Presidential candidate Rudy Giuliani recently made the mistake of trying to turn his brush with prostate cancer into a campaign issue: “I had prostate cancer, five, six years ago. My chance of surviving prostate cancer, and thank God I was cured of it, in the United States, [is] 82 percent. My chances of surviving prostate cancer in England, [is] only 44 percent under socialized medicine,” Giuliani declared.
Rudy, of course, was wrong.
Merrill Goozner has done the best job that I’ve see of cutting through to the truth of the matter. In a Nov. 2 post titled “Columnists Miss Chance to Educate on PSA Testing,” he points out that “Paul Krugman’s column in the New York Times and Eugene Robinson’s column in the Washington Post justifiably attack Rudy Giuliani’s misuse of prostate cancer stats, all but accusing him of lying.
“Krugman begs political reporters to make the Republicans’ false
attacks on Democratic health care plans as ‘socialized medicine’ as big
an issue as Clinton’s laugh or Edwards’ hair,” Goozner observes, and he
quotes Krugman explaining that the difference between survival rates in
the U.S. and the U.K. “turns out to be mainly a statistical illusion.
The details are technical, but the bottom line is that a man’s chance
of dying from prostate cancer is about the same in Britain as it is in
“That’s fine as far as it goes,” says Goozner.
But he wishes that the columnists had gone on to tell their readers that “thousands of American men are incorrectly diagnosed with prostate cancer each year.
The prostate specific antigen (PSA) test has a very high false positive
rate, identifying ‘tumors’ that will never threaten patients’ lives or
well-being. Moreover, to ‘survive’ that non-cancer, they are
subjected to needless treatments—costly operations, drugs, and/or
radiation—that leaves many of them impotent and incontinent. [my emphasis]
Merrill is absolutely right.
I wrote about prostate cancer when I started this blog back in August. but since most of you were not reading HealthBeat then, let me briefly recap what I said.
First, the PSA test we use to screen for prostate cancer isn’t very
good. The biopsy which follows (if the PSA test proves positive) is
better, but it still doesn’t tell the doctor whether this early-stage
cancer will progress.
What’s tricky about prostate cancer is that it grows very, very
slowly—so slowly that most men who have early-stage prostate cancer
will never experience symptoms. Nevertheless, until recently, men over
the age of 50 were routinely sent for PSA testing. Indeed, two-thirds
of all men on Medicare have been screened for the disease. And because
we do so much more testing than the U.K. we find more cancer earlier.
If testing continues at the current rate, 20% of American men will be
diagnosed with prostate cancer at some time in their lives. Yet most of
those men don’t need treatment. Only three out of twenty will die of
the disease; the other 17 will die of something else, in most cases
long before the prostate cancer ever gives them any trouble. If they
hadn’t been tested, they wouldn’t even know they had it.
Meanwhile, men who are diagnosed have three options: surgery, some form
of radiation therapy or “watchful waiting”—which means that the
urologist doesn’t treat the cancer, but keeps an eye on it in the years
that follow, to see if it grows. Usually, it doesn’t.
Nevertheless, the majority of men choose surgery or radiation because
they feel that they must do something. The idea of watching and waiting
is just too stressful. Thus, what Dartmouth’s Dr. H. Gilbert Welch has
called an “epidemic” of diagnoses of very small cancers leads to an
“epidemic” of (sometimes harmful) treatments. In the case of prostate
cancer, as Merrill notes, the treatments can have life-changing
side-effects: namely impotence and/or incontinence. Moreover—and this
is almost unbelievable—we have no evidence that any of the treatments
for early-stage prostate cancer save lives, or even extend life by one
I’m sure Rudy wouldn’t believe me. He is convinced that his treatment
“cured” him. But the National Cancer Institute isn’t so sure. In June,
the Institute spelled out its position: “Screening tests are able to
detect prostate cancer at an early stage, but it is not clear whether
this earlier detection and consequent earlier treatment leads to any
change in the natural history and outcome of the disease."
The American Cancer Society agrees. That’s why the ACS no longer recommends PSA testing. As the Society puts it in its 2007 review of guidelines
for cancer screening, "because the current evidence about the value of
testing for early prostate cancer detection is insufficient to
recommend that average-risk men undergo regular screening,” it would be
“inappropriate” for a doctor to recommend PSA testing. Hedging its
bets, the ACS also says that it would be “inappropriate” for a
physician to discourage PSA testing. Instead, doctors should “offer”
the test to men beginning at age 50, and then discuss the “potential
benefits, limitations and harms associated with testing.”
Admittedly, the patient who suffers from prostate cancer faces some
tough choices. We don’t know for sure that the treatments we have don’t
help—but we don’t have any solid evidence that they do. Skeptics point
out that if early detection and treatment saved lives, one would expect
that the mortality rate (or deaths per 100,000 in the population) would
have plummeted in the twenty years since the PSA test was developed.
But the number of men who die of prostate cancer has fallen by only a
Moreover, researchers are not certain that PSA testing and subsequent
treatment has caused the slide; multiple factors could be involved. We
need controlled, randomized clinical trials, they say, before we can
measure the benefits of any of the treatments. But because prostate
cancer usually moves so slowly, a trial must follow patients for
decades. In 1993, the National Cancer Institute began a 23-year trial
that it projects will end in 2016.
In the meantime, Merrill Goozner suggests that “Americans need to hear
the message that many aspects of our vaunted ‘best health care system
in the world’ are wasteful when not downright harmful.” He wishes that
columnists in the mainstream media like Krugman and Robinson would help
spread the word, proposing “a column that begins by begging readers to
bear with [the columnist] as he explains the technical reasons” why
five-year survival rates in the U.S. are not significantly better than
five-year-survival rates in the U.K. (In the U.S., if a man is tested
every year beginning at age 50, the cancer might be discovered at 62.
If he died of the cancer at 70, he would have survived more than five
years. If the same individual lived in the U.K., the cancer might not
be caught until he was 67; if he died at 70 he would not have survived
five years. But either way, he would be dead at 70).
Goozner goes on to suggest that the columnist could then make the
argument against consumer-driven care, by “using the ‘complexity’ of
this one example to show why forcing ‘consumers’ to understand all this
on every medical situation they may face is a completely unrealistic
approach to holding down health care costs. What we need is an unbiased
comparative effectiveness institute…to generate these analyses, and
then pay primary care doctors enough money to help their patients
understand these choices.
“Instead,” Goozner reminds us, “what we have is fee-for-service
medicine where the specialist doctors who operate, chemically castrate
and radiate make the big bucks; many men needlessly suffer; and our
health care outcomes in terms of survival are no better than Great
Britain, where they spend 41 percent of what we do on health.”