Friday, April 27, 2012

Why Warren Buffet may finally be making a mistake

When I saw that Warren Buffet was diagnosed with prostate cancer, I wondered, why did he even get his PSA checked?  I often tell my patients that if a man lives to be 100 years old, he will have prostate cancer and he will not die from it.  Granted, there are exceptions to every rule, but in my career as a geriatrician, I have seen two men over the age of eighty die from prostate cancer.  I’m pretty sure that both of them had the disease before they turned seventy.
I don’t know the specifics of Warren Buffet’s prostate cancer diagnosis.  It is theoretically possible that he has an unusually aggressive form of the disease.  It is much more likely that he has a PSA of 6 or 7, and that a biopsy showed that he had evidence of prostate cancer.  In this case, before undergoing treatment, he needs to take a long, hard look at the risks of treatment.  Being a multibillionaire will not keep him from the potential side effects of treatment!
Radiation has become a common treatment for prostate cancer.  While radiation will kill the prostate cancer cells, it can also cause side effects like radiation proctitis, incontinence and erectile dysfunction.  
Another common treatment are medications that lower a mans testosterone level.  This will also kill prostate cancer cells.  The problem with this is that low testosterone levels also have their own pathology.  The classic triad of symptoms of low testosterone in an older man is heart disease, muscle weakness and anemia.
Our health care system is structured to pay for treating disease, regardless of whether the treatment is beneficial to the patient.  In the case of prostate cancer, the doctors get paid, the pharmaceutical companies and medical device companies make money.  What about the patient?  Men over the age of 80 should look carefully at the risks of treatment versus the potential benefit.  We really have no scientific evidence that treating prostate cancer in men over the age of 80 either saves lives or improves the quality of life.  
For the past twenty years as a geriatrician, I have approached prostate cancer in my patients very conservatively.  Two stories illustrate my experiences and the potential consequences of treatment.
About five years ago, one of my 89 year old patients was showing evidence of decline in his functional abilities and overall health.  He was hospitalized for pneumonia and had been to the emergency room for episodes of passing out.  He had been treated for several years for his diagnosed prostate cancer so that his PSA was maintained at zero.  We discussed stopping treatment.  His urologist balked when I called to suggest not only discontinuing his hormonal therapy, but putting him on topical testosterone to get his testosterone level back to normal.  I pointed out to the urologist that there is good evidence that PSA’s under 20-30 are generally not associated with extension of the prostate cancer to the bone.  He agreed.  Over the past five years, my patient has maintained a relatively healthy and functional life.  In fact, he has not been hospitalized once during that period of time.  His PSA has slowly risen and now hovers around 17-18.  
Several years ago, I saw an 85 year old man for the first time.  He had moved from another state where for four years he had multiple hospitalizations for falls.  His medical records indicated that hundreds of thousands of dollars had been spent on his health care needs.  He was now in a wheel chair.  It turned out that he had been diagnosed with prostate cancer and had actually been treated with the least costly antihormonal therapy.  His testicles had been removed.  We put him on topical testosterone and within six months he was out dancing!  He lived another five years and died from natural causes not remotely related to prostate cancer.
If you are over the age of eighty and are diagnosed with prostate cancer don’t accept the recommendation of treatment without grilling your doctors about the risks and benefits of treatment.  Ask them to provide scientific evidence that the treatment is beneficial.  Make sure that they tell you all of the potential side effects.  
Warren Buffet, are you listening?

1 comment:

Marcus said...

Great post doc. I think it's more widespread than just geriatrics. It's seems doctors anywhere are reluctant to deviate from the "rules" of treating X. I often wonder about Janet's situation if Muirie hadn't been proactive in researching alternative treatments. Or, in fact, pushing for the shunt, etc.
I suspect on the States, it's worse, as there's the added Risk of being sued (doctors can't be sued in NZ) if you do something "different". Listening to the patient (and common sense) seems to be missing these days.