My dad died this year of multiple myeloma at age 86. For three and a half years at the end of his life, he received good treatment for this difficult disease. During the late 1990s, however, he received aggressive surgery and radiation therapy when a routine PSA test came back positive. The treatments left him impotent and incontinent for the rest of his life. He never expressed doubts about the treatment, but I can tell you I had doubts.
Here are a few thoughts I wrote down after I read an article on this subject in the Los Angeles Times.
At first I thought, this article confirms my views about PSA tests. As I read further, the information made me think more of my dad. It reports one million prostatectomies since PSA screening came into wide use! The disturbing thing about my dad is that I don’t think his doctors did further tests or analysis to determine if his test result was a false positive – or, if there was cancer, to determine how aggressive it might be. From what he told me, they just fed him into the prostatectomy and cancer treatment machine because that’s the protocol. One million! Seven out of eight test results turn out to be false positives. He spent almost fifteen years with the consequences of that treatment, and almost died from the surgery. And he was a healthy man before he walked into the doctor’s office.
It never made sense to speak against the treatment after he had it, but I wish he had sought more advice before he had surgery. Problem was, his test occurred near the beginning of the PSA screening boom. Doctors pushed the test and treatment as the latest advance to prevent what had been a scourge for older men. We didn’t have data then about how much harm the test and treatment would do in the next decade and a half.
The article also mentions the strong opposition we observed when the U. S. Preventive Services Task Force recommended that doctors stop using the PSA blood test to screen healthy men for prostate cancer. When you have a huge outcry over a recommendation not to have the test, you know something other than individual care is going on. If these decisions are just between you and your doctor, why the hell would anyone care, in public, about recommendations a professional board makes to doctors? They care because the test and treatment regime involves more than confidential decisions between individual patients and their doctors.
I don’t want to say that profits for all the people who gain from delivering so much treatment are the only key factor here. We can also see a desire to save face – that is, not admit to mistakes in the face of evidence that demonstrates you were wrong. Plus, people have a sincere desire to save lives, so if you’re a true believer in the efficacy of the tests and treatments, you don’t want to see people suffer and die because some professional board makes a recommendation you regard as fishy. The whole controversy does demonstrate, though, that decisions about cancer screening and treatment are not confined to private conversations between a doctors and their patients.
The private conversations occur at the end of life, when the doctor wants to end treatment. At the beginning of the road, starting with the first screening test, so many actions become automatic. I’ll say this much: nothing my dad told me at the time indicated that he made a decision to have surgery. He just followed his doctor’s advice, because doctors know best.