Prostate Cancer – Multiple Choice Disease with No Right or Wrong Answers

Want to elect there is but me,
‘Tis Hobson’s choice take that or none.

Hobson’s Choice

December 1, 2011 - As I was reading the November 24 issue of the New England Journal of Medicine containing these articles – “Prostate-Cancer Screening – What the U.S. Preventive Services Left Out,” One Man at a Time – Revolving the PSA Controversy,” “Stratifying Risk – The U.S, Preventive Services Task Force and Prostate-Cancer Screening,” and “Screening for Prostate Screening” - I was thinking of PSA screening for prostate cancer as a multiple choice question.

As a patient you live uneasily with a borderline PSA – even knowing full well prostate cancer is a slow growing disease, and you may die with something else. Or you may panic – knowing this could be the start of something big, bad, and ugly. Or you can’t live with the thought of harboring a malignancy- so you want it cut.

So you begin to investigate the myriad of noninvasive techniques for ablating prostate cancer - hormones, seeds, cryotherapy, cyberknives, plain old radiation, or that new wunderkind IMRT (Intensity-Modulated Radiation Therapy).

You fantasize about life without sex. You try to decide whether a needle biopsy with its possible complications - infection, impotence, incontinence - is worth the risk.

Or you go back to your primary care doctor, who most likely will advise watchful waiting. If you choose biopsy, he may refer you to a urologist fora biopsy, If positive, he may put you on hormones to knock back the testosterone, or send you to a radiation oncologist, who may implant radioactive seeds or start various forms of external radiation, or you may end up in the hands of a surgeon, who believes he can take it out without causing impotence or incontinence.

Or, if you’re a doctor like me, you may read the NEJM articles in search of rational answers.

• The first article, “Prostate-Cancer Screening – What the U.S. Preventive Services Task Force Left Out, “ points out that the Task Force recommendation against routine PSA-screening is a good thing, but it doesn’t end the confusion.

• The second, “One Man at a Time – Resolving the PSA Controversy,” says “we must ensure there is no more routine, indiscriminate screening- and no washing our hands of responsibility we must help put the controversy to rest ...one patient at a time.”

• The third, “Stratifying Risk- - The U.S. Preventive Services Task Force and Prostate-Cancer Risk,” says doctors should take risk factors – e.g. cancer in blood relatives, race, and so forth, into account, before dismissing the value of the PSA, so “screening should be made on an individual basis by an informed patient and his clinician, after weighing the patient’s individual risk factors.”

• The fourth, “Screening for Prostate Cancer,” a case study, stresses shared-decision making between patient and doctor based on values and risks of potential consequences with an eye on criteria for biopsy referral – age, family history, findings on rectal, PSA characteristics, and co-existing conditions.

In other words, deciding whether to screen for prostate cancer, biopsy and what to do with a positive biopsy, is still a multiple choice question.

Tweet: PSA Screening is controversial – to screen routinely, not at all, or just with positive risk factors – is the multiple choice question.