On a delightful spring day five years ago a vintner pal and I motored down to Yountville for lunch. This was not, however, a typical social outing. We were in pursuit of knowledge on a subject vital to any male in St. Helena: prostate cancer.
This luncheon was hosted by St. Helena Hospital and the main guest speaker was Dr. Peter Carroll, chair of the Urology Department at UCSF. Carroll emphasized the utility and importance of getting a series of PSA tests over time (prostatic specific antigen – PSA – is the somewhat rough and clumsy blood marker for prostate cancer). He said if we’ve got an established base line of PSA results over several years, and then the PSA number starts escalating, that’s something that merits serious investigation.
Reassuringly – for someone my age – he also suggested that if we have had a series of low number results by the time we’re in our late 60s, then it would be highly unlikely we would ever get prostate cancer.
Prostate cancer is Mother Nature’s gift to equalize us guys with girls out there trying to get a handle on breast cancer. In both cases, it can be difficult to distinguish between slow-moving and aggressive cancers. If not caught early, aggressive prostate and breast cancers can kill painfully as the cancer spreads through the body. And for both diseases, the most common tests, PSAs and mammograms, are imperfect tools.
My vintner pal paid close attention to Dr. Carroll’s remarks, and continued getting regular PSA tests. The results led to more exams and then a biopsy. Four years after our springtime luncheon, Peter Carroll operated on him to remove his prostate. Post-op tissue pathology showed this was an extremely aggressive cancer; Carroll most likely saved his life. Now, a year later, my friend is totally recovered from his surgery with no side effects and is looking forward to the 2017 growing season.
I was reminded this month of our luncheon – and its aftermath – when I saw a headline in the Wall Street Journal, “Guidelines Changed Again for Prostate-Cancer Screening.” We have in this country an entity called the U.S. Preventive Services Task Force. This panel consists of MDs and PhDs who recommend health care policy to the government.
They have chosen to advise the government – and all men – on the PSA test. Their new draft report says that if you’re aged 55-to-69, then the pluses and minuses of screening are “closely balanced” and we should talk it over with our doctors. But, if you’re 70 or over, don’t bother to get screened: the pluses “do not outweigh the harms,” which is the advice they previously had for everyone.
So if you’re 69 years and 360 days old, by all means consider getting a PSA test. But if you’re 70 years and 10 days old, don’t bother. Such numerically silly advice doesn’t pass the laugh test. If my vintner pal had followed it, he might well be dying right now. As he told me last week, “The more aggressive tumors tend to show up in your 70s.”
This federal Task Force doesn’t have a urologist among its members. They are a group of non-specialists with broad medical interests. There is one Bay Area member in this group, and she turns out to be its Chair: Dr. Kirsten Bubbins-Domingo of UCSF. The impressively credentialed Dr. Bubbins-Domingo is a “general internist” in practice at SF General Hospital. Repeated attempts to contact her for an interview were not successful.
Had I reached her, I would have asked Dr. Bubbins-Domingo why, on this issue, we should pay attention to a panel of generalists without a urologist among them. And I would have asked her to comment on the starkly different opinions held by her and her UCSF colleague Peter Carroll.
Back here in Napa County, one of our local urologists has said that because of the Preventive Services Task Force’s previous advice against getting the PSA test, he’s been seeing more and more men coming in with advanced prostate cancer.
There are few sure bets in the race against cancer. Imperfect tests can result in false positives that lead to more testing, some of which is invasive and potentially harmful. And expensive. But dealing with a diagnosed cancer is way more expensive, and the more extensive and aggressive the cancer, even more money is spent.
But ultimately cancer isn’t about dollars, it’s about individual patients like my vintner pal. And because he dismissed the directives of the Preventive Services Task Force, he’s alive today, savoring his newly released 2014 cabernet.
Mark G. Epstein moved to St. Helena from the East Coast early this century after a career in international business.