Powerful editorial by Otis Brawley on prostate cancer screening


This week's Journal of the National Cancer Institute includes a new analysis by Gilbert Welch and Peter Albertsen showing how much overdiagnosis and overtreatment have been the result of 20 years of more aggressive prostate cancer screening.

American Cancer Society chief medical officer Dr. Otis Brawley wrote an accompanying editorial. Excerpts:

In this issue of the Journal, Welch and Albertsen presented information that every man considering prostate cancer screening and treatment should know and understand. Prostate cancer screening has resulted in substantial overdiagnosis and in unnecessary treatment. It may have saved relatively few lives. Results from this article and recent results from prostate cancer screening and prevention trials demand reflection about what we as a society have done and are doing. Lessons to be learned have ethical and economic implications and involve our lack of respect for the scientific process and scientific evidence.

As I sat down to write this editorial, I heard a radio commercial that brings perspective to the issue. A local celebrity was promoting prostate cancer awareness. He said, "Prostate cancer is 100% curable when caught early." He encouraged all men to get screened and announced that a van was touring the area offering screening in supermarket parking lots. This was a community service project sponsored by the radio station, the supermarket chain, and a radiation oncology practice.

A commercial like this plays to our fears and prejudices. ...

Many screening advocates (both physician and lay) have had difficulty accepting that some cancers are not going to progress and cause symptoms or death within the lifetime of the patient. The distinguished urologist Willet Whitmore recognized overdiagnosis as a problem in his famous quote, "The quandary in prostate cancer: Is cure necessary in those for whom it is possible, and is cure possible in those for whom it is necessary?"

Brawley also includes some very important lessons - for medicine and for health care consumers:

Have respect for science and the scientific process. Understand and address the truly important questions.

In the past we have truly not appreciated the need for scientific evidence. In the future, will we accept scientific evidence?

Know what is known, know what is not known, and know what is believed. Label them accordingly.

I come from and have been supported by an African American community, where many are suspicious of physician motives and are convinced that doctors and those in medicine will take advantage of them and not tell them the truth. Distrust is actually a major reason for many disparities in health faced by black Americans . A closed-minded medical culture is a part of the problem. The well-meaning uninformed layman with a sound bite is also a part of the problem. Both can cause serious harm.

...The benefits of prostate cancer screening are still open to question. This means that informed or shared decision making should be done using the data now available before screening is performed. Some of the confusion of prostate cancer screening can be avoided if we all clearly label what we know, as what we know; what we do not know, as what we do not know; and what we believe, as what we believe. Of course, one must not confuse what is believed with what is known to do this.

Recently, a reader of this blog wrote:

With all the rhetoric from the U.S. Preventive Services Task Force (USPSTF) and their ilk, I still fail to see how PSA testing can in ANY WAY be harmful.

Rhetoric? Since when is evidence rhetoric?

"Their ilk?" Their ilk includes those, like Dr. Brawley, who responsibly and rationally assess the evidence.

Brawley said the Welch/Albertsen study presents information "that every man considering prostate cancer screening and treatment should know and understand." They should read his editorial while they're at it.


Reading Dr. Brawley's column I get a sense of unreality. It seems like I live in a different world from him. He lives in a world of impersonal statistics. (Already being revised to show further evidence of life saving benefits of PSA testing -- the Europeans just went from 20% to 30% as Dr. Walsh wrote months ago. The American studies remain largely contaminated by lack of controls). I live in a world of men and women trying to maximize the joys of being alive. Metastatic prostate cancer is clearly something one wishes to avoid in my world, and there is absolutely no doubt that PSA screening, when properly utilized, is a positive tool in my world. In my world when one takes about Prostate cancer and deciding whether and what treatment to pursue words like PSA velocity, PSA density, free PSA, biopsy, gleason score, margins, come into view. Death is an outcome we all face, the question for me is whether we spend a good part of our life fighting a spreading prostate cancer. I don't know who the men and MDS are that Dr. Brawley is envisioning, making uneducated decisions out of fear and greed, but they are not the dozens of men and MDs who I know of who have fought prostate cancer together. In 1997 when my PSA showed a worrisome rise, a biopsy was recommended. It showed a majority of cores with fairly aggressive cancer. My urologist told me the options at that time (things have progressed substantially) -- surgery, radiation, watchful waiting, seed implantation. He showed me the predictive charts taking into account the various indicators. I could read the odds that I still had organ confined disease and they were in my favor but in a significant minority of men with my readings the cancer had already left the prostate. I also learned that most men of my age had some cancer in their prostate and would die with it, but not of it. I learned that I could "watch and wait" but didn't know what I would be waiting for given that in a significant number of cases men like me already had invasive prostate cancer (nowadays the protocols are much more nuanced and detailed and active surveillance has replaced simply waiting). I learned of the likely side effects of treatment: impotence and incontinence, etc. as well as the possible progression of prostate cancer if left in the body. I weighed the options as best I could in discussion with my wife and getting other opinions from MDs. I prayed. Then and only then after a couple of months of study I made my decision. The surgery was successful in that no cancer escaped the prostate, and as far as I know 12 years later all is gone. Also gone are the erections of my youth. My wife and I discussed this before deciding what to do and from her perspective she wanted me alive to enjoy our grandchildren which I now can do. From my community and professional connections I know many many men who have gone through a similar path. If one wishes to study the role of PSA screening, then all the above aspects need to be included, not a simple "what was the PSA reading" and "what was the cause of death". PSA screening helps one along the path of life by beginning to provide information that can help one avoid metastatic prostate cancer --- so wear seat belts, stop smoking, and get regular PSA testing -- your well being will depend on it.

I, too have dealt with cancer. Not personally, but have watched a number of family members die from it. And yes, most listened to and trusted their physicians, oncologists. My problem is that it is a problem when the persons administering expensive treatments are also the ones who get paid enormous sums to administer them. It takes away their objectivity, whether intentionally or not. But that is an entirely different, although related, issue.

So the PSA test may be a tool to use, but it isn't the panacea that the hype suggests. The issue here is that people are questioning the value of a PSA test when the results are ambiguous, at best. It seems like a herding of men into treatment groups, although many probably don't need it. Statistics seem cold and impersonal, until you become one.

The problem with this test is that it tends to create fear and anxiety in many men with no real basis. Nobody knows beforehand which men probably will not need treatment and who will. But by the time that a man tests positive for a PSA, he may be in advanced stages of cancer when the probability of conventional treatment success is low. And if a man was not going to have any problems with cancer, is it really ethical to ask him to basically lose his manhood and dignity because of what basically amounts to a hunch?

The bottom line is that ED and incontinence are a very high price to pay for a test result of "maybe". But it should be an informed, researched decision, not a decision where people are pressured, and frightened into undergoing treatment. A cancer diagnosis is extremely stressful, and many people will simply undergo treatment because of their fear of death, regardless of how small the probability of it may be.

I think that people should become more informed and knowledgeable about cancer, and all health topics because it will determine the quality of life one experiences. We will never have high levels of health as long as people give their power to others to be responsible for their health issues.

About this Entry

This page contains a single entry by Gary Schwitzer published on August 31, 2009 3:54 PM.

Congresswoman Michele Bachman adds to her fairytale career, ignores international evidence on health care was the previous entry in this blog.

Watchful waiting OK for many men with prostate cancer is the next entry in this blog.

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