Prostate cancer decision-making on treatment: Would you cut off your left foot?

Paul VanDevelder, a middle-aged journalist and father, learned five years ago that his PSA (prostate specific antigen) test showed a sudden spike in his PSA level, making him feel panicked. A doctor friend calmed him and had him learn a lot more. Paul learned that for 88% of men with elevated PSAs, the results were a false positive.

The prominent Dartmouth Medical School researcher, Dr. H. Gilbert Welch, explains the odd truth: "The presumption often is that anyone who has had cancer detected has survived because of the test, but that's not true. In fact, and I hate to say this, in screen-detected breast and prostate cancer, survivors are more likely to have been overdiagnosed than actually helped by the test." Indeed, the U.S. Preventive Services Task Force formally recommended in October 2011 that doctors stop using the PSA blood test to screen healthy men for prostate cancer.

Paul will get retested in a year, and will think carefully before any prostate surgery. He explains his decision this way to his urologist: "If your doctor told you that an asymptomatic, non-life-threatening tumor was growing on the instep of your left foot, would you cut your foot off?"

Advice to men with elevated PSA levels: Think carefully before deciding on prostate surgery.

Read about another journalist's decision on prostate cancer. Thanks to Paul for sharing his story in today's Los Angeles Times, where the full article can be found.

A "do it now" kind of guy: Slow medicine at the end of life

Edie Gieg, 85, strides ahead of people half her age and plays a fast-paced game of tennis. But when it comes to health care, she is a champion of "slow medicine," an approach that encourages less aggressive – and less costly – care at the end of life.

At the end of her husband's life, she was spared extreme options because she lives at Kendal at Hanover, a retirement community affiliated with Dartmouth Medical School where it is possible – even routine – for residents to say "No" to hospitalization, tests, surgery, medication or nutrition.

Her husband, Charley Gieg, was 86 at the time, and was suffering from a heart problem, an intestinal disorder, and the early stages of Alzheimer's Disease when doctors suspected he also had throat cancer. A specialist outlined what he was facing: biopsies, anesthesia, surgery, radiation or chemotherapy. His wife doubted he had the resiliency to bounce back. She worried, instead, that the treatments would usher in a prolonged period of decline and dependence. This is what the Giegs feared even more than dying, what some call "death by intensive care."

During her husband's out-of-town consultation with a doctor, Edie stayed in touch by email with a nurse practitioner (NP) at Kendal.

"It is imperative that none of this be rushed! Think about all the what-ifs," wrote the NP. The doctors the Giegs had chosen, she wrote, “tends to be a 'do-it-now' kind of guy." The NP asked whether Charley would want treatment if he was found to have cancer. If not, why go through a biopsy, which might further weaken his voice? Or risk anesthesia, which could accelerate his dementia?

"Those are the very questions in my mind too," Edie replied. The Giegs took their time, opted for no further tests or treatment, and Charley came back to the retirement community to die.

Outside of Kendal, it is rare for patients and their families to make these vital decisions. As the chief medical officer for UCLA Medical Center explained, the culture at an acute care hospital "has a built-in bias that everything that can be done will be done." The pace of care at the hospital, he added, discourages "real heart-to-heart discussions." Once a patient is drawn into that system, "it's really hard to pull back from it."

Advice: Decide how you want to live your life – even at the end.

Read another end of life story.

Thanks to Jane Gross for the source article in today's NY Times.