don's report archive

by Donald B. Ardell, Ph. D.

Wellness in the Headlines
(Don's Report to the World)

A recent Wall Street Journal (WSJ) article ("Prostate Test Often Misses Cancer," July 24, 2003) described the latest study indicating that medical testing can be hazardous to your health. This is not to say that tests are always hazardous. Medical testing can and usually does more good than harm. In fact, medical tests are of unquestioned benefit, but such tests are not infallible and oftentimes are unnecessary at best and harmful at worst. Testing is also expensive for individual patients and for society. A significant amount of the $1.3 trillion spent on "health care" is, in fact, occasioned by "cover your butt" testing by doctors concerned more with protecting themselves against malpractice than you against disease. The key is to know the limits, merits and costs of the tests you are contemplating and the steps you can take to reduce the risks of procedures unlikely to be of benefit. The first step is to refuse to submit to tests that are not clearly warranted.

The WSJ story, based on a study described in the latest issue of New England Journal of Medicine (NEJM), indicates that some blood tests used to screen for prostate cancer are inaccurate. The procedures do not spot cancer in eight of ten cases. Rather than calling for less testing, the study authors advise MORE tests, with a lower risk threshold. In other words, change the protocol so more people will be given a diagnosis of cancer! Sounds like a possible "cover your butt" strategy to me.

The effect of a "lower threshold" for what doctors would consider a "problem" (the high likelihood of cancer), will lead to more medically invasive procedures. The latter will take the form of more -- and scarier -- tests. The second tier of prostate screening entails surgical removal of prostate slices. Ouch! While anyone who goes through this would surely be delighted and hugely relieved to discover that he did NOT have cancer, someone might also be a bit perturbed a bit later when he considers that maybe he did not need the procedure in the first place! This assumes, of course, that he lived through it! (Besides the pain and expense, infection -- not death, is the likeliest adverse consequence. Of course, surgery and radiation can also cause incontinence and impotence.)

According to the latest research, only 30 percent of biopsies detect prostate cancer. When the NEJM published the study calling for a lower threshold (more testing), it also ran a dissenting editorial by other researchers opposed to such action. The reason? At least as many investigators are convinced that a lower PSA threshold will invite more biopsies and higher rates of over-diagnosis and over-treatment.

How extensive is this kind of testing? The WSJ piece suggests, "About three-quarters of the men over 50 in the U.S. have been screened by the test, known as the prostate-specific antigen test, or PSA." Think of the costs associated with such extensive testing. Under the new guidelines of a lower risk threshold, a lot more men will face a decision to undergo or skip the dreaded biopsy. No wonder there is controversy around the issue of whether such testing is justified. Quite a few experts do not think the evidence indicates that early detection improves patient outcomes. However, the American Cancer Society (ACS), which has a vested interest in promoting cancer anxieties and attendant testing for fund-raising and related purposes, is big on testing. Under existing protocols, the ACS expects 220,900 men will be diagnosed at risk annually -- and nearly 29,000 will die from prostate cancer! These figures justify their calls for annual PSA tests and digital exams for all men 50 and over. Many doctors think this advice is not helpful or sensible. The ACS does not usually disseminate information to the effect that men can live for years with prostate cancer before medical treatment is essential, or that the only "benefit" of early detection might be living longer with the stress of knowing you have the disease or undergoing unnecessary or overly extensive treatment for it.

The bottom line seems to be this: There is no clear answer one way or the other, in particular cases, to test or not. Some males will benefit, some won't from this and other forms of medical testing. However, to an extent, all testing is a crapshoot, and some tests offer better odds than others. Or, worse odds, depending upon how you choose to look at it. My advice? Know how the game is played -- learn as much as you can about the odds in YOUR situation, and proceed cautiously, whether you decide to go to one level or the next. Where medical testing is concerned, we should all be Missourians -- make them show us that it's really necessary.

If you want more information on the pros and cons of prostate cancer screening, check out the decision guide provided by the Centers for Disease Control and Prevention. The experts who wrote this guide state the ultimate reality, the basis for a wellness lifestyle of personal responsibility (not delegation as in "doctor of ACS or other expert knows best) when they remind us all that ultimately, "the decision is yours." Please also check out our Prostate Health Center where you can learn the latest thinking about what you can do to prevent prostate cancer through diet and exercise.

The decision is yours, too, to decide to look on the bright side of life, to be as well as possible as long as you can and when all else fails, give a whistle. Best wishes.

(Note: This essay will be filed in the archives in the MENTAL DOMAIN under the skill area of effective decisions. Additional articles related to this theme may be found there.)

(Ed. Note: Views expressed in this and other columns are those of the author and not necessarily those of the SeekWellness Editorial Board.)

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