Prostate Cancer. Mens Rea: Who Knew What And When?

For those of us who are either rusty in our knowledge of the Law or Latin, mens rea means ‘guilty mind.’ In a bit you will see why I rehearse this bit of arcana.

The U.S. Preventive Services Task Force has recently advised against routine PSA screening for prostate cancer; in men of course. Let’s set the stage:

  • Prostate cancer incidence is 2 times that of the #2 cancer which is lung cancer
  • Prostate cancer is the #2 cause of cancer death among men

Any way you cut it prostate cancer is a very serious player in the death games of life. The old saw ‘at autopsy almost all old men have prostate cancer’ is used in conjunction with another old saw- ‘almost none of them died from the prostate cancer’- in a strange kind of formal logic to prove that no one needs to be concerned about prostate cancer. This is a lie.

The rest of the logic, pay attention here, goes like this: most of the ‘old guys’ would have died of something else before the prostate cancer would have killed them. Still, somewhere between 30,000 and 40,000 men, in the U.S, die every year from prostate cancer; more than colon, brain, pancreas- may Steve Jobs R.I.P.- or many other cancers; with the exception of lung cancer more than most other cancers combined.

So here is where ‘mens rea’ comes in to the story. The panel points out correctly that prostate cancer is over treated; by this meaning too aggressive, invasive, destructive of quality of life treatment for many who need no or very little treatment. This applies to the aforesaid ‘old guys who would have died of something else.’ Fair point. They further point out that PSA screening, note this part carefully, ‘the way it is routinely done’, is a very poor way to detect prostate cancer and to then help sort out that which requires treatment from that which is amenable to observation or what is called ‘watchful waiting.’ ‘The way it is routinely done’ is the qualifier that keeps the recommendation not to screen from the criminal accusation entailed by the mens rea of understanding and then intent to do harm.

Several of the largest studies to address the value of PSA screening, both here in and in Europe, have shown lives saved by coherent PSA screening. The advantage was not dramatic, unless of course it was your life saved! But the lives saved by screening were real and this effect has been seen repeatedly. And here’s the rub. Random, occasional, PSA screening can lead to inappropriate biopsy, treatment and the possible subsequent serious side effects of such treatment. Furthermore wending your way helped, not harmed, through the maze of diagnostic and treatment options of discovered prostate cancer is not easy.

If your PSA was checked 5 years ago and it was, let’s say, 1.0 and you then have it rechecked and it is now 3.0 you don’t know if it went from 1.0 to 3.0 just yesterday or gradually over time in a gentle crescendo. The first case could be serious and the latter case likely represents nothing but the normal enlargement of the prostate gland. Still, on the morning when you find out it is now 3.0, the question you might ask yourself is whether this new number represents prostate cancer, a new infection or just the normal process of aging-related enlargement of the prostate. Think through this example and you will see why more or less random occasional PSA measurement can be misleading; even ill advised.

One my favorite parts of the Task Force recommendation is the advice not to screen ‘in healthy men.’ Hilarious. It is a tautology that by the time you are no longer healthy you might want to look for prostate cancer among other things. As it seems to have escaped them, the reason you look for prostate cancer ‘in healthy men’ is because you would like to keep them that way and not try to rescue or salvage them from advanced prostate cancer.

The appropriate thing to do is to fund and support finding a better tool than PSA screening for prostate cancer, there are a few leads and additional tests now available, and to use the one rather blunt tool we have, PSA, in a rational manner. Regular, frequent, carefully interpreted PSA attended by subtle additional diagnostic tools like free PSA, PCA, rt-PCR, high resolution ultrasound and color flow Doppler; there are others. None of them are perfect, none of them exempt one from risk, we are human after all, but used with care they can help a man avoid unnecessary surgery and still find and mange prostate cancer when it matters and can make a difference.

Oh, and remember to be the guy healthy enough that the question doesn’t even come up of whether or not you will outlive your prostate cancer because you are so healthy that you darn well will if the blasted thing is diagnosed and treated correctly.

Smile, Have Fun, God Speed,

Dr. Mike

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