WHEN
A CANCER DIAGNOSIS IS WRONG
This
is an extract from the Presentation by DR. CHRISTOPHER LOGOTHETIS, M.D. of M.D.
Anderson Cancer Center, Houston, TX to TEX US TOO Prostate Cancer Support Group
December 13, 1993. The full presentation can be read at Logothetis
[this link is part of the Prostate Pointers site which is having some problems
at present - if it is not accessible a Word.doc copy
can be downloaded.
One
of the problems with prostate cancer is definition. They label it as a cancer,
and they force us all to behave in a way that introduces us to a cascade of events
that sends us to very morbid therapy. It's sort of like once that cancer label
is put on there we are obligated to behave in a certain way, and its driven by
physician beliefs and patient beliefs and frequently they don't have anything
to do with reality.
People
who come from a totally different social background like the Swedes are very frustrated
with us for the frequency with which we do prostatectomies. In fact, they are
very angry. And urologists are probably the most embattled surgeons across the
country in the United States. If you go overseas, and you are a urology surgeon
in the U.S., there is a reputation that you carry with you that you are willing
to operate on anybody the minute they sneeze. Now that's not necessarily true.
Actually, the U.S. surgeons are driven by attempts to cure more people. So I think
the motives are very correct in the overwhelming majority of them.
But
one can't ignore the paradox that the earlier you treat, the larger number of
patients you do operations on who would do well despite you. So proportionately
the patients who benefit, that is those patients who are cured by your operation,
start becoming a smaller and smaller fraction of the total. So there's the paradox
with prostate cancer. The earlier you treat, frequently the therapy is more effective,
but the cure rate from the operation actually gets reduced. This is because you're
doing an operation on people more and more frequently who need it less and less.
So
there are now these conflicting interests, and how are we going to solve that
dilemma? All of you will tell me the exact same thing, and that is, "You've lost
your mind! Once they've told me somebody has prostate cancer, I want it out of
there, and that is the exact thing that we need to do right now."
And
the answer is that, by studying patients with very advanced disease, we may find
hints of what predicts that this cancer will spread, and this cancer will not.
This will then permit us, when you come with prostate cancer, to tell you, "You
have a prostate cancer that carries with it lethal potential and an operation
is justified." That will give us the moral strength to move in early and even
biopsy patients and screen patients earlier for their disease at age 50, knowing
that we're not going to operate on people unnecessarily by doing that. And currently
the only crude way we have of doing this is by indiscriminately operating on everybody.
This is completely unacceptable; perhaps it is the least of the evils, but it's
hard to justify. So that's why I believe treatment of late and advanced disease
is really complementary to treatment of early disease. So my personal interest
and my research interest is in very advanced disease. And I think it will also
help patients with very early disease.
Q.
Do the same numbers apply to radiation treatment?
A.
Yes, the exact same figures apply to radiation. The dilemma with radiation is
it's even worse than that. Because the radiation data goes like this. You don't
solve one problem with radiation, you don't take the organ out that is responsible
for the cancer. So you have two dilemmas with radiation. One is that you may eradicate
the primary tumor, like prostatectomy does. But by not removing the organ that
is responsible for the malignancy, you actually leave sort of the germ behind
for the malignancy, so it can make a new one. That difference seems to come very
late in the disease so that, if there are any differences between a prostatectomy
and radiation, it would be very late somewhere between 7 and 10 years. Or, in
those patients where there is a surgical risk, then radiation is clearly preferable.
But, even if there's a difference, the difference lies in the ability to make
a new cancer from the old organ.
Q.
Are you saying what we use as the gold standard to find cancer of the prostate
is not really accurate?
A.
It's not accurate at all.
Q.
Does this mean that a lot of people who are diagnosed as having cancer really
don't?
A.
Yes, if one accepts the diagnosis that the cancer is a disease that is potentially
lethal, which is the one that all of you have with you. That's why you submit
yourselves to prostatectomies and run around trying to do everything, which is
appropriate. It's the wrong diagnosis because everybody doesn't have it.