The Last Word On Nothing

When is a sin a virtue?

When the sinner is an assasin, and the sin is laziness.

In cancer, however, it’s diffiult to know which tumors will be slothful and which will be aggressive. This is the dilemma behind the ongoing controversies in screening and treatment for conditions such as breast and prostate cancer.

Prostate cancer is the third most common cause of cancer deaths in men, and ever since doctors began using a screening test to check for prostate cancer in the 1980s, more and more men are getting prostate cancer diagnoses. It is now the most commonly diagnosed cancer in men.

The prostate cancer screening test checks for levels of a protein called prostate specific antigen (PSA) in a man’s bloodstream. Levels of this protein can rise when a man has prostate cancer. But PSA levels can also rise for other reasons.

And even when the PSA test leads to a diagnosis of cancer, there’s no way for doctors to tell which newly diagnosed cancers are growing so quickly that they could kill a patient, and which will laze slothfully along, growing so slowly that they pose no threat to a man’s life.

But faced with the prospect of dying, many men and their doctors choose to undergo surgery and radiation to obliterate the tumor – even though these treatments can lead to impotence and incontinence.

More and more, the medical establishment is questioning the wisdom of this approach, because it does not appear to be saving lives. Earlier this month, a panel of experts convened by the National Institutes of Health said that treating newly diagnosed prostate cancer immediately does not save more lives than observing the tumor before deciding whether drastic treatments are necessary.

In October, the United States Preventative Task Force recommended against PSA testing in healthy men, after reviewing the evidence from large clinical trials that found that screening did not appear to decrease death rates from cancer.

And the American Cancer Society does not recommend that the PSA test be offered routinely.

These declarations have been met with outrage – much like the angry debates over mammography that Christie has written about here. Cancer is scary, and when faced with the prospect of this dread disease, we’d rather sav ourselves and damn the consequencines than feel helpless to stop it.

In this society, after all, we believe that we are all the masters of our own destiny, and sloth -standing by as if we have no control over our lives – is the worst sin of all.

That’s why doctors are very deliberately changing the language they use to describe some cancers and their treatments.

Not opting immediately for surgery used to be called “watching and waiting,” but no one wants to be a passive observer to his or her fate. So that strategy is now called “active surveillance,” to convey a more hands-on, in-charge approach.

Some doctors even think we should stop using the word “cancer” to describe certain types of tumors, because its mortal connotations drive a fear that may be out of proportion to the actual disease.

Changing medical practice is going to take a lot more than rebranding treatments, of course. Researchers are working on methods to sort out the slow-growinga from the zealous cancers.

Until then, we’re all going to be living with the uncertainty of not knowing when a cancer is the equivalent of a bloodthirsty beast – or just a harmless, pokey sloth.

***
Image: Baby sloth lounging, courtesy asirap/flickr.