Whenever I have a medical appointment, my wife inquires, "What did the doctor say?" I always give the same answer: "She said I'm going to die." Not because I have some fatal illness, but because life is a terminal condition.
Americans might keep that fact in mind in considering the recent news made by the U.S. Preventive Services Task Force. It recently recommended against routine screening of healthy men for prostate cancer, on two grounds: The test doesn't save lives, on balance, and the treatments are usually worse than the disease.
Everyone who gets prostate cancer will die. But usually not from prostate cancer.
There are lessons in the task force report, both for individuals and for institutions that pay for screening of this sort. But chances are, those lessons will be ignored. In the American health care system, the pressures to do something, useful or not, are more powerful than the pressures to do nothing.
Prevention is a totem of modern medicine. Under his health care reform, President Barack Obama says, insurance companies will have to provide free mammograms and colonoscopies because "it saves money, and it saves lives." He stuck to this position even after this same Preventive Services Task Force came out against routine mammography for women under 50.
This is one of those conditions where ignorance can truly be bliss. Most men who live long enough will develop cancer of the prostate. And for most of them, it will be effectively harmless.
The idea of a harmless cancer may be hard to grasp. Typically, though, prostate cancer grows very slowly and has no symptoms, and by the time it gets around to killing you, you're already dead.
In the old days, countless males walked around with a song in their hearts and a spring in their steps, despite the malignant cells in their nether regions. They didn't know, and it didn't matter. But then scientists invented the PSA test, doctors started using it, and men by the millions found out they had prostate cancer.
Worse yet, they—or, rather, their doctors—proceeded to do something about it, namely surgery. When physicians wielding sharp instruments start removing stuff down there, the endeavor has definite drawbacks, such as sexual and urinary dysfunction.
What it doesn't have is definite benefits. A 2004 study found that for every 48 men who undergo operations for prostate cancer, only one will live longer as a result. But half will suffer permanent side effects affecting a certain cherished organ. Other studies are even more damning, finding that screening had zero effect on the death rate.
How can that be? Several reasons: The test often yields false positives, it can't tell if the cancer is truly dangerous, and surgery doesn't always work. A lot of patients get treated for cancers that won't kill them, and others get treated for cancers that will kill them anyway.
Richard Ablin, a scientist at the University of Arizona College of Medicine, discovered the enzyme that the test picks up. But he wrote last year in The New York Times that PSA screening is "a hugely expensive public health disaster."
Some 20 million men get the test each year, to find out something that will almost certainly do them no good. We assume that knowledge is always a boon. But this time, it isn't.
The prevailing approach to prostate cancer illustrates our collective disregard for medical expense. Some $3 billion a year is spent in this country for PSA screening, with Medicare, Medicaid and the Veterans Administration often picking up the tab.
That doesn't count the cost of the roughly 85,000 surgeries done each year on cancerous prostates, or the expense of treatment for the side effects that often ensue. The federal task force didn't factor finances into its recommendation. But the rest of us ought to.