On making choices…

 by Don Curto

Harrison Salisbury, author and late New York Times reporter said: if a reporter is not “a disturber of the peace” he should go into cost accounting…a rule not often suggested these days but one with which I am in full agreement. So, look ahead here for some “disturbing of the peace.”

On March 19, the New York Times joined other outlets in publishing the results of “two large studies,” one in Europe and one in America, concerning the value of Prostate-Specific Antigen (PSA) testing for prostate cancer.
I am writing about these studies as presented and criticizing their conclusions. I am not a medical researcher, a doctor or an epidemiologist. But I was born with some brains and the ability to detect uncaring illogic. Let’s look at the Times’ reporting on the studies, which we can probably safely assume is accurate.
“The PSA blood test, used to screen for prostate cancer, saves few lives and leads to risky and unnecessary treatments for large numbers of men, two large studies have found.
“The PSA test, which measures a protein released by prostate cells, does what it is supposed to do—indicates a cancer might be present, leading to biopsies to determine if there is a tumor. But it has been difficult to know whether finding prostate cancer early saves lives. Most of the cancers tend to grow very slowly and are never a threat and, with the faster-growing ones, even early diagnosis might be too late.
“Prostate cancer treatment can result in impotence when surgery is used to destroy the prostate and, at times, painful defecation or chronic diarrhea when the treatment is radiation.”
Here is where I think the peace needs to be disturbed. All of the bad results noted above occur after the PSA and by no logic is the PSA test responsible for them. It makes sense to me that one should know whether he has prostate cancer; then decisions need to be made what to do about the cancer, if anything. It is nonsense to make a decision about treatment of cancer before knowing it is present.
Because the treatment of prostate cancer can be so difficult and open to so many errors, possibly bringing on poor results, the detection of a possible tumor should be suspect and possibly suspended? Does any intelligent man really believe the early detection of cancer is the first cause of poor treatment results?
What utter nonsense is this? I am sure we untrained people should all agree it is far better not to know and not have to get involved in possible bad decisions. This kind of thinking is medical science?
It is clearly not the PSA that is the problem. It is what the doctors do with the PSA information that might be the problem.
Prostate cancer is the No. 2 killer of men who have cancer. Because treatment appears to be so difficult, the study report tends to lead to the conclusion that it is better not to know about a possible tumor. If one doesn’t know, then there is no possibility of making a treatment error—sort of like running a prostate cancer lottery.
This kind of “study” sets me off because I was the patient of a doctor many years ago who did not think PSA testing was important. One day, in December, 1995, I received a telephone message to go to the doctor’s office immediately. I did. When the doctor came into the room, he was pale, literally shaking and worried. He told me that my PSA was fifty. Normal is somewhere near zero, but no more than four.
He said he would make an appointment for me immediately with a urologist for further checking. He did, and the urologist said I needed a biopsy. If you have never had a biopsy to check for prostate cancer, I am here to tell you it is not the kind of activity one does for fun on vacation. But it also is not horrible and in itself apparently not dangerous if done with some skill.
The tumor was not operable, leaving open the possibility of “watch and wait” (a really foolish plan at this stage) or radiation. Fortunately, the luck of the draw hooked me up with Dr. Cheryl Davison, a radiation oncologist then at Marquette General Hospital, who has since left the area. Our initial conference lasted more than an hour. As she outlined her thoughts and plans for my treatment, I began to get jolts of confidence…and to fall in love with the doctor. It was, she said, a very bad tumor in a very bad place, but she thought her treatment would destroy the tumor.
I elected early morning for my radiation periods so I wouldn’t sit around all day thinking about them. I can’t remember now whether there were thirty-eight or thirty-nine radiation treatments, but whatever the number, it was the maximum radiation.
So for thirty-eight mornings, weekends off, this was the routine: wait in the small room to be called for radiation. Usually this was about 8:45 a.m. Stand by the huge machine with a bed in front of it, awaiting your turn. The technicians were mostly young, very personable women eager to save your life. The conversations each morning went like this: I am standing there, trousers off, shorts on and the lead technician orders: “OK, Don, drop your drawers.” I do as ordered, lie down on the “bed” and am covered with a white cloth. The radiation period is short, and I am out of there. I had few side effects, mostly tiredness at the end of the week. But it is pretty hard to have a bad day when it begins this way.
I had some side effects, some of them unpleasant. However, over time, they went away and my life became quite normal. Radiation cystitis, with its frequent bleeding, was a very big factor until I made a trip to a urologist in Detroit who said, simply, as though I should have known all along, stop the use of aspirin and any other blood thinner and there will be no trouble with the cystitis. I did and there hasn’t been any further trouble.
All this was almost fourteen years ago. Without the PSA and the resulting treatment, there is little doubt that I would not be sitting here pounding this keyboard. One could say, I suppose, that the tumor would have grown slowly and it might not have killed me. However, the preferred path, almost the only one sometimes, for metastasis of prostate cancer cells is into the bone—a painful way to leave this world.
As a matter of fact, one could say my treatment options were reduced seriously by the delay in getting the original PSA. This delay eliminated the possibility of surgery and left radiation the only route. Cancer cells have cropped up again in what is left of the prostate, and they are being controlled by using a monthly PSA to determine cell level and, every three months, a shot of Lupron to reduce testosterone, the food for cancer cells.
By and large, these fourteen years have been pretty good; they might well have been better had I had an early PSA. How many people have to have their lives saved before a test becomes valuable?
Here is a repeat of the headline in the newspaper about these tests: “Prostate Test Found to Save Few Lives”
What if one of the “few lives” is yours? 
Get a regular PSA test. If your doctor doesn’t order it, get another doctor. Find the very best medical help you can to determine what to do with the results. Remember, it is not the PSA test that is bad. There is no law that says you must go through surgery or radiation, but at least you will be operating with facts and not someone’s statistical fantasy.
Have I “disturbed the peace?” I hope so.

Footnote
The Ann Arbor Daily News essentially is going out of business. For a short period after WWII, I worked as a freelance editorial writer for that paper. My editor was Mr. Arthur Stace, every inch the editor and gentleman. He gave me an important lesson about being a professional writer.
When one time I complained about being given a position on a subject that was “Republican,” he told me that a truly professional writer could, with equal ease, write a compelling piece on either side of an issue. I was paid $10 per column, and, as editorials were set two columns wide, I frequently made $20, a fortune to me. I was paying my dues in those days to the Pretzel Bell. He also introduced me to his friend, former Senator Arthur Vandenberg, Michigan’s conservative and sensible pillar on foreign policy.

— Don Curto
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