By Dr. Ronald Hoffman
Stars are lining up, telling us how to vote, what wireless networks to use, what luxury cars to drive. Now they're weighing in on our health choices. Recently, Ben Stiller offered his take on the PSA test, a screening exam that's designed to predict the risk of prostate cancer.
In a well-publicized essay , Stiller claims "The PSA saved my life":
"Taking the PSA test saved my life. Literally. That's why I am writing this now. There has been a lot of controversy over the test in the last few years. Articles and op-eds on whether it is safe, studies that seem to be interpreted in many different ways, and debates about whether men should take it all. I am not offering a scientific point of view here, just a personal one, based on my experience. The bottom line for me: I was lucky enough to have a doctor who gave me what they call a "baseline" PSA test when I was about 46."
Stiller acknowledges that there has been controversy over the use of the PSA as a screening tool. The American Cancer Society suggests waiting until 50 for a man's first PSA test, unless there is a strong family history, suspicious symptoms, or membership in a high-risk group, like African-Americans.
Even more nihilistic are the recommendations of the US Preventive Services Task Force (USPSTF) which recommends against screening PSAs at all. Admittedly their position is controversial; most urologists have pushed back, insisting the PSA saves lives. Stiller writes:
"But without this PSA test itself, or any screening procedure at all, how are doctors going to detect asymptomatic cases like mine, before the cancer has spread and metastasized throughout one's body rendering it incurable?"
It turns out Stiller had a Gleason 7 cancer score-the most "curable" form of prostate cancer with radiation or surgery. A prostate cancer with a lower Gleason score of 6 or less has now been shown to be safely treatable with Active Holistic Surveillance-careful monitoring accompanied by diet, exercise and supplements
Why is Stiller's claim that his life was "saved" by aggressive, early screening dubious? A useful corrective is provided by Anna Almendrala, Senior Healthy Living Editor of The Huffington Post:
"Counterintuitively, while Stiller believes that he saved his own life by getting a PSA test early, his example goes against medical recommendations that are in place to protect men from unnecessary treatment and serious, potentially life-threatening side effects that can come from treating a cancer that probably won't kill them."
Since prostate cancer is often a slow-growing, indolent disease, many men get aggressive treatment for a cancer that might not kill them until they're, say, 110-in the unlikely event that other diseases don't fell them well before.
The fact of the matter is, according to autopsy results, the average man over 75 is almost certain to harbor prostate cancer cells when the pathologist slices and dices his prostate. These are men who died from causes other than prostate cancer!
The side effects of treatment are not negligible-urinary incontinence and impotence are frequent, disabling consequences. Biopsies, too, are not without complications of infection or bleeding. One man I saw recently who had "routine" radiation that was claimed to be safe and "highly-focused" had such severe radiation burns of his rectum that he now suffers from chronic diarrhea.
Hence, the "cure"-which, by the way, is not always definitive-is sometimes worse than the disease.
Not that we shouldn't attempt to identify prostate cancer early to save the small percentage of men who will truly benefit from aggressive, lifesaving therapy, even with its side effects. What we need are better tests that will help differentiate slow-growing prostate cancer from its rampantly-progressive, life-threatening counterpart. Such tests are under development now, but are only being used in small research studies and not generally available.
Additionally-and this needs to be stated-we're currently "curing" only the easier prostate cancers. The more aggressive kind inevitably breaks through our current therapies. So, while it may seem cynical to say so, a majority of men diagnosed with prostate cancer either don't need treatment, or will die eventually no matter what we do-at the cost of debilitating, life-shortening side effects like diabetes, loss of mojo, and heart disease. Granted, a certain percentage-Stiller may or may not be among them, and we'll never know?are destined to be saved by strenuous interventions.
The tendency when threatened with a life-threatening circumstance is to retrospectively attribute one's survival to an antecedent "correct" decision. That personal narrative may be validating for "survivors" of cancer like Stiller, but it hardly constitutes scientific advice to guide the decision of other men.
The issue of overzealous screening was recently tackled in Overdiagnosed: Making People Sick in the Pursuit of Health by Dr. H. Gilbert Welch. The PSA is not the only test on the chopping block: routine screening mammograms, colonoscopies and PAP smears, especially in older patients with previous normal exams, have recently been challenged.
Angelina Jolie recently entered the medical arena with her essays about preventive mastectomy and hysterectomy. Arguably, her BRCA1 genetic status conferred a higher risk of breast and ovarian cancer, and her decision to have her breasts and ovaries surgically removed could be warranted. But interestingly, the publicity attendant to her announcement has prompted a rise in at-risk women undergoing "prophylactic" mastectomy-sometimes for reasons far less compelling than Jolie's.
Some women with Jolie's predicament have consciously opted for surveillance instead of surgery. For example, DCIS, a form of pre-breast cancer previously routinely treated with bilateral mastectomy, has now been deemed less dangerous and amenable to just plain lumpectomy or even watchful waiting. We recently published a natural surgery-free protocol for some women with this condition.
Celebrity endorsements of medical therapies are not a new phenomenon. In 1958, Milton Berle became one of the first stars to promote a pharmaceutical drug, according to a review published in the American Journal of Public Health. Calling himself "Miltown Berle," the comedian joked about his use of a sedative called Miltown-a drug long since discredited due to its serious side effects and addictive potential.
Celebrities from Bob Dole (Viagra) to Sally Field (Boniva) to Bruce Jenner (Vioxx) to Larry the Cable Guy (Prilosec OTC) have garnered endorsement fees by touting drugs with sometimes questionable efficacy and possible side effects. They are not scientists or health professionals, and deny responsibility for unforeseen consequences of the medications they promote.
Public Citizen weighed in: "Consumers should beware of medications promoted by celebrities in direct-to-consumer advertisements. A celebrity endorsement of a drug does not make the message any more valid from a health care perspective."
So when your favorite celebrity comes on TV touting a procedure or drug for a condition that matches your own, crank up your skepticism and perform due diligence via careful research with the aid of a trusted health professional.
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