James consulted about a simple ear infection. It didn’t take long to deal with, and I was pleased at the prospect of making up time in a late-running surgery. But as he got up to go, the 60-year-old had a “By the way, doc” question for me: should he be screened for prostate cancer?
I motioned him to sit back down; it’s a difficult one to answer. We can try to detect the disease with a blood test for prostate-specific antigen (PSA). But in men without symptoms, PSA misses at least 15 per cent of tumours, coming back normal despite there being cancer there. On the other hand, fully 75 per cent of men with an abnormal result turn out not to have cancer after all – but they have to endure weeks of anxiety, as well as an unpleasant set of biopsies taken through the rectum, before they can be given the all-clear.
It gets even trickier for the 25 per cent with a positive result who do have a tumour on biopsy. They face a dilemma. Most prostate cancers are indolent and do not cause symptoms or shorten life; some, however, go on to behave much more aggressively. We can’t reliably tell which ones are which. Potentially curative treatments – surgery or radiotherapy – frequently cause substantial problems such as impotence and bladder or bowel incontinence.
If you try to “cure” everyone with a proven prostate cancer, for every life you save you end up blighting the lives of dozens of other men who ultimately derive no benefit from radical treatment.
Such is the inaccuracy of PSA, and the uncertainties over how to treat cancer if found, that there is currently no national screening programme for this common cancer. However, the Department of Health still recommends testing any man who requests it after being given full information. I explained the ins and outs to James. He weighed it up carefully, and decided against proceeding.
I didn’t see him again for another two years, but a few months ago he returned saying he’d developed a poor urinary stream and was needing to go to the loo several times each night. These are classic prostate symptoms, and I hoped that they would be due to common-or-garden, benign, age-related swelling of the gland.
A PSA is more accurate in men who have symptoms, so it was disconcerting to find James’s level substantially raised. I referred him for biopsies, and unfortunately these showed a cancer. Scans revealed spread to local lymph nodes and a possible deposit in bone. Cure is no longer possible at this stage, though James’s cancer is likely to be controlled for many years by hormone therapy.
Going back through his records, I revisited the entry from a couple of years earlier. It was difficult not to feel disquieted reading my notes. James’s cancer had almost certainly been present at that time.
If he had gone forward for screening, might it have been caught early enough to have effected a cure? I had tried to give him a balanced account of the pros and cons, but I also realise I have a personal view: which is that, given our current inadequate tests and knowledge, prostate screening causes more net harm than good. Had I allowed my own beliefs to colour our discussion, subtly biasing James against a PSA test? Had I, in effect, talked him out of it?
It’s one thing for me as a doctor to go through these imponderables in my mind; quite another for a patient now grappling with a serious diagnosis. I felt apprehensive when James came to see me after being given his results at the hospital. Would he be angry and blame me for his predicament? It would have been a understandable reaction, especially given the way hindsight can colour our view of past events.
But it was my own sense of guilt (rational or irrational) that I was wrestling with. James had lots of questions about the hormone treatment and the future, but he was entirely at ease with me, and was focused solely on the road ahead, rather than that which had passed.
This article appears in the 14 Jun 2017 issue of the New Statesman, Corbyn: revenge of the rebel