In Prostate Cancer, Pick a Number, Any Number

bdhilton

In Prostate Cancer, Pick a Number, Any Number
by Burt Solomon | The New York Times | 08.25.2008
My internist warned me that nobody understands enough about prostate cancer to make easy decisions about how to treat it, but he didn’t prepare me for the barrage of numbers that kept pretending that all is known.

The P.S.A. result was just the beginning. I was grateful, of course, for a simple blood test as an early warning. When mine registered 4.6, crossing the threshold of evil at 4, my internist suggested that I see a urologist, largely because my father’s nonfatal prostate cancer increased my risk by 30 percent. (Later I learned that my neighbor’s prostate had turned cancerous when his P.S.A., a measure of prostate-specific antigen, doubled from 1 to 2.)

A follow-up test at the internist’s, measuring the proportion of antigens clinging to a protein, prophesied a 17 percent chance that I had cancer.

“That sounds high,” I said.

“I thought it sounded low,” my internist replied. It wasn’t his prostate.

After I saw the urologist, the biopsy showed that I was right.

“It’s positive,” the urologist told me over the phone, with a forced bonhomie. When it comes to cancer, “positive” means negative — bad news. I’d entered a looking-glass world; everything was the opposite of what it seemed.

Yet the unceasing flow of numbers kept promising precision. These were numbers, for God’s sake. Of the 12 snippets of my prostate sampled in the biopsy, only 2 pieces showed any cancer, and then just a dusting, of 10 to 12 percent. And the cancer was judged to be only moderately aggressive, a 3 on a scale of 5. I was counseled to pooh-pooh the higher-than-desirable Gleason score of 6, derived by adding the aggressiveness in every spot of cancer, because there was so little cancer in each.

Eager to be convinced, I took heart. My wife accuses me — accurately — of being a glass-half-empty guy, but the flow of happy numbers (plus perhaps a touch of maturity at last, at age 58) left me uncustomarily serene.

I was only dimly aware of the evidence that most prostate cancers never become dangerous, even if left alone. But because nobody can tell which ones will and which ones won’t, the information was useless to me.

I quickly decided to have surgery to remove the prostate, but I had to choose between the two types. I cared most about my plumbing returning to normal. But this was when the numbers really began to confuse things.

One option was to go to Johns Hopkins in Baltimore, my hometown, where the older-style, slash-and-scoop surgery was devised. But the doctors there, my urologist said, cherry-picked their patients — no fatties need apply — to minimize the complications in getting the plumbing up and running again.

The other choice, called robotics, was newer and cooler. The surgeon sits at a console across the operating room and essentially plays a three-dimensional video game inside the patient, controlling two thin robotic arms slipped through inch-long incisions. The computer’s 15x magnification improves the subtlety of movement, and the less invasive surgery means faster recovery.

But the procedure has statistical distortions of its own. Some robotics surgeons have been known to exaggerate the speed of recovery by removing the catheter too early.

So both sides were skewing the numbers to market themselves.

A college classmate, a physician with a low opinion of his profession, advised me to forget the numbers, to visit both surgeons, look them in the eye and decide which one I liked.

Huh? Why should I care? I wasn’t drinking a beer with the guy. Partly, my friend said, a likable surgeon would respond if something went wrong; an arrogant one might not admit a mistake. And partly, well, my friend really couldn’t articulate it, but he felt certain.

“Likable” and “surgeon” don’t ordinarily cohabit a sentence, but when my wife and I met with the robotics surgeon, we loved him. Patient, personable and the furthest thing from arrogant, he told us how his technique had improved from his first 200 operations to his second 200. (I was No. 431.) Only twice, he said, in Nos. 4 and 17, had the robotics failed and he had proceeded to the more intrusive surgery. His percentage of complications, he added, was as low as at Hopkins. I canceled my appointment in Baltimore.

The surgery wasn’t bad at all, and my recovery was startlingly swift. Eight days afterward, I returned to have the catheter removed — none too early — and to learn if the cancer had spread. When I asked the surgeon if the pathology report was “positive” — meaning good news — he winced.

The news was good: The cancer had not spread beyond the prostate. But 35 percent of my prostate had turned out to be cancerous, considerably more than a dusting. I had dodged a bullet; the numbers had lied again.

Burt Solomon is a contributing editor to National Journal.

Copyright The New York Times 2008