The Prostate Cancer Dilemma

The country is embarking on a huge screening program for prostate cancer which is likely to cost billions and may lead to many unnecessary operations, especially for elderly patients. But what may be bad at the national-policy level could be a lifesaver at the individual level for men in their fifties and early sixties.

Because the individual patient cannot know whether he is one of the lucky men with a slowly progressing case, it is likely that most of those 405,000 men would undergo radical prostatectomy. What would happen? The conservative approach to this question is to find out the results obtained from operations in the past and project them into the future. According to the Prostate Patient Outcomes Research Team, which did just that using data on prostatectomies performed from 1981 to 1991, between 0.5 percent and two percent of all radical prostatectomies led to death within a month, with older men facing the most risk. More than five percent led to pulmonary embolism or some other serious complication in the hospital. At least 30 percent of the potent men who underwent prostatectomy in this period became impotent; seven percent lost all urinary control; many more had intermittent difficulties in both areas. And perhaps 20 percent were told that during surgery it was discovered that the tumor had already spread, and they would need further treatment (radiation, hormone therapy, or removal of the testicles). These figures imply that operating on all 405,000 men would result in 2,000 to 8,000 deaths, at least 20,000 cases of serious complications, at least 120,000 cases of surgeryinduced impotence, about 28,000 cases of surgery-induced total incontinence, and more than 80,000 cases of cancer requiring more treatment, along with many other cases of lesser problems. Meanwhile, men with elevated PSA levels but no sign of cancer would be likely to have biopsies again and again, because of the red flag in their blood - a process one doctor jokingly calls "prostatectomy by installment."

THE effort would be very expensive. PSA tests and rectal exams cost about $80 together; biopsies cost perhaps $350. If 20.6 million men had PSA tests and rectal exams and two million had biopsies, the bill would be in the neighborhood of $2.3 billion. The average cost of a prostatectomy is about $20,000, according to Kit Simpson, a healthpolicy specialist at the University of North Carolina at Chapel Hill; 405,000 of them would cost $8.1 billion. Treating the impotence or incontinence caused by surgery can cost $10,000 per patient. The total price of remedying such side effects would depend on how often they occurred, but in 1990 an economic study by a statistician and a urologist at the U.S. Army medical complex in Fort Sam Houston, Texas, projected that the extra expense for side effects might reach $2.1 billion. At the time, the two men pointed out, the national bill for prostate cancer was $255 million. An immediate nationwide program of screening all men in the proper age category, they said, would drive the price up to $28 billion - a hundredfold increase. To critics, such figures suggest that a screening program could sentence hundreds of thousands of people to immediate and costly suffering in the name of avoiding a disease that will kill only a small number of them many years in the future.

Nobody I have spoken with thinks that the United States could examine and treat 20.6 million men cheaply and painlessly. But proponents of mass PSA screening argue that estimates like these are based on inaccurate data. Claims that side effects from operations in the future will be at the level of those in the past ignores evidence from surgeons like Walsh and Catalona that the nervesparing technique is an important advance. Instead of a death rate of one in a hundred, these surgeons report death rates of zero to one in 600. Walsh and Catalona say that instead of seven out of a hundred becoming completely incontinent, and many more having problems, not one of their first 1,200 patients lost all urinary control, and only six to eight out of a hundred had any problems whatsoever with incontinence. Although these figures should not be taken as national averages, using them in calculating the cost of treating side effects would change the projections drastically. Indeed, it was the publication of the pessimistic estimate by the Prostate Patient Outcomes Research Team, which made little allowance for the improvement in surgical techniques, that caused the calls from the newspapers which so exercised Walsh during my visit.

Proponents also accuse critics of skewing their figures by overestimating the costs (such as saying that many seventyfiveyearolds will have the operation) and underestimating the benefits (failing to include the avoided years of pain from bone cancer, for instance). A prostatectomy today may cost $20,000, but treating that same cancer at a later, more advanced stage may cost $70,000. Most important, although many men diagnosed as having prostate cancer will never feel any effects from the disease, failing to treat the rest would sentence thousands of people to a death of rare awfulness. "Every fifteen minutes an American man dies of prostate cancer," Catalona says. "And when that happens, he's been through hell. None of them have a pleasant death. There's a long period of pain and agony with broken bones, urinary obstruction, constipation from all the morphine - it's horrible."

"The screeners say, How can you deprive all these people of a valuable treatment?" says Gerald Chodak, a urologist at the University of Chicago School of Medicine. "The other side says, How can you do all these things to people and not know if they really have any benefit?" It seems impossible to resolve the issue rationally, because the evidence is of such poor quality. The American Board of Urology and the American Urological Association have no idea, for instance, how many surgeons have been trained in Walsh's techniques. Surgeons like Catalona and Walsh assert that many of their colleagues know the new methods; outside observers like Wasson suspect that they don't.

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Charles C. Mann, an Atlantic contributing editor, has been writing for the magazine since 1984. His recent books include 1491, based on his March 2002 cover story, and 1493.

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