News, news everywhere

You will have heard by now that Stephen Fry has prostate cancer. This was announced by a Twitter video; try this link. (Thanks, Jane, for alerting me to this.) Apparently he had a radical prostatectomy – a robotic one, not an open like mine – in January. (Radical, as you aficionados know, is where the pelvic lymph nodes and various other bits such as the seminal vesicles are removed as well as the prostate.) He also has a Gleason score of 9. His cancer was first diagnosed from his PSA test. Along with millions around the world, I wish him well in his recovery. I especially wish him well for lending his public profile to prostate cancer.

Stephen Fry’s revealing his diagnosis is timely because of the publication of an article in The Age critical of prostate cancer screening programs based on PSA testing. The author, Paul Glasziou, is the professor of evidence-based medicine at Bond University and a GP. He declared that he had never had and would never have a PSA test. You can read his reasoning, and the comments that have been made about his article, at The Age.

As one of the commenters pointed out, Professor Glasziou is viewing the issue at a population level. Seen from this perspective, there is no doubt that surgery  based on PSA tests has been carried out when it has been unnecessary. Governments therefore have reason not to fund screening of the at-risk male population based on this test. Because Professor Glasziou is viewing it on a population level, it is therefore irrelevant to respond with anecdotes about individual cases of prostate cancer which were detected by a PSA test. He is talking about populations, not individuals. (However, he did extrapolate from his population-based findings to decide a course of action for himself.)

To quote one of the pieces of evidence from his article: PSA testing might only allow two men out of every 1,000 tested to avoid metastatic prostate cancer before the age of 85. Looks like a bad bargain for governments to fund! However, you’d feel differently about it if you were one of those two guys. This is really the dilemma for men. Do I have the PSA test and have an unnecessary operation which leaves me incontinent and impotent? Or do I run the risk of getting killed by a cancer that could have been stopped if it had been operated on when diagnosed?

The PSA test does open up a Pandora’s box, leaving men in the impossible position of having to decide on a course of action for reasons that they, not being physicians, don’t fully understand. It is a good illustration of Sartre’s existential angst: being forced to make a choice in the absence of any guidelines as to how to choose. The Mayo Clinic has what seems like an even-handed treatment of the issue in a document aimed at men considering having a PSA test. (This document has a date of October, 2015, so has been fairly recently updated.) Their conclusion: “talk to your doctor”. I would add two extra recommendations:

  1. read as much information as you can from reliable sources, and
  2. go to a survivors’ group and talk to those who have been through what you are thinking about.

For myself, I don’t regret having my PSA test done. My thoughts on this are contained in a letter I wrote to The Age, which they didn’t publish (although they did publish another pro-PSA letter). Bear in mind I only had 200 words in which to summarise the issues! My letter is pasted in below.

I would like to comment on Paul Glasziou’s article about PSA testing. My comment is based on experience. I have a Gleason 9, early stage 4 prostate cancer. I had no symptoms, so this cancer would not have been detected if I had not had a PSA test. After the test, a biopsy and several scans were used to identify the aggressive nature of this cancer and its extent. So while the PSA raised the red flag, my decision to operate on my cancer was based on these biopsy and scan results.

Men need to realise that prostate cancers are not all the same. Some are much more aggressive than others. Highly aggressive cancers like mine need different treatment than benign ones do. The age at which the cancer is diagnosed also affects the treatment required. Because I am in my early sixties, the cancer had more time to grow than if I had been diagnosed in my seventies. Left untreated, it would have killed me.

Having a PSA test led to early diagnosis of my cancer. So men need to think carefully before deciding not to have this test. You cannot act if you don’t have information.

One thought on “News, news everywhere

  1. Hi Joseph

    thanks for this. I’m responding here in case others are thinking the same thing. I did start paragraph three saying “As one of the commenters pointed out …”. I meant this to apply to the next few sentences as well. This obviously wasn’t clear. So where I said “Because Professor Glasziou is viewing it on a population level, it is therefore irrelevant to respond with anecdotes about individual cases of prostate cancer …”, I should have said “Because Professor Glasziou is viewing it on a population level, *as one of the commenters observed*, it is therefore irrelevant to respond with anecdotes about individual cases of prostate cancer…”. (I have to use asterisks as I can’t bold text in a reply.) But I don’t mean to be Jesuitical about it. It wasn’t clear. So why am I dragging in my (obviously individual) experience into an argument about population?

    My response to Prof Glasziou wasn’t on the basis of “I’m right, therefore he is wrong”, or “He’s right, therefore I am wrong”. I would be wrong if I said he was wrong – which I didn’t. His approach to the issue is orthogonal to mine. (I’ve been waiting a long time to use that word!) He is coming at it from one angle, I am coming at it from another. He is talking about populations, I am talking about me. He didn’t cite any papers, so I can’t comment on the evidence on which he is basing his conclusions. Nevertheless, let’s grant he is correct that, *in a population*, more prostates have been removed unnecessarily, than have been removed resulting in lives saved. A lot of smart people are saying this, who can’t all be wrong.

    I wasn’t actually arguing this point. What I did say was “PSA testing might only allow two men out of every 1,000 tested to avoid metastatic prostate cancer before the age of 85 [ … ] However, you’d feel differently about it if you were one of those two guys”. Again, he is talking populations, I am talking individuals. We are both right.

    I did observe that Prof Glasziou segued from the population-based argument to a personal one, i.e. from saying “PSA testing is unreliable in a population” to “I have never had my PSA tested and I’m never will”. Well, if he can address the personal dimension, so can I! I acknowledge he carefully didn’t give any yes-no advice about whether men should have their PSA tested or not. (I didn’t either.) Nevertheless, I didn’t want his article to go without a response. There are always reasons for inaction, especially when the finding out the answer involves a digital rectal exam, and possibly the big C. So a man might think, “Oh well, Paul Glasziou said he’d never have his PSA tested, so I’m not going to have mine tested”. I was trying to say, talk to your GP, read up about it – preferably from reputable sources such as I have listed in my blog 😉 . Then decide.

    Thanks for the suggestion re writing to Stephen Fry. It’s actually not easy to do this – he keeps his email address closely guarded. One could comment on his Twitter or Facebook page (along with hundreds of thousands of others). Of course, he’d want to respond to my comments – they are so fabulously insightful! Hope springs! Lotsa.

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