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With cancer, it's always personal

Studies concluding that screenings are overused and their importance is overstated fail to account for that one life saved, especially if it happens to be your own.

October 25, 2009|Paul Lieberman | Paul Lieberman, a former Times staff writer, lives in New York.

The American Cancer Society tried to downplay news reports last week that it was toning down its endorsement of the long-ballyhooed screening tests for breast cancer in women and prostate cancer in men. But in a statement, the group acknowledged that the "advantages of screening for some cancers have been overstated."

Like a lot of other Americans, my first response was: What about me?

Medical authorities have "overpromised" and "exaggerated," in the words of a top Cancer Society official, the benefits of mammograms for women and PSA blood tests for men. The popular tests, it seems, too often result in over-treatment of milder cancers while failing to prevent enough deaths from the most aggressive types.

That was the same conclusion reached by massive studies, published last spring, that tracked 259,000 men for almost a decade and found no significant difference in prostate cancer death rates between those who had PSA monitoring and those not screened at all. The yearly blood tests instead resulted in a profusion of questionable radiation treatments and surgery directed at men whose prostate cancer was unlikely to ever kill them. A nine-year European portion of the research calculated that regular screening led doctors to subject dozens of men to arguably unnecessary operations or radiation -- with potentially serious urinary and sexual side effects -- for every life saved.

To be specific, doctors had to screen 1,400 men and treat 48 less-serious cancer cases, with all the nasty consequences -- perhaps doing more harm than good -- to save one solitary life.

How do you argue with that sort of science, that sort of cost-benefit analysis?

Well, maybe you do if yours was the one life saved. Which brings us back to: What about me?

Three years ago, a routine blood test found that my PSA (prostate-specific antigen) level had jumped since my last screening. Though it still was in the "normal" range, my internist thought I should be checked further. A urologist decided a biopsy was prudent and called days later with the results, along with a common line given new prostate cancer patients to soften the blow, "You will die someday, but this isn't going to kill you."

Then he added the gut-punch: While my tumor was small, some cells were the "aggressive" variety, a finding later confirmed by pathology tests after I opted for surgery (and quickly). Despite the initial reassurance, this indeed was the type primed to spread to the bone and elsewhere, a type of cancer expected to kill 28,000 men in the U.S. this year, according to the Cancer Society. The good news was that the tissue surrounding my prostate was clear, and so were nearby lymph nodes. There was no guarantee it would not return someday -- they give you this wonderful chart listing the likelihood year by year -- but the odds are in my favor.

In other words: The deadly form. Found (seemingly) in time. Thanks to routine screening.

Of course, there are plenty of other cases like that of a cousin of mine who got his diagnosis 15 years ago, a time when many people still only whispered the word "cancer" and shook their heads at the poor victim. Well, after I joined the crowd and studied up on the fine print of the disease, I learned that he'd hardly even registered a Gleason score, the measure of prostate cancer aggressiveness. He very well may not have needed the radioactive seeds doctors implanted in him and that have caused him complications since.

The exhaustive studies published in the New England Journal of Medicine likely will prompt more "watchful waiting," rather than treatment, in insignificant cases like his. With 186,000 American men expected to be diagnosed with prostate cancer this year, most will think twice -- at least -- before proceeding with surgery or radiation that can bring on impotence and urinary incontinence. The big picture conceivably could prompt insurance companies to reconsider the care they will cover for the majority of men found to have very slow-growing forms of the disease. Certainly, more men will feel comfortable ignoring the public service announcements urging them to get yearly PSA tests once they reach 40 -- if we continue to hear such urgings at all.

But thank goodness I didn't take that approach.

With breast cancer, meanwhile, a "special communication" in the latest Journal of the American Medical Assn. reports that the mass screening of women in recent decades has resulted in a 40% jump in detection of breast cancer, and far more treatment for the early stage "low-risk" variety. But that increase in early detection has come "without significantly reducing the burden of more aggressively growing cancers and therefore not resulting in the anticipated reduction in cancer mortality." The article in the AMA journal calls for new approaches to screening for breast cancer -- and prostate cancer too.

I won't argue with the experts, but I will say this: The call for reconsideration of routine mammogram screening came out this week just as my wife was completing the second phase of surgery for breast cancer. As with me, routine screening -- in her case an annual mammogram -- prompted additional tests and early discovery of cancer. Pathology tests found no evidence that it had spread, but her tumor cells -- like mine -- registered high on the scary scale. We're quite a couple.

So perhaps we should view those huge, important studies as a Seurat painting. Only when you get real close do you see the individual dots. From that perspective, the big picture looks different.

Let's make it: What about us?

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