Know Your Stats But Don't Be A Number

Jeannette M. Potts, MD

When I was in medical school, one of our professors emphasized the importance of treating patients rather than numbers. We were to look at the entire patient within the context of his entire body and his social context and not just his labs.

Years later, this lesson could not be more poignant, when the PSA (Prostate Specific Antigen) blood test was introduced as a screening test for prostate cancer. As I counseled so many about their PSA results and biopsied thousands more, “treat patients, not numbers!” echoed in my mind every single day. As early as 1996, every “simple” blood test I ordered, was a shared decision moment with my patients, and so was the choice to proceed with a biopsy. My primary purpose was to assuage fear, rather than to capitalize on it! Over the years I performed fewer prostate biopsies and also helped men become more comfortable with the option of active surveillance in lieu of surgery or radiation when prostate cancer was diagnosed.

I have not changed the way I practice, even after the 2012 statement made by the US Preventive Task Force, recommending no prostate cancer screening whatsoever. But then again, I did not abuse this privilege. My patients were never just a PSA or a Gleason score (This is a designation given by the pathologist who evaluates the patient’s prostate biopsy specimens under a microscope. It is a scale of aggressiveness.).

You see, the US Preventive Task Force reviewed numerous trials and concluded that prostate cancer screening had actually led to more harm than good. Their review revealed that men were:

1. Inappropriately screened‐ that is they were either too old or too unhealthy to ever benefit from screening much less treatment of prostate cancer.
2. Too aggressively biopsied‐ again, not being qualified to benefit from such a procedure which is associated with bleeding, infection, pain, stress and other side effects.
3. Being overdiagnosed with low grade, low volume disease, which, often did not require treatment.
4. Too aggressively treated. Even men who had low grade and low volume disease, who would have benefited equally from active surveillance, underwent surgery or radiation. Treatment of these men, in turn, caused higher rates of urinary leakage and erectile dysfunction afterwards. Many of these adverse effects could have been prevented if patients were appropriately counseled and properly reassured. (There is a study revealing that up to 40% of men with low grade, low volume disease were never even counseled about this option. And more recently, yet another large study proved that men who are not treated but actively observed, are living well even after 10 years.)

To me, all four of these errors could have been greatly mitigated through shared decision making. Unfortunately, research indicates that shared decision making requires TIME and is RARELY practiced in the real word of busy clinics.

So… do not let anyone treat you like a number… and do not let anyone SCARE you. In the setting of this particular malignancy, the most important role for your doctor is to assuage your fears (not foment them or capitalize on them) by educating you and individualizing your care.

I wish to conclude with this excerpt from the beautifully written letter which was published in the New England Journal Of Medicine:

“… we primary care clinicians must ensure there is no more routine, indiscriminate PSA screening — and no washing our hands of responsibility once the patient is referred to a specialist for prostatecancer treatment. We owe it to our patients to provide them with the kind of guidance about this screening test that they need and deserve. That's the way to help put the [PSA] controversy to rest . . . one man at a time.”

References

Moyer VA; U.S. Preventive Services Task Force. Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012 Jul 17;157(2):120‐34.

Shteynshlyuger A and Andriole G. Prostate Cancer: To screen or not to screen? Urol Clin N Am 37 (2010) 1‐9.

Mary F. McNaughton‐Collins, M.D., M.P.H., and Michael J. Barry, M.D. One man at a time‐ Resolving the PSA Controversy.N Engl J Med 2011; 365:1951‐1953 November 24, 2011 .

Trevor Royce, MS4 Affiliation: University of North Carolina at Chapel Hill, Chapel Hill, NC. Does Patient Life Expectancy Affect Receipt of Routine Cancer Screening in the United States? A Population‐Based Study. Reported by: Abigail Berman, MD Affiliation: The Abramson Cancer Center of the University of Pennsylvania Last Modified: October 31, 2012

Gorin MA, Soloway CT, Eldefrawy A, Soloway MS. Factors that influence patient enrollment in active surveillance for low‐risk prostate cancer. Urology. 2011 Mar;77(3):588‐91.

Potts JM. Screening for Prostate Cancer in Potts first edition Men’s Health: A Head to Toe Guide for Clinicians. Springer Press, 2015.