The Author Replies: I reviewed Dr Berke's letter and his meaningful questions. These are the same questions, unfortunately, that were asked 20 years ago, and we still do not have answers. They will be the same questions asked 20 years from now unless the medical world and "men" gain further knowledge through scientific research.
The prostate-specific antigen test has flamed the controversy surrounding prostate cancer. Does early detection affect outcome? Are there two "types" of prostate cancer, each with a different natural course? What is the optimal treatment? How effective is treatment?
The oncology world and "women" faced similar problems over the treatment of breast cancer. The information that we have about long-term survival after radical mastectomy vs less aggressive surgery would not be available if patients, oncologists, gynecologists, and internists had not made the difficult decision to undertake a study.
Now, urologists, radiologists, and oncologists must come together with patients to design and carry out a study on the results of various approaches to prostate cancer treatment. This requires overcoming any biases of what is the optimal or preferred treatment. Until then, the data we need will be unavailable.
As a further point, Dr Berke's comments erroneously suggest that prostate cancer is a benign disease. It is wrong to assume that "by extension," the 12 cancers that we discovered are clinically unimportant tumors. Several of the cancers had high Gleason numbers and had extensively spread within the capsule.
About 40,000 men die from this disease annually. These 40,000 men will not be concerned that prostate cancer can be an incidental finding at autopsy in elderly men or that prostate cancer does not compete for the cause of death in many cases. Their question will be, "Could this have been caught early while it was still curable?"
Our article was not designed to address optimal care or predict outcome of treatment. The paper was designed to: (1) determine the costs of discovering prostate cancer; (2) demonstrate a protocol that could be used by large corporations for screening; and (3) obtain a baseline statistic to help determine a comparison between screened and unscreened men to allow, in the future, an insight into whether morbidity and mortality are different between these two populations.
Employees with disease were referred to their primary care physician or urologist for decision and options regarding treatment.
The entire program cost $72,000. We discovered 12 cancers. If just one of those 12 patients were destined to be one of the 40,000 men who dies each year, the program would have been cost effective, considering the medical costs associated with a prostate cancer death (surgery, radiation, hospitalization, chemotherapy, etc). And, of course, even more costly are the years of productive life that are lost.
In summary, research is necessary to answer questions and settle the controversy surrounding prostate cancer. We hope that our study and article helped to add to the knowledge about prostate cancer and the viability of large-scale screening for this potentially serious disease.
Warren Kantrowitz, MD
Corporate Medical Director; Polaroid Corporation Cambridge; MA 02139
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