dr. John Ioannidis I recommend you find him on the web. His view of the state of medical research is summarized as "Lies, damned lies and medical research."
The original quote actually was by the British prime minister, Gladstone: "There are three kinds of lies, lies, damned lies and statistics."
The recent study out of Canada declaring the value of mammograms in women under fifty without value is noted. One doctor at Sloane Kettering has already balked and we have yet to hear from the Susan Komen foundation. The other disqualifying report identified antidepressant medication as simply placebo with no valid clinical evidence to the contrary. As a clinician my experience does not support that position, but there are facts that are hidden from us. For example, the FDA requires two "positive" studies to approve a medication for the treatment of a condition. That there may be six negative studies is not required to be revealed to us, and, as Ioannidis points out, many of the "successful" studies measure the new product against drugs that are known to be less than effective, if effective at all.
But it is prostate cancer I want to focus on. To PSA or not to PSA, that is the question. (Excuse me Prince Hamlet.) I have learned a great deal about this question from a man whom I have known for many years and who has had prostate cancer diagnosed. There was a series of articles in the popular press questioning the need for and value of the PSA test around the time his PSA began to increase incrementally. "You will more likely die with the prostate cancer than from the prostate cancer." This is very reassuring, unless you have witnessed a patient or a relative die the excruciatingly painful death of metatstatic prostate cancer.
The concerns expressed, in our behalf, is that the PSA can lead to biopsies which can be painful and prone to serious complications. While I am not a urologist, I can say I have seen one man who complained of persistent pain following a biopsy. That is all. What most of the articles failed to make reference to is something called the Gleason Score, an assessment of the aggressiveness of the tumor's malignant cells. The numbers of the score range from low to high but what you need to know is that a score of Seven is at the dividing line of could be serious and is serious. Eight and up are without question serious. Without that information one cannot make sensible judgements about how to proceed and one can only have that with the prostate biopsy. You can see the circularity of this process. With that information in hand one is then given a menu of treatment choices to consider. Watch and wait, radiation, surgery - robotic and standard supra-pubic surgical removal of the prostate gland, proton beam treatment, cyberknife, aggressive sonic ablation - more than most doctors, let alone lay people, can assess when in a state of some anxiety. Every treatment brings its own list of complications and ill consequences. "5%" risk of whichever one sounds reassuring but, if it is you who experiences that ill consequence it is 100%.
And what is most important is, as my friend learned, there is no evidence that any treatment is superior to any one of the other treatments and there may never be a study to pit one against the other to determine which is best. He chose surgery and has done well now for a few years. His PSA is zero and hopes it will remain that way. So, we ponder these three conditions, each afflicting roughly 10% of the general population, and we are asked to act or not act on the basis of flawed and insufficient information. What else are we missing?
Makes you think, doesn't it?
