In our journey around the sun, we have reached the shortest day of the year, which, although my brother-in-law informs me is not to be feared…"the sun shall return"… is still not a bad time for reflection.
This was a year when I said goodbye to one of my oldest patients, a retired physician with whom I had coffee or breakfast every Wednesday for over 20 years. He came to my lab or office, and in the last years, I went to his home. We measured our lives to some extent by those intervals, sharing stories of our families, our medical training, and of course solving the world’s problems. One thing we did not do was obsess about his PSA. Indeed, for the most part we ignored it.
I cannot count the number of times I have thought to myself (and occasionally commented aloud), “If it were not for the PSA, you would no doubt be out there playing golf, skiing, biking, taking a grandchild to the park, or just enjoying life.” Far too many of my patients let their PSA control their lives. Living from one PSA to the next is a bad way to mark the passing of time.
In a lovely essay in this week’s New Yorker, Alan Burdick discusses “how time became psychological.” He quotes Plato: “The instant, this strange nature, is something inserted between motion and rest, and it is in no time at all.” And he proposes that Augustine, writing in the year 397, “plucked time from the realm of physics and placed it squarely in what we now call psychology. ‘In you, my mind, I measure time’…To consider this present is to glimpse the soul, Augustine argued.”
The PSA clock, for many physicians and patients, is dehumanizing. It is a technical artifact of modern medicine, one so sensitive that it provides a second hand when we should be looking at the hour hand, the calendar, or the seasons. Imagine if your cardiologist could measure the thickening of your coronary artery year by year in microns as plaque builds up. Would you want that test? Would it change how you lived if you knew for certain that you will die from a stroke in 8 years?
This is not to say that we can’t use the PSA to guide treatment or make decisions. A younger person with aggressive prostate cancer who must fight with every tool available may well benefit from close observation of the PSA. On the other hand, in Dr. Walsh’s series of men (reported by Pound) who had rising PSA after surgery, it was 8 years on average before anything was revealed on a bone scan or CT scan, and another 5 years before they died. Did these men benefit from the PSA tests? To be sure, treatment options have changed in the 17 years since that series was reported, but we need perspective. Another of my physician patients (a thoracic surgeon) had his prostate removed and never checked his PSA again. About 9 years later, he presented with bone metastases, and is now doing well on androgen ablation. He doesn’t come in for PSAs. He is in his early 80s and enjoying his life. I suspect I will see him when he develops new symptoms, and then we can discuss his alternatives. I hope that won’t be for many years, and indeed, that is entirely possible.
So on this winter solstice you might pause to consider all of your blessings and turn off the PSA clock in your mind. Forty-seven years ago today (on the longest night of the year), I got married. Two careers, three kids, four grandchildren later, I don’t look at my PSA. Rather, I try to enjoy my "Time in a Bottle." If you are in a contemplative mood as this year ends, click on that link and enjoy the holidays!
Good wishes and glad tidings to you and yours in the coming year.
This post originally appeared on prost8blog, a blog to help patients and their families understand various aspects of prostate cancer, and is republished with permission from Dr. Glodé.
Daniel F. Hayes, MD, FASCO, FACP
Dec, 28 2016 2:20 PM
Mike: great commentary, and I agree. As you know, in breast cancer we have randomized trials that tell us that following MUC1 (CA15-3; CA27.29) in asymptomatic patients with no evidence of recurrence does not improve outcomes AND decreases quality of life. Further, I tell everyone I can: "we are not treating a tumor marker; We are treating a patient." As you note, the rising tumor marker in a patient with established metastases may be very helpful in putting together a complete clinical scenario regarding whether it's time to restage a patient (or a non-rising marker can keep them out of the radiological suite and instead skiing, etc) or if an odd symptom or two really represents progression or just the aches and pains of everyday life. We should not be slaves to tumor markers - and as you've heard me say, "A bad tumor marker is as bad as a bad drug." I'll revise that "A bad use of a good tumor marker is as bad as a bad use of a good drug!"
Daniel A. Vorobiof, MD
Jan, 07 2017 1:01 AM
Thank you both for your important comments. I believe that the majority of medical oncologists feels the same and we are not "tumor markers addicts"as many of our patients are. And in spite of our daily explanations to the patient and their families, they 'need to do something for themselves". The most common reply I get is: I do understand you Dr, but I need to know how my body is behaving and that is the only way I can monitor/check myself.
The other side of the coin is that a patient never has only one treating Dr, besides the MO there are physicians, general practitioners, surgeons, that , in my opinion, do not have the fortitude to tell the a cancer patient that to repeat a marker is not really necessary, and the patients exploit that circumnstance and request from them and not from us, to undergo more often tumor markers tests.
Much of our efforts should also be directed to educate our peers in other specialties. Regards Daniel Vorobiof