Opinion: Prostate cancer: Questions of medicine, money and risk

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On Sunday came word that former President Joe Biden has stage four prostate cancer that has metastasized to the bone. We don’t know definitively whether he had been tested for the disease regularly, but it seems that if he had been, he — and we — would have known sooner, at an earlier, more easily treatable stage. Bone metastasis is a big problem.

Maybe he was tested and it was kept secret. Alternatively, he followed U.S. Preventive Services Task Force (USPSTF) guidelines not to test men 70 and older, which makes no sense for a sitting president.

Two to three percent of men, mostly older, reportedly die from prostate cancer. However, in one study, autopsies of men never diagnosed revealed that nearly 35%, ages 70 to 80, died with, if not from, prostate cancer. With more time, some of the cancers might have caused those deaths. An estimated 12.5% of men will be diagnosed with prostate cancer in their lifetime, yet fewer than 50% are regularly screened, if at all. Prostate cancers are mostly found in men 65 and older but can be found in men 40 to 50. Of men diagnosed with prostate cancer, 10-20% will have locally advanced/regional or distant metastasized cancer. Statistics on prevalence and mortality rates in Black men are around twice that of white men. Conclusion: Prostate cancer is fairly common, increasingly so in older men, and for a minority of men it can be deadly.

With that confounding statistical backdrop, in 2012 the USPSTF astonishingly recommended with unambiguous clarity that doctors should not screen for prostate cancer. Their rationale was that harms outweighed the benefits of screening. For if you tell a man he has cancer, he’ll want it gone the fastest way possible, usually surgically, even with unpleasant, though normally temporary side effects. (Citing similar statistics on prevalence and mortality rates, the USPSTF has worryingly drawn similar conclusions regarding overdiagnosis and overtreatment of breast cancer.)

Here’s the calculus: With a first prostate-specific antigen (PSA) blood test, a second confirmatory PSA, then an MRI and a biopsy followed by surgery, combined, too much money is spent on treating the majority of diagnosed men who would probably not die from prostate cancer anyway. The USPSTF reasoned thus, with a spreadsheet-like medical perspective.

In an overextended medical system, cost savings was a worthy, and maybe the most important, goal of the task force. Though, in a commentary published by the Minnesota Star Tribune on March 24 — “Is the now-standard approach to prostate cancer too lax? In my case it was.” — I observed that in fact the cost of treating aggressive or metastasized cancers is orders of magnitude greater than if the cancer is found and treated earlier, thus negating part or all of the projected cost savings from not screening. Did the guidelines meet that goal?

Since diagnosis with a locally advanced/regional cancer, I have received three years of androgen (hormone) deprivation therapy (ADT), two concurrent years of androgen receptor pathway inhibitor drugs, quarterly labs, 45 days of high-dose radiation, genetic testing, two bone density scans, oncology visits every six months and two surgical procedures to correct the toxic effects of radiation, plus miscellaneous office visits to address other side effects.

Because my cancer had regionally metastasized, though it is now dormant, it probably will recur and spread to bones, liver and lungs, if it follows a normal progression. The standard of care would then entail at least one high definition scan and a course of ADT until the cancer becomes treatment resistant. Thereafter may follow five courses of injections of a radioactive molecule that kills cancer cells and extends life an average of 15 months. Though, alternate treatment approaches may be indicated. The grand total cost of all my treatments could, at current prices, range from $500,000 to $650,000, depending on treatment approach, and assuming no intervening cause of death.

If my cancer had been caught early, while the lesion was still encapsulated, and had been treated by a radical prostatectomy, possibly curatively, those costs would have totaled about $60,000 to $70,000. Thus, the total cost of treating aggressive or metastasized prostate cancer, as may be true in my case, can be up to around seven to 11 times greater.

Managing risk is appropriate, but risk is like a two-sided coin. On one is probability of occurrence; on the other, consequence. On multiple levels, USPSTF guidelines, and their adherents, failed in managing risk well. Others are paying the cost.