Treating or Ignoring Prostate Cancer

MR. STEVE ROBERTS

10:06:55
Thanks so much for joining us. I'm Steve Roberts, sitting in today for Diane Rehm while Diane is away on vacation. The U.S. Preventive Services Task Force has announced it can no longer recommend a routine prostate cancer screening test. They say this form of screening presents more risks than benefits, and healthy men should not get it.

MR. STEVE ROBERTS

10:07:14
Joining us in the studio to discuss the pros and cons of the prostate specific antigen -- that's P.S.A. -- exam are Dr. Patrick Walsh of Johns Hopkins Hospital Center and Dr. Chiledum Ahaghotu of Howard University Hospital. Joining us from KWMU in St. Louis, Mo., Dr. Gerald Andriole of the Washington University School of Medicine. Doctors, welcome to you all this morning. And...

DR. PATRICK WALSH

10:07:41
Thank you.

ROBERTS

10:07:42
And on the phone with us is Shannon Brownlee, a longtime medical journalist and also a foundation executive who has written an article -- co-written an article in The New York Times Sunday magazine yesterday on this very subject. Shannon, welcome to "The Diane Rehm Show."

MS. SHANNON BROWNLEE

10:08:00
Thanks, Steve. It's been a long time.

ROBERTS

10:08:01
It's been. We used to -- Shannon and I used to work together a long time ago at U.S. News. Give us a sense, Shannon, of what this study says.

BROWNLEE

10:08:09
So what the U.S. Preventive Services Task Force did was they looked at the data that's out there, and what they said was, while P.S.A. screening may reduce prostate cancer deaths, the net benefit does not appear to be there. In fact, what they're suspecting is that the number of men who may avoid dying from prostate cancer may be offset by the men who are harmed by the treatment itself and by further testing, like biopsies.

ROBERTS

10:08:45
And given that -- this recommendation not to get a test is so counterintuitive, particularly given all the advances in medicine, to be told not to take advantage of this test, a lot of people just can't follow that reasoning.

BROWNLEE

10:09:04
Sure. I mean, you know, we've been told that screening is a good thing for a long time. But in some ways, P.S.A. testing is the poster child for why we really need to rethink the whole notion of screening for diseases. Sometimes screening is beneficial, but not always. And the reason my co-author Jeanne Lenzer and I wrote this story was that we think men should be aware that P.S.A. testing is not a slam dunk.

ROBERTS

10:09:29
And -- but -- and you also report, Shannon -- and these are your words in the piece -- that, for a lot of men, knowing you have cancer, which is -- can often be the case when you do have the P.S.A. test, and not doing something about it, not following up with the kind of treatment you just described that could be potentially dangerous, that it's psychologically unbearable. Talk about that dimension of this whole picture.

BROWNLEE

10:09:57
Well, you know, we have -- it's very hard for people to understand that not all cancers are created alike. And the fact is we know that huge numbers of men who are treated for prostate cancer have a condition that actually would not have bothered them in their lifetime. Now, there are prostate cancers that are quite dangerous.

BROWNLEE

10:10:15
But many prostate cancers grow so slowly that the man would have died of other causes before his prostate cancer was even symptomatic, much less dangerous. That's a really hard idea. We have this idea that all cancer ultimately is dangerous, all cancer kills you, but that's not necessarily the case.

ROBERTS

10:10:34
Well, as someone very near and dear to me who was suffering from cancer at one point said in a fit of anger and frustration, there's something inside me that's trying to kill me. Now, how do you tell a man who has been diagnosed with cancer and has that psychological feeling that, actually, you're better off not dealing with it?

BROWNLEE

10:10:59
Well, that's why the decision has to be made as a shared decision. The man and his physician have to make the decision together. There may be some men who can make that decision, who can say, you know, I know I have a low-grade cancer, and I'm really -- I'm not interested in getting treated. And, together, they can make that decision, that it's okay to do active surveillance or even watchful waiting, which is less invasive than active surveillance, where you get regular P.S.A. test and regular biopsies.

BROWNLEE

10:11:30
There are some men who probably can do that, but I think it's probably very, very difficult. The decision should come before you even do the P.S.A. test. Men need to understand that P.S.A. testing can lead to a whole series of downstream decisions that they will have to make. And those downstream decisions may be much more difficult to make than the decision about whether or not to get tested.

ROBERTS

10:11:55
But, often, men don't even know that they're having a P.S.A. test. It happened to me just the other day.

BROWNLEE

10:12:00
Yes.

ROBERTS

10:12:01
I was at the doctor. He drew a blood sample, and he says, oh, we'll do -- run a P.S.A. test as long as we have the blood sample. It often is not a particularly monumental or even a very widely discussed decision.

BROWNLEE

10:12:14
I think it's actually unethical to do that. Because the downstream effects of P.S.A. testing can have so much -- there's so many big decisions that men may have to make downstream. They need to talk to their physicians. That decision to get tested really needs to be the first one that is really shared. And to give a man a P.S.A. test without even telling him that you're giving a test is not -- men are not giving informed consent to something that, actually, they need to understand.

ROBERTS

10:12:44
Shannon, final question here, if you -- a man you loved, a husband, a father, a friend, was faced with these decisions, as someone who has studied this very carefully, what would you advise him?

BROWNLEE

10:13:03
So I actually can give you two examples. My father had a very high P.S.A. -- not very high. He had a high P.S.A., little bit over normal. And he called me and said, haven't you written something about the P.S.A. test? And I directed him to talk to a urologist in Portland, Ore. where -- near where he lived, and they went over what his options were. And this was 10 years ago. My father is now 81.

BROWNLEE

10:13:28
And out of that discussion with his physician, he made the decision not to go ahead and get a biopsy. And he's -- he has no symptoms of prostate cancer. My husband, who is younger, had the decision about whether or not to get P.S.A. testing. And what I -- he said, what should I do? And I said, well, it's not my prostate, but here's some information for you.

BROWNLEE

10:13:53
And I offered him a patient decision aid, which is a brochure and a video that actually helped him walk through what the decision was. And then he talked to our doctor about it. And so, you know, he was able to take in the information and make the decision for himself.

ROBERTS

10:14:11
That's Shannon Brownlee. Thank you so much. Shannon is the co-author in the -- of an article in last Sunday's New York Times, Do I Have Cancer? Yes, No, Don't Tell Me. And Shannon is also acting director of the New America Foundation Health Policy Program, an instructor at the Department Institute of Health Policy and Clinical Practice. Thanks again, Shannon. We appreciate it.

BROWNLEE

10:14:32
My pleasure.

ROBERTS

10:14:33
Now, for you doctors on the panel here, you heard Shannon lay out the options. And I want each of you to give our listeners a sense of how you would answer the question that I asked Shannon, what recommendations from your expert position you would give. And, Dr. Andriole, you're on the phone from St. Louis. And why don't you go first?

DR. GERALD ANDRIOLE

10:14:58
Steve, thanks very much. I think Shannon made some excellent points. And we really do emphasize to men that there are substantial downstream effects. The one thing I really think we're doing improperly in this conversation is posting a lot of headlines that are attention-grabbing, that sort of distill to a single recommendation a very complicated issue.

DR. GERALD ANDRIOLE

10:15:29
And so if a man reads or hears a headline that says don't get a P.S.A. test, he may not even want to think about it or talk about it at the appropriate time. My view is that I think -- be to take risk-adjusted approach to P.S.A. testing. There are clearly men out there in the population who will benefit from P.S.A. testing.

DR. GERALD ANDRIOLE

10:15:52
We sort of know who they are, and I think those are the men who, when they come in and have this conversation with me, I recommend to them that they do undergo P.S.A. testing. Because if we can test the population of men, enriched for men who are at risk for this disease, our potential benefits from the screening test will be greater than the studies that have evaluated men at average risk. And the harms of the test will be commensurately less.

ROBERTS

10:16:21
So what you're saying is that you have to be more careful in the use of this test?

ANDRIOLE

10:16:27
Right. I think a global recommendation to do it, just because you're 50, is wrong. I think a global recommendation to not do it is equally wrong.

ROBERTS

10:16:36
Okay. Interesting. Dr. Walsh from Johns Hopkins, what's your take here?

WALSH

10:16:42
Well, the way I talk to patients is I tell them that the P.S.A. test has given them an opportunity that people didn't have 20 years ago. Prostate cancer produces no symptoms until it's too far advanced to cure. So if we're going to catch it early, people have to be screened.

ROBERTS

10:16:59
Mm hmm.

WALSH

10:16:59
Twenty years ago, 1990, one out of every five men, 20 percent of men presented with metastases to bone. It's now one out of 25. It's -- so, today, men have a choice. They can be screened. They can -- out if they have cancer. They can make a decision about being treated or not. And I would disagree with our -- Dr. Brownlee that, you know, we have 800 men on active surveillance who have no problems with that.

WALSH

10:17:28
Or they cannot get a P.S.A. test and run the risk to being diagnosed with prostate cancer when it's too late to cure. I agree 100 percent with what Dr. Andriole just said, and that is we -- healthy men. And we look at men who don't want to die from prostate cancer and have a 15-year lifespan or greater.

ROBERTS

10:17:49
Dr. Ahaghotu, you're view on this subject?

DR. CHILEDUM AHAGHOTU

10:17:52
Well, thanks, Steve, for having me. I have tremendous concerns about the way that this is being reported. I have concerns about what screening is all about. That is, for the most part, most men who are diagnosed with prostate cancer in this modern age do not have symptoms, whether or not they go through the so-called screening process or whether they're diagnosed when they go into the urologist for non-specific symptoms.

DR. CHILEDUM AHAGHOTU

10:18:28
Bottom line is that these patients, who are being detected, are being detected at a point primarily because their P.S.A. is elevated. And so to now say that, okay, well, it's okay to do a P.S.A. test on individuals who come in with non-specific symptoms, but it's not okay to screen for patients in the general population, I think, is a flawed argument.

ROBERTS

10:18:53
We'll get back to this conversation with your phone calls and your comments in just a minute, so, please, stay with us.

ROBERTS

10:20:03
Welcome back. I'm Steve Roberts -- today for Diane. And our subject this hour is prostate cancer and a new government study, which recommends that men not take a very widely used test, P.S.A. test. Prostate-specific antigen is what P.S.A. stands for. And it's a controversial recommendation, and we're discussing this with doctors from major hospitals who have different viewpoints on this.

ROBERTS

10:20:30
Dr. Patrick Walsh of Johns Hopkins is with us in the studio. And Dr. Chiledum Ahaghotu of Howard University Hospital is with me as well. And joining us by phone is Dr. Gerald Andriole of Washington University School of Medicine in St. Louis. It seems to me, Dr. Andriole, that one of the problems here is defining what the danger is.

ROBERTS

10:20:55
And there seems to be some confusion. And maybe you can help us understand this because some people focus on this question of overdiagnosis. And some say that means that the test shows that some people who don't have cancer are diagnosed wrongly.

ROBERTS

10:21:17
Others say that they might, in fact, have cancer, but they won't die of it, that most men who are diagnosed actually have a slow-growing form of cancer that they will die with, not from, and that only three out of 100 men will be diagnosed with a fast-growing form of cancer that can threaten their lives. Thread your way through this problem of overdiagnosis and your take on it.

ANDRIOLE

10:21:43
Well, Steve, I think you started us out on a good pathway there. So if we took a group of 100 men and all we knew about them is that they were age 50 or older, the most we could say about it is that prostate cancer is apt to kill about three of those men. There are 97 men in there who are destined never to die of prostate cancer.

ANDRIOLE

10:22:05
And the challenge or what's been happening with P.S.A.-based screening is that if we screen all 100 men, okay, the potential winners are only those three men who are destined to die of this disease. Among the potential losers, the guys who will suffer some harm, are the 97 men who will have a P.S.A. test, some of whom will have elevated P.S.A. tests and, as a result of that, undergo some biopsies that have side effects and an infection rate and whatnot.

ANDRIOLE

10:22:36
And they suffer the anxiety of being labeled with having an elevated P.S.A. and not knowing for sure whether or not they have cancer because the biopsy can miss the cancer. And those men, among the 97, who are discovered to have cancer, well, they are the ones who tumble often to aggressive treatments. They shouldn't always, but many of them do for all the reasons cited in the article.

ANDRIOLE

10:22:58
And so, among these 97 men, there are a variety of ways in which they become losers and suffer harms. So my thought on this matter is that instead of screening an average population, where only 3 percent of men are destined to die of prostate cancer, couldn't we change the risk benefit ratio and try to screen a population that's enriched for men destined to die of prostate cancer?

ANDRIOLE

10:23:26
So imagine another scenario where we had a population of 100 men, where we knew 15 or 20 of them were going to die of prostate cancer.

ROBERTS

10:23:33
And how would you know that? Because of...

ANDRIOLE

10:23:35
Well, we...

ROBERTS

10:23:36
...predetermined risk factors?

ANDRIOLE

10:23:37
We know that because of family history. We know that because of race. And there's some intriguing evidence that a P.S.A. obtained very early in middle age, when a man is in his 30s or 40s, before he has BPH, which can confound the interpretation of the -- of P.S.A….

ROBERTS

10:23:57
What's BPH?

ANDRIOLE

10:23:57
...and then with -- benign enlargement of the prostate.

ROBERTS

10:24:00
Okay, okay.

ANDRIOLE

10:24:01
A process that can coexist with prostate cancer.

ROBERTS

10:24:04
Right.

ANDRIOLE

10:24:04
And it's very common in men over 50, but it also elevates the P.S.A. test.

ROBERTS

10:24:08
Right.

ANDRIOLE

10:24:09
But if we have knowledge of the P.S.A. value before a man develops this benign enlargement of the prostate, we could target our efforts at the men who have the highest P.S.A. values at that time in their life and aggressively screen them and maybe not so aggressively or at all screen the other men whose P.S.A.s are very, very low.

ROBERTS

10:24:32
Okay. Dr. Ahaghotu, it seems to me that another variable here is what people do with the results of the test. It's not just the test itself. But as Shannon was talking about, one of the big concerns here is the aggressive treatment, either the biopsies themselves or treatments that -- radiation surgery, which can have very serious side effects, impotence, incontinence. And these are the losers in Dr. Andriole's view.

ROBERTS

10:25:05
Is this part of what has to happen, a better management of the post-test protocols?

AHAGHOTU

10:25:16
Absolutely, I agree. I think that over-treatment is a big problem with prostate cancer. However, on the flip side, I think that we have opportunities of identifying individuals who are at higher risk of dying of their disease. Dr. Andriole talked about men of African descent. That's primarily my patient population. African-American men are three times more likely to die of prostate cancer.

AHAGHOTU

10:25:39
We have about a fourfold higher risk of having advance disease. So even if we don't die of the disease, we carry a disproportionate burden of the disease. And so to now put out a statement that we shouldn't be testing anybody, without commenting on those high-risk populations, I just think is not doing the public a service.

ROBERTS

10:25:58
So, presumably, you would agree with Dr. Andriole that one of the key lessons here is to be more careful and more selective, so that you get a -- you test the population for whom the benefit, the cost-benefit ratio is stronger on the benefit side.

AHAGHOTU

10:26:13
I think it comes down to having that conversation with patients. Unfortunately, we are not doing that as well as we used to as a group of -- in terms of physicians. We have to be able to have that conversation. You know, you can get a P.S.A. test. It doesn't guarantee you have to get a biopsy. But having the conversation about those risks are very important.

ROBERTS

10:26:32
Now, Dr. Walsh, another dimension here -- as I was reading materials, it struck me -- is that when you're talking about treatment and the potential side effects of treatment, these are highly emotional side effects, incontinence and even more so, perhaps, impotence. We're not talking about someone's big toe here.

ROBERTS

10:26:50
We're talking about some vital functions that are very tied up with men's concepts of themselves. And that adds to the emotional charge of this debate, doesn't it?

WALSH

10:27:01
Of course, it does. And it's all the more reason why men, if they have a diagnosis, need to seek out the best care.

ROBERTS

10:27:08
Mm hmm.

WALSH

10:27:08
They need to get a second opinion. The operation is a very tricky operation. You don't want someone who's just good at it. You want someone who's the best at it -- the same thing with radiation. Wonder if I could just add one point.

ROBERTS

10:27:20
Sure.

WALSH

10:27:21
You know, the risk of a woman dying from breast cancer is also 3 percent. So when we think about prostate cancer being only three out of 100, it's true for woman as well. And the problem is also that you don't wake up dead the next morning. The steps upon which you go through, the hormone therapy, the metastases, which are not counted as being a downside of not being screened, have to be taken into consideration.

ROBERTS

10:27:47
Well, also the point that Shannon made that I thought was so interesting is that we all know far more than when we used to about cancer. And because some of these treatments have been so successful, and also because there have been these public education campaigns about prostate cancer, about breast cancer, you can't turn on the television without seeing a public service ad, saying keep Dad in the game, urging people to get screened.

ROBERTS

10:28:15
That part of the education, it seems to me, is helping people understand that prostate cancer is different from some other forms of cancer, and that it is not necessarily as aggressive, and that, therefore, aggressive treatment is not always the best answer, and that people put a frame around this cancer. But all cancers are not the same.

WALSH

10:28:34
Well, I wrote a book for laypeople, which spells that out in black and white and, I think, clearly tells people about their options and encourages them.

ROBERTS

10:28:44
Let me ask another question. Several of you have said that it would be more helpful to screen for high-risk individuals. There's also that 3 percent who could die of prostate cancer because they have a faster growing or more malignant form of the disease. What is available to screen for those people, either pre- or post-test, and, therefore, also, refine the more aggressive treatments to the people for whom this could be most beneficial?

AHAGHOTU

10:29:21
Well, you know, there are number of tumor markers and biological markers that are being looked at to see whether or not they can improve the specificity of screening, that is, being able to identify those individuals who are at higher risk. Unfortunately, none of those studies have confirmed that these can be used generally. But, you know, there are a lot of smart people working on that.

AHAGHOTU

10:29:45
But, in the meantime, what we have is a test that can tell us whether or not you may be at risk of having prostate cancer. And then the conversation has to be about other factors, you know, ethnicity, family history, other factors that may drive that risk to more substantial levels. And at that point, a biopsy could be considered.

AHAGHOTU

10:30:06
The other thing is that, if you do have a biopsy, which is a relatively benign procedure -- it does have some possible small side effects, like infection and such -- you don't necessarily have to get treatment. And I think that conversation needs to be a little bit more robust and sophisticated, so that, you know, you don't just kind of wheel people into the operating room or into the radiation suite.

AHAGHOTU

10:30:27
You know, you have to have this conversation about what is their risk of actually dying of the disease after the diagnosis.

ROBERTS

10:30:35
Now, Dr. Andriole, we touched on this briefly with Shannon Brownlee, the question of what character and what kind of person is capable of watchful waiting, knowing that he has a cancer inside him and that how difficult that can be. Talk about your experience with patients and how you try to deal with men in this position.

ROBERTS

10:30:59
And is this one of the things that's important to emphasize, this kind of counseling and conversations, telling patients that they don't necessarily have to seek these potentially dangerous treatments?

ANDRIOLE

10:31:13
Yeah, I, like Dr. Walsh, have several hundred patients on active surveillance. And, in many respects, it's a lot more work than recommending that the man undergo treatment because the treatment seems easy, and it's "a slam dunk," as one of the speakers put it. But, you know, if you develop a relationship with your patient and you explain to him and his wife and other family members exactly what we know about his cancer and what the odds are...

ROBERTS

10:31:46
Mm hmm.

ANDRIOLE

10:31:46
We can never predict the future for sure, but we can use all the best available information we have. How many of the biopsy cores showed cancer? How aggressive under the microscope was that cancer? How rapidly is his P.S.A. rising? Or did it rise prior to the diagnosis of the cancer? All of these factors can give us a reasonable chance to predict the future course of that man's prostate cancer.

ANDRIOLE

10:32:12
And the thing is, you know, men are all over the map. Men -- some men, if you told them there's only a 1 percent that their cancer will kill them, they'll say, I want to get into the operating room tomorrow. On the other hand, you could have a second man in front of you, and you tell him, gee, there's a 35 percent chance that you're going to die of prostate cancer. And he says, well, look, that's two chances in three I'm not going to die of prostate cancer.

ANDRIOLE

10:32:38
Just, you know, keep -- continue to watch me. And I'm not sure either guy is wrong. I'm only satisfied when I'm confident that each of those two men has been fully appraised of the odds and is making the decision in conjunction with his family members that works best for him.

ROBERTS

10:32:57
I'm Steve Roberts. And you're listening to "The Diane Rehm Show." We have a lot of callers, of course, who want to enter into this. And you look at The New York Times this morning, and several very forceful and emotional letter writers saying, a P.S.A. test saved my life. And this is something that you hear as doctors all the time, which goes, again, to some of the recommendations that we've been talking about.

ROBERTS

10:33:23
And let me just read one email, of many we've gotten, from Bruce in Maine. "I am 57 and a seven-year prostate cancer survivor. Because of a P.S.A. test, my cancer was detected early, and I have had no lingering effects or treatments post-surgery. I find all the buzz lately about P.S.A. testing being unnecessary, disturbing. I know many prostate cancer survivors through support groups.

ROBERTS

10:33:45
"I know of no..." -- no, capitalized -- "...no prostate cancer survivors who did not have a P.S.A. test." Dr. Walsh, reaction to that viewpoint.

WALSH

10:33:56
I think he's absolutely right, and I think that Shannon Brownlee really kind of misinformed us. She said that the task force looked at the data out there. They did not. Deaths from prostate cancer have fallen 40 percent since P.S.A. testing was introduced, more than any cancer in men and women. In 2007, 27,000 lives were saved if you calculate the data based upon the A-specific death rate in 1990 compared to 2007.

WALSH

10:34:29
The task force did not use any of these numbers. They sat in offices out in Oregon. They looked at two randomized trials with less than 10 years follow-up. We all know that P.S.A. testing or treatment is not indicated in a patient with a lifespan less than 10 years, yet their recommendation is based upon two trials, one with seven years of follow-up and one with nine years.

WALSH

10:34:54
I think they have misinformed the public and have done a disservice in that recommendation.

ROBERTS

10:35:02
Dr. Ahaghotu, do you agree with that or disagree?

AHAGHOTU

10:35:05
Yes. I think that they've done more harm than good. I have no doubts about that. I think the other thing that I wanted to comment on is, you know, this sort of black and white, if you will, portrayal of prostate cancer.

ROBERTS

10:35:17
Mm hmm.

AHAGHOTU

10:35:18
You've got the good, and you've got the bad. It doesn't work like that. There's all the in-between. In fact, we know, based on the biology of prostate cancer, that it evolves over a person's lifespan. So, yes, there are men who will not die of prostate cancer. But there are men who, originally, may appear to have a relatively indolent disease.

AHAGHOTU

10:35:37
But if you follow them over time, just like these patients who are being followed for active surveillance, a percentage of those patients will go on to show evidence that they're going to need treatment. So to just throw this P.S.A. test out the window, I think, is not a good thing.

ROBERTS

10:35:51
Dr. Andriole, what do you say to the many men who -- either ordinary folks like our listeners or the more prominent advocates, like Michael Milken, Joe Torre, the baseball manager and others who have been very public in their advice to men to get tested. What's your take on this?

ANDRIOLE

10:36:14
Well, you know, I think we're talking around many of the same points here. Having a P.S.A. test, there will be winners, and there will be losers. And for some men, they will look at the information and want to be screened. And I think it's perfectly appropriate for them to be screened provided that, at every step along the way, if the P.S.A. is elevated, they make an informed decision about whether to be biopsied.

ANDRIOLE

10:36:42
Should that biopsy show cancer, they need to make a hard decision about whether or not they want aggressive treatment. We can do a lot better than we have been doing by individualizing our recommendations in our approach to screening and to treatment.

ANDRIOLE

10:37:00
And I do think, as all the other panelists have said, that it is a bit of a disservice to put out a headline that says don't get a P.S.A. test because there are definitely men who will benefit from P.S.A. testing. We know who they are, and we've got to have them come and see us.

ROBERTS

10:37:19
But part of your message is use this information much more carefully than it's been used up to now.

ANDRIOLE

10:37:27
We have to use information on an individual level that -- and make it apply directly to the patient sitting in front of us in the office, not from a statistical level.

ROBERTS

10:37:40
Excellent. Thank you so much. We're going to be back with your phone calls. A lot of you are on the line. I'm going to get to you as soon as we come back, so stay with us.

ROBERTS

10:40:03
Welcome back. I'm Steve Roberts, sitting in today for Diane while she's away on vacation. And our subject this hour is prostate cancer and a major new study that has caused a lot of discussion, a lot of controversy on the efficacy of the very common test, the P.S.A. test, that many men take for detecting whether they are at risk of prostate cancer.

ROBERTS

10:40:24
Three experts with me today: Dr. Patrick Walsh of Johns Hopkins, Dr. Chiledum Ahaghotu of Howard University Hospital here in Washington and, joining us by phone from KWMU -- we're always grateful for their help in St. Louis -- Dr. Gerald Andriole, who teaches at the Washington University School of Medicine.

ROBERTS

10:40:42
Gentlemen, here's a very interesting email from Ben in Baltimore, who says, "If the government says a test isn't needed, doesn't this give insurance companies leverage to deny coverage?" Dr. Walsh?

WALSH

10:40:54
Sure, it does. They're claiming in the newspaper they're not going to, but we all know what will happen. I think everyone needs to know that that panel had no urologist or no specialist on prostate cancer on the panel. And that's why, I think, it came off so lopsided without recognizing that their recommendations, really, are discordant with the observed data.

ROBERTS

10:41:17
Well, there's also another factor, in addition to the insurance company, Dr. Ahaghotu, is the fact is that treatment of cancers, prostate cancer, is big business. There are lot of companies who market medicines and treatments. And is that weighing at all on this discussion, the financial interest that's (word?) ?

AHAGHOTU

10:41:40
Well, it has to. I mean, you know, finances play a role in pretty much everything we do. And so, obviously, that is a concern. But once again, I think that it should fall back on the stakeholders who are involved in managing prostate cancer to sort of take the reins again and really develop guidelines on how we use the P.S.A. in our practice on a daily basis.

AHAGHOTU

10:42:04
And that involves conversations with patients. But I think that we, you know, as group should have guidelines to assist us on how to have that conversation.

ROBERTS

10:42:14
Well, let's have a conversation with some of our listeners who want to contribute to this conversation. And we'll start with Hazel in The Woodlands, Texas. Hazel, welcome to "The Diane Rehm Show."

HAZEL

10:42:23
Thank you for taking my call. And, like you said, I agree that it's a highly emotional conversation. And I wonder -- my father was diagnosed with prostate cancer at the age of 61, 20 years ago. I know that treatments have changed. And diagnosis has changed in how they're perceived when you get that P.S.A. reading, and it's high. And I have a 20-year-old son.

HAZEL

10:42:52
At the time my father was diagnosed, he was given, with or without treatment, three to five years to live. Twenty years later, he's still with us and relatively healthy, and his cancer specialist tells him, Mr. Edwards, this may not be what kills you. So that's a positive thing. I'm curious as to how will that affect my son's life and whether he should be aggressively tested or skip it altogether?

ROBERTS

10:43:19
Good question. Dr. Andriole, we were talking about enhanced risk factors as a critical dimension to this. How would you answer our caller?

ANDRIOLE

10:43:27
She's absolutely right. I mean, there is no question that there are familial clusters of prostate cancer. Now, we generally would say for a man who just has one relative who have prostate cancer, and particularly if that prostate cancer was discovered when he was an elderly man in his 70's or 80's, that's not nearly as meaningful as a scenario where a man has two or more first-degree relatives, and particularly if their diagnosis of prostate cancer occurred at a young age, during the 50s.

ANDRIOLE

10:44:02
That is a good working definition of a strong family history for prostate cancer.

ROBERTS

10:44:07
That sounds...

ANDRIOLE

10:44:08
And men who fit in that category, I think, should really think long and hard about getting a P.S.A. test.

ROBERTS

10:44:14
That really sounds rather familiar in terms of the guidelines for breast cancer as well, isn't it, in terms of the kind of family history that is an indicator of elevated risk?

ANDRIOLE

10:44:25
There are many similarities between prostate cancer and breast cancer and between the screening tests we use for prostate cancer and breast cancers. So that's an interesting story in itself.

ROBERTS

10:44:37
Let's turn to Katie in Tallahassee, Fla. Welcome, you're on "The Diane Rehm Show," Katie.

KATIE

10:44:42
Hi. Thank you for taking my call. My father was diagnosed in his 50s, and he is not in one of the elevated risk factor groups. He's a white male, and, you know, he did not have a high P.S.A. They had, you know, taken it routinely for years. It wasn't a high number, but it had doubled from one year to the next. And so he had the biopsy, and it was shown that he did have prostate cancer. And he had a radical prostatectomy, like most people.

KATIE

10:45:17
But he had it with the robotic technique, so it was a bloodless field. And they were able to get clean margins. And he's had, basically, no -- after he, you know, recovered from surgery, he's had visibly no negative side effects of everything. And his P.S.A. is, you know, non-existent now, and they're continuing to monitor it.

KATIE

10:45:37
And I feel like, would we really be recommending women -- you know, because there's lots of things that show up on mammograms that somehow, you know, might not have ever turned into something major in terms of breast cancer or a fast-growing malignancy, would we recommend women not getting mammograms? And the P.S.A. is, in my opinion, less expensive and less invasive than a mammogram.

KATIE

10:46:04
And isn't it a kind of a well-established medical fact that, you know, men tend to not, you know, get tested and not take, you know, steps toward their own health care? I mean, I feel like this is kind of, like -- this is kind of dissuading a population that needs to be encouraged to seek medical treatment more often.

ROBERTS

10:46:31
Thank you very much. Dr. Ahaghotu, what about that? We were talking earlier about these major campaigns to inform men, to say get tested, be aware. As I say, you see them on every baseball game. There is a -- they know who's watching the baseball games. And our caller makes a very good point, that, often, men don't take good enough care of their health. So how does that factor into your reaction here?

AHAGHOTU

10:46:57
Well, you know, health-seeking behavior is a very important concept that we're looking at when it comes to early detection strategies. And, you know, in the African-American population, we believe that that is a big factor that may be playing a role in delayed diagnosis and possibly not as good outcomes as you see in other populations. But I think that the bottom line here is that we need to educate our patients better.

AHAGHOTU

10:47:22
We need to empower them to make the decision about what they want to do with their body. I think that's what it really comes down to.

ROBERTS

10:47:30
Would you change the P.S.A.s? Would you have them read differently than they do now?

AHAGHOTU

10:47:34
Well, I'm not sure about having them read differently, but I do think that, you know, having multiple P.S.A.s are certainly more helpful than having one P.S.A. I think that looking at other factors, you know, family history, ethnicity, other factors, other medical problems may help in making that decision.

ROBERTS

10:47:56
Dr. Walsh?

WALSH

10:47:56
I think the caller brought up a very important point, and that is looking at P.S.A. change from year to year. Her -- this young man's result, his P.S.A. was low. If your P.S.A. is less than four, but it's going up by more than .4 per year, you really need to be seen.

WALSH

10:48:13
Studies by my associate at Hopkins, Dr. Carter, have shown that those men who have rises like that, when they were in their 40s and got no treatment, had about a 50 percent mortality from prostate cancer 20 years later.

ROBERTS

10:48:27
Let's turn...

ANDRIOLE

10:48:27
Steve...

ROBERTS

10:48:28
Yes.

ANDRIOLE

10:48:28
...in St. Louis, if I could...

ROBERTS

10:48:30
Sure.

ANDRIOLE

10:48:30
...amplify on Dr. Walsh's comment and get back to what the caller said, you know, most of the data that the task force looked at considered only a P.S.A. threshold change. They waited for the P.S.A. to become above a certain level and then trigger a biopsy and a potential intervention. We've learned a lot about P.S.A. And as Dr. Walsh and the caller said, we now would use P.S.A. differently.

ANDRIOLE

10:48:57
We wouldn't monitor the men who were in these screening studies until their P.S.A. rose to the level that we thought was the appropriate level in 1993 when we designed these trials. We know more now, so it may well be that if we did another screening trial using P.S.A. in the refined way that we've learned over the last 20 years that we would do a better job.

ROBERTS

10:49:23
Oh, that's a really interesting point, that with all of these long-term medical studies, as knowledge changes during the course of the study, which makes -- to some extent, renders the results at least, if not obsolete, that they're not necessarily current with current information.

ANDRIOLE

10:49:42
Absolutely correct. We have to put an asterisk on everything that we know because we pivoted all of our decision making off a rule that has since been modified.

ROBERTS

10:49:53
Now, a very good point. Thank you for making it. Let's turn to Hamish, (sp?) if I have your name correctly, in Sycamore, Ill. Welcome. You're on "The Diane Rehm Show."

HAMISH

10:50:02
Yes. Good morning. I have cancer in my family, and my uncle died from prostate cancer. I was -- had a blood test, and they called me in. And then I had an examination, and I had a lump. I went for the -- have samples taken out of my prostate. And the lump was perfectly healthy, but they found, on another section, cancerous cells. I went and got a second opinion. I had -- I made the decision to go ahead and have it out.

ROBERTS

10:50:50
Right.

HAMISH

10:50:51
I went and got another opinion, and they have decided to have it out. Or, you know, I still maintain the decision.

ROBERTS

10:51:01
Right.

HAMISH

10:51:02
But nobody, at any time, said much more about the different treatments. Now, my -- when the prostate came out, it was enlarged, but there was only -- like, it was less than 5 percent of the total prostate that was cancerous.

ROBERTS

10:51:29
So what's your question for the doctors here?

HAMISH

10:51:30
Well, that -- I think I was very much misinformed about the seriousness of it. I mean, to me, you say cancer, okay. It's going to come out. And I think that I should've had other treatments. I mean, the decision was mine. I'm not trying to put all the blame on the doctors.

ROBERTS

10:51:49
Right.

HAMISH

10:51:50
But I think they should talk more, get to know their patients better.

ROBERTS

10:51:55
It's an excellent point. Thank you very much. You're listening to "The Diane Rehm Show." Dr. Walsh, how do you respond to the caller?

WALSH

10:52:02
I absolutely agree with him. And you always get a second opinion.

ROBERTS

10:52:06
I think you all agree, right? You all agree with this.

WALSH

10:52:07
We all agree. Absolutely. And, you know, one of the reasons I wrote a book for laypeople is it spells it out in there. And this man could've looked at that and seen that the risk of him having low volume cancer was very high and that he had other options, including observing it for a time.

ROBERTS

10:52:25
You know, you've -- you and Dr. Andriole had both made this point that you have several hundred patients under surveillance...

WALSH

10:52:33
Eight hundred.

ROBERTS

10:52:34
That's -- surveillance sounds like you're peeking in their windows, but I know what you mean. And is this increasingly the treatment of choice, at least for some segments of the population?

WALSH

10:52:46
The NCCN guidelines, National Comprehensive Cancer Network, says that for men with low volume cancer who have a less than 20-year lifespan, that is the number one choice. And patients can go on the NCCN guidelines and look themselves up in those tables to see what's best for them.

ANDRIOLE

10:53:06
Steve, I tell my patients, you know, they can make an initial decision to go on active surveillance, and they could readdress that decision periodically. So they're not -- it's -- a man with a diagnosis...

ROBERTS

10:53:17
It's not a one-time only judgment.

ANDRIOLE

10:53:21
Correct. And he's not sitting there with a gun to the back of his head, saying, do something, make a decision right now, one way or the other. So we have plenty of time with this disease.

AHAGHOTU

10:53:31
But I think it's important also to remember that you have to really be careful about who you're defining as good candidates for active surveillance because, unfortunately, patients will sometimes just kind of pick up what they want to hear. And so there are patients who probably are not good candidates for the active surveillance. I think the guidelines are fairly defined.

ROBERTS

10:53:51
Let's turn Robert in Baltimore who has a special take on this. Robert, welcome, you're on "The Diane Rehm Show."

ROBERT

10:53:57
Good morning. And good morning to your guests.

ROBERTS

10:53:59
Thank you.

ROBERT

10:53:59
Yeah, I actually -- I praise the P.S.A. in that, and I also was quoted in The New York Times piece this past weekend. My dad had prostrate cancer. And so, at 40, I began to really rely on that P.S.A. test to...

ROBERTS

10:54:16
And you're also African-American, so you have double risk.

ROBERT

10:54:18
African-American. Exactly. And one of the things that I thought that was misleading about the news is that men generally don't do health well. You know, unless you're losing a limb or bleeding from the head, you know, you're not going to see a doctor. And I just thought the study gave men just another reason to put this on the back burner. And, again, I felt that by me having the P.S.A. done, that it saved my life.

ROBERT

10:54:46
But, you know, Dr. Walsh hit it on the head as well, and so did the other doctors, in that you really need to get a second opinion. I think, you know, you have to have the frank conversation with your doctor to point out everything that's involved, even the post-treatment, you know, some things that may go on. I've been out of my treatment for the last 10 months. No incontinence, no impotency, so it's been -- it's worked well for me.

ROBERT

10:55:14
But given my history and family history, I thought it was an important decision for me to make to make sure that I'm around for my family and to make sure that, you know, other men just don't leave this on the -- by the wayside and not get tested.

ROBERTS

10:55:30
Robert, thanks so much for your call.

ROBERT

10:55:32
You're quite...

ROBERTS

10:55:33
Dr. Ahaghotu, Robert would clearly fall into your definition of someone at higher risk who is different from other parts of the population, and this is a big part of your message, that not everybody is the same.

AHAGHOTU

10:55:44
Absolutely. But, again, there are men of African descent who would meet the criteria for active surveillance. I also have, maybe not several hundred patients, but I do have a few hundred patients who are on active surveillance protocols. And, you know, it's about, again, making that -- having that relationship with the patient, coming to a decision together, and then moving forward together.

ROBERTS

10:56:05
Each of you, a final word, what do you want our listeners to take away from this conversation? Dr. Andriole?

ANDRIOLE

10:56:12
Well, don't just read the headline. You know, the headline can be misleading, but let it serve as a guide to start a conversation with your family doctor 'cause many of these patients don't see a urologist. They're dealing with their family physician and caregiver. Start the conversation there.

ROBERTS

10:56:32
Okay. Let me...

ANDRIOLE

10:56:32
And if you need additional information, then come to your urologist.

ROBERTS

10:56:36
Dr. Walsh, quickly, I'm afraid.

WALSH

10:56:37
Men need to educate themselves.

ROBERTS

10:56:40
And Dr. Ahaghotu.

AHAGHOTU

10:56:41
Avoid broad and sweeping recommendations.

ROBERTS

10:56:44
Including from us.

WALSH

10:56:47
Touché.

ROBERTS

10:56:48
Excellent. Gentlemen, thank you so much, Dr. Patrick Walsh from Johns Hopkins, Dr. Chiledum Ahaghotu from Howard University, and Dr. Gerald Andriole -- thanks to KWMU St. Louis -- teaches at Washington University School of Medicine. I'm Steve Roberts, sitting in today for Diane while she's on vacation. And thanks so much for spending an hour of your morning with us.

ANNOUNCER

10:57:08
"The Diane Rehm Show" is produced by Sandra Pinkard, Nancy Robertson, Susan Nabors, Denise Couture, Monique Nazareth, Lisa Dunn, and Nikki Jecks. The engineer is Erin Stamper. A.C. Valdez answers the phones. Visit drshow.org for audio archives, transcripts, podcasts, and CD sales. Call 202-885-1200 for more information. Our email address is drshow@wamu.org, and we are on Facebook and Twitter. This program comes to you from American University in Washington. This is NPR.
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