Even non-hypochondriacs such as I sometimes worry fleetingly about their health when, having reached a certain age, some of their friends and acquaintances fall foul of a disease, namely (in this case) cancer of the prostate. But my anxiety does not last long and so far I have managed successfully to resist all attempts by my medical colleagues to measure my prostate specific antigen (PSA). I want to have as little to do with doctors as possible, other than socially of course, and there is nothing quite like a high PSA level to provoke doctors’ interference in a man’s life.
Would this interference, though, prolong my life if I allowed it to take place? A recent paper in the New England Journal of Medicine starts optimistically and ends pessimistically. It draws attention to the fact that mortality from prostate cancer has fallen drastically and attributes this to improvement both in early diagnosis of the cancer by means of screening and of treatment once diagnosed.
The body of the paper, however, is less sanguine. First 18,880 elderly men were divided into those who were given finasteride, a drug that was hoped would prevent cancer, and those given placebo. Some years later it was discovered that finasteride did indeed reduce the numbers of patients who developed cancer, in fact by nearly a third.
So far so good: but this is not the end of the story. Unfortunately, prostate cancer is a very variable disease such that, while some men die of it, many more men die with it than of it. And while finasteride seems to have prevented many low-grade cancers, those that would not have killed the men in any case, it seems also to have increased both the number and proportion of the more serious kind.
The upshot of all this is that, followed up fifteen years later, there was no difference in the death rates of the two groups, either from all causes or from cancer of the prostate. If the object of the preventive treatment with finasteride was to prevent death rather than diagnosis with prostate cancer it was a resounding failure. One cannot but feel sorry that an awful lot of work went into proving this particular negative.
Of course, it might be argued that the avoidance of death, important as it undoubtedly is, cannot be the sole purpose of life in general or of medicine in particular. We do not visit the doctor only that he might prevent us from dying. And it might well be that the avoidance of a diagnosis of prostate cancer brings with it immense benefits from the point of view of quality of life: for if you are diagnosed with a cancer, however benign it is supposed to be, your anxiety is likely to be raised and you will be subjected to medical procedures that may themselves be unpleasant or even hazardous (the paper mentions that the sepsis or infection rate after biopsy of the prostate is 2-4 percent, so that if you have several such biopsies the cumulative chances of such sepsis must be high, at least if each biopsy is an independent variable for sepsis). So finasteride might do some good even if it does not save life.
On the other hand, like all drugs, finasteride has its side effects. And one has to remember to take it to obtain even its muted benefits, which is a bit of a nuisance. All in all, the paper is not encouraging: except to me, of course, who wants desperately to have to do nothing for the sake of my health. This paper provides me with a partial justification for my inaction. I’ll wait for my symptoms to develop, and then we’ll see.