March 20, 2000
Prostate Cancer and Screening
It is a numbers game
Recently in a ABC news broadcast, it was said that 17,000,000 men have prostate cancer. Where did this come from has been a question. There are some 130 million men in this country. Of this there are about 45 million who are over 45. Now if we look at the figures that have been determined that have prostate cancer (although not necessarily know at the time) I would think that 17 million as reported is probably a good number.
This means that there are 17,000,000 of us past some age (unknown where they got their figures), 185,000 will be diagnosed this year and about 38,000 are going to die directly from this disease. Furthermore lets assume that we have 5 years of diagnosed men still alive which would equal someplace in the 1,000,000 area plus or minus a few thousand. (Many have died from other causes.). OK, lets accept these numbers as being in the ball park and work from there.
If we take the 1,000,000 men already diagnosed from the 17,000,000, who have CaP, we than have 16 million men running around out there who have CaP and do not even know it. That is a lot of men. If you had mass screening what would you do with 16,000,000 or even half or that 8,000,000 men with prostate cancer. In order to find these 16 million men you would have to screen some 45 million men. If we just screened half or them we would be at 22,500,000 men and might find only 8,000,000 million prostate cancer patients. To carry the problem even further - we have many men who have high PSA's and the doctors cannot find the cancer in the biopsy and they are sent home saying, "not to worry". I am told that now only about 1 out of 4 biopsies show cancer. Out of the 8,000,000 then we are down to 2,000,000 men who might get caught in mass screening at the most. We now catch 10% of those.
We only have about 1,000,000 hospital beds in this country. Obviously, under our present system, most of these men will get an RP's, do we have enough hospital beds to even treat these patients.
So much for mass screening. Under our present medical establishment it is not practical to do. This is not even considering the damage done to the 2,000,000 men and their families who are diagnosed with the big "C". Loss of jobs, loss of friends, a major reduction in their quality of life are further considerations. The question that needs to be answered is the trauma of the disturbance of 2 million men and their families. Lets face it if we found every one of them, we don't know if we would change the deaths appreciably. Actually we may find that they could increase from the mishandling of their cases by incompetent doctors.
Forget mass screening
Now lets talk about what we might be able to do using our present knowledge and facilities. How we can screen the most men possible.
First we need an education program for the GP's and the Urologist. A program that teaches the Urologists the information they need with requirements that they pass certain courses on prostate cancer every x years. Then a requirement that with every CaP patient the doctor is required to hand out a standard brochure giving information about CaP and its treatments. A list of support groups in the area and the availability of Internet services for prostate cancer.
In addition an educational program for GP's to bring them up to date when a PSA may be dangerous. At this point many of them have no idea. Lets forget the GP's of having to do DRE's. They miss so many by their inexperience in doing DRE's why not just have them do a PSA and if it is above some certain figure like 2.0, refer them to the Urologists.
Now lets get back to screening. Since many men never go to their doctor there is substantial numbers of men who will never be screened by their doctor so, at least to me, this does not make any sense. But is there another way, perhaps
Lets open up the hospitals, clinics, public health facilities, doctors (GP's and primary care) support groups, places of employment, annual checks at shopping centers, even the insurance companies would participate, etc. Lets do it like we presently do for flu shots. Lets do only one thing at all of these and that is to draw blood. No DRE's, no doctors appointments, just draw blood and do PSA's. Lets do this for all men over 40. Lets make a decent charge that would pay for the procedure so that insurance is not involved. Let's bargain with one assay company to supply the assays at the smallest cost possible. Those that can pay for it, they can. The ones that cannot can go to the public health facilities.
The process of getting men
Now do the necessary promotion to draw the men to have their blood drawn. At the time they have their blood drawn they are given information on prostate cancer and what to do if they have a high PSA. Write something like I use called For New Patients Only do it with professional writers, attractive, readable (mine is none of those). They could be given some guidelines to repeat the PSA, go to the doctor and get a PSA II and/or ProstAsure.
The doctors are taught to do no biopsies without at lease two PSA's one being a PSA II and perhaps a ProstAsure and of course a DRE. At some point a biopsy would be done and the doctor would have an idea based on the PSA, PSA II, DRE and the ProstAsure that there is an almost certain chance that there is cancer there before the biopsy. Maybe it would increase out incidence of finding cancer in a biopsy.
Now the man has to know all of the choices he has including Watchful Waiting. We have enough information now available to give data to him as to what the chances are. The doctors should be taught to do the various tables such as Partin to educate the patient what his chances are. Complete staging should be done before any treatment is commenced. All of this would be discussed in the document he receives at the original blood draw and additional material as he precedes down the line.
Without the DRE, I think we will get more men to undergo a screening. With education of those that do get the test, education of the doctors, and a plan on when and what to treat drawn from the data we have available today we could increase the men being diagnosed, increase the men in early treatment and hope that we decrease the rate of death.
I think all of this is possible but as long as we use the DRE for screening we will not reach the men we need to. We need a quick, easy way to reach out and touch these men I think the blood test will help us do this with the idea making it universally available without a doctors appointment.
We over treat and over diagnose now
What I am concerned about is the men who are diagnosed with a low PSA and low Gleason and are on the table in a week to have it cut out. I am concerned for any man who gets a biopsy after one PSA, I am concerned about any man who gets a treatment with one unverified Gleason reading. This happens every day in thousands of men and to me it is tantamount to a crime. We are a long way to having our docs educated enough to give the patients all the options and in the case of a low PSA and low Gleason - the patient just MAY be better off getting no treatment at that time. Johns Hopkins calls it insignificant cancer.
I think almost universally, at all clinics, we treat too soon with too little information; hardly any staging and we then we force the men into a treatment by fear. We over treat as it is now, what would it be if we need mass screening without safeguards.
This is my thoughts, perhaps in an ideal world but it is a starting point that just might work.