Advocacy in Disguise

I often wondered what life would be like when my generation started to assume responsibility. Then I read this headline (via mefi):

Optimus Prime Dies of Prostate Cancer
Popular Transformer’s Death Calls for Annual Screening

I have a lot of conflicting emotions about this. First, it's sad to see Prime die, again. And yet, I'm always a fan of creative marketing to reach new audiences. Make no mistake -- this is a real press release from a real organization -- the National Prostate Cancer Coalition. They have a staff and budget and stuff. The press release goes on to describe how the leader of the Autobots succumbed to cancer on a Cartoon Network show called Robot Chicken. The release continues:

“When it comes to prostate cancer, there’s more than meets the eye,” National Prostate Cancer Coalition CEO Richard N. Atkins, M.D. said. “Often times when one has symptoms for prostate cancer it’s already in its late stages, that’s why early detection is so important.”

Above the text is a photo of several men with latex gloves prominently displaying their index fingers.

At first I thought the tone of this site was pitch-perfect -- using a little absurd humor and capitalizing on male squeamishness to raise awareness. But as I kept browsing, I realized the authors of the site weren't kidding when they said "more than meets the eye." In fact, I'm inclined to think the NPCC can identify with Optimus Prime's enemies, the Decepticons.

On the issue of PSA testing, the advocacy group writes:

There are some who say that because of false positives and false negatives early detection is not worth it. These individuals or institutions are misguided. While there is no perfect test for prostate cancer, PSA and the physical exam (in our opinion) do more good than harm for men’s health and long lives.

One institution this group characterizes as "misguided" is the United States Preventative Services Task Force. This is an organization of medical experts, charged by law to make evidence-based recommendations to clinicians on matters such as screening for illness. They do this by thoroughly examining peer-reviewed literature and government statistics.

In short: the USPSTF is as impartial an organization as we're likely to see. Their funding is transparent and their mandate is clear. Unlike NPCC, they base their recommendations on extensive, readily available citations. And when it comes to PSA screening, USPSTF was not as enthusiastic as those mourning the dead Transformer:

The USPSTF found good evidence that PSA screening can detect early-stage prostate cancer but mixed and inconclusive evidence that early detection improves health outcomes. Screening is associated with important harms, including frequent false-positive results and unnecessary anxiety, biopsies, and potential complications of treatment of some cancers that may never have affected a patient's health. The USPSTF concludes that evidence is insufficient to determine whether the benefits outweigh the harms for a screened population.

It's so tempting to do a simple blood draw for PSA in an a healthy patient and, if it's high, congratulate yourself for finding early cancer and go about treating it. But the truth is more complicated. Most forms of prostate cancer are really slow-growing. So slow, in fact, that most men diagnosed with prostate cancer actually live long enough to die of something else. And most treatments for prostate cancer aren't simple, either.

Consider it this way, using the stats collected by USPSTF: if you give this PSA test to 1000 people without any sign of the disease, maybe something like 150 or so will have a positive test. Those 150 will get poked and prodded and biopsied and might get worried, probably for nothing. They might seek treatment they don't need, suffering complications such as incontinence and erectile dysfunction. Of those 150 who test positive, only a few dozen will actually have prostate cancer. And even then, even after all that, we can’t tell if treatment is worth the harm and the stress, or actually prolongs life.

None of these figures appear on the NPCC web site. Instead, there's a self-contradictory barrage of unreferenced stats, many of which mislead readers into thinking PSA is unambiguously helpful. It's not. Their conclusions about a drop prostate cancer mortality are wrong -- deaths aren't down because PSA is helping men beat cancer, but because PSA is uncovering many cases of slow-growing, nonlethal cancer.

Sadly, I think Optimus Prime's death is being used to advance an agenda, and that the motives of the NPCC are not in the best interests of patients. I'm going to trust the bland, dry presentation from USPSTF over the kitschy hipsters from NPCC, whose idea citing references is namedropping 80's cartoon heroes.