I wish u knew… Understanding prostate cancer screening

“I’m like the manager of the store,” said the legendary surgeon Alan Wein. He was reclining in a plush swivel chair at the head of a conference room table, distinguished in his long-point collar. He really did look like a well-polished shopkeeper. “I really want you to get your treatment here. I want you to have it in this store. Whether you get it from the first floor or the third floor or the fifth floor, or the fourth floor where the have radiotherapy, I’m perfectly happy.”

Dr. Wein is proud of the work that happens at Penn. In a city full of top-notch urologists, he leads the pack working from the epicenter at HUP. He likes that Penn gives patients “the whole team” – radiotherapists, surgeons like himself, medical oncologists – every kind of cancer specialist works here because they care about what customers leave the store with.

When you walk into the store looking for prostate cancer treatment, Dr. Wein makes sure you find what you’re looking for.

First of all, there’s surgery. He can do this himself. He can take out your prostate through your lower abdomen or through your perineum. Or he can refer you to one of his robotic surgeon colleagues. But if you have heart problems or blood clotting issues, or if you’re old enough that surgery might not be worth the trouble and your cancer won’t affect you much before you die, he’ll move you along to a different floor.

Perhaps radiotherapy will strike your fancy that day. The long-term benefits would be undeniable, and you probably wouldn’t be all that symptomatic. But if you have IBS, forget about it. Maybe go to the back of the store where you can place a bet on active surveillance.

At this point in the interview, I was intrigued. What is active surveillance?

As it turns out, prostate cancer often doesn’t develop to a point at which it becomes too much of an issue. Many men get it without even knowing about it. This knowledge gives rise to two sticky issues in the field:

1. Should we just let some people ride it out without treatment, checking up on them every once in a while to make sure it doesn’t get too bad?
2. If so many men get prostate cancer (one in six is expected to deal with it), but so many also live happily with it, should we be conducting screenings?

The answer to the first question is “yes.” It’s called active surveillance.

“What I tell people is this: active surveillance is a bet. You’re betting that under whatever program we institute, the disease is not going to progress to a state where it’s less curable than it is now, at whatever time we may decide to actively treat it,” said Dr. Wein.

All betting involves risk. In the case of active surveillance, the risk is that the stakes get higher. Eventually you might not be able to afford not having bought something at the store. But Dr. Wein is fine with that. He understands that surgery and radiotherapy can both go horribly wrong as well. So how does he know when to advise his customers to place their bets?

For that, he looks at the prostate like an apple. “It’s like an apple with the skin around it,” he said. “Best state of affairs is that the cancer is all inside the skin and the apple looks normal. If you mash on it, you might feel something, but it’s mostly fine.” If the cancer is contained within the prostate, and is mostly localized, there is less risk of it spreading. He also takes into account age as a risk factor. If a younger man comes in with prostate cancer, he presumably has a while to live, and a while for the cancer to advance. It is probably best to do something and risk the side effects. But if the man is elderly, and his cancer isn’t spreading, he might just skip the difficult treatments altogether. That type of man is “most apt to win the bet,” according to Dr. Wein.

Issue number two is the question of screening (done through a process called PSA, or prostate-specific antigen.) The problem is that screening detects prostate cancer, but prostate cancer doesn’t always need detection. In many men who develop it, the treatments for it affect them more negatively than living with it. So should we even be screening for it?

Dr. Wein recognizes both sides of the story. But he stands by his store’s merchandise. According to him, there are two facts about PSA screening that “are not able to be contradicted.” (Dr. Wein, like a French essayist, likes lists of two to four items.)

1. As a percentage of the cases diagnosed, there are far fewer deaths from prostate cancer than there were before PSA screening. (“Explain that to me,” he added with swagger.)
2. There are far fewer people who present with advanced disease now than there were before PSA screening. (“Explain that to me,” he said as he completed his neat rhetorical parallel. Saying it again made his opponents sound like sniveling libertarians.)

Ultimately, he’s all about options, and he is proud to offer so many. So does he always know best? Is he not only a French essayist, but also a French shopkeeper, someone who never allows the dim consumer to choose for himself?

Far from it. Dr Wein told us that he wishes “people would at least understand the facts” before making a decision. But the way he approaches his patients is not as the ultimate authority (though he is.) He told me, “Look, there are basically two parts to the story.”

Of course there are.

“The first part is what’s the best cure for what you have, and the other part is what’s the best treatment for you as a person. And the two answers may not always be the same. Your opinion, if you’re adequately informed, trumps mine.” Like the best of managers, he’ll sell you whatever it is that you need.