Kevin Lomangino is the managing editor of HealthNewsReview.org. He tweets as @Klomangino.
Comedic actor Ben Stiller clearly had the best of intentions when he decided to write about his experience with prostate cancer and urge men to get a prostate specific antigen (PSA) test starting at the age of 40 – advice which contradicts the guidelines of all major professional organizations.
I admire Stiller’s intention to help out help out his fellow man, and I am glad to hear that he’s apparently doing well and satisfied with his treatment choices. I also applaud Stiller for acknowledging the controversy surrounding PSA testing with the following:
The criticism of the test is that depending on how they interpret the data, doctors can send patients for further tests like the MRI and the more invasive biopsy, when not needed. Physicians can find low-risk cancers that are not life threatening, especially to older patients. In some cases, men with this type of cancer get “over-treatment” like radiation or surgery, resulting in side effects such as impotence or incontinence.
That’s important context that’s often missing from similar celebrity health stories — and he also tells men to have a discussion with their doctors about the test. That’s certainly the best way for men to sort through their options and make an informed choice.
My problem with Stiller’s piece is that it makes a number of false or misleading assertions and fails to accurately reflect the evidence on prostate cancer screening. And because Stiller is smart, persuasive, and famous, his skewed piece may do a great deal of harm to men who may be led astray by his faulty reasoning.
NO PROOF that a PSA test saved Ben Stiller’s life
The most glaring problem with Stiller’s argument is that it’s built on a false assumption. He says, “Taking the PSA test saved my life. Literally. That’s why I am writing this now.”
He can’t say that with any certainty.
The facts are these: Prostate cancers vary in their aggressiveness, and some very aggressive cancers will prove fatal despite early detection and treatment like Stiller received, whereas the majority grow slowly and might never pose a problem to the patient. Stiller says his cancer had a Gleason Score of 7, but doesn’t offer full details about his case that would allow experts to assess the likelihood that he’d benefit from prostate removal. Even with those details, it would be impossible to know for certain whether his cancer would have spread or not.
For that reason, no one–-including a celebrity with greater-than-normal access to top-notch healthcare–can say whether the test saved his life, or merely detected a cancer that could have been monitored and might never have bothered him.
Here’s how oncologist Vinay Prasad, MD, MPH, explained the flaws in Stiller’s logic to me:
Before embarking on any screening test, a physician MUST council a patient about harms of screening, including false positives and overdiagnosis–where a real cancer is found and treated, but it would not have caused the person problems. Ben Stiller’s strong faith that the test “saved his life” is incompatible with a true understanding of overdiagnosis. If he really understood overdiagnosis, he would understand that he could not say this definitively. Gil Welch has shown that often most people with breast cancer diagnosed by screening cannot claim to have their life saved. The same principles that apply in this study also apply to prostate cancer, and no person whose cancer was found by PSA screening can say definitively, “The test saved my life.”
HealthNewsReview.org contributor Douglas Campos-Outcalt, MD, agreed that the evidence cuts against Stiller.
When someone says “Taking the PSA test saved my life,” they have over a 95% chance of being wrong. There is a spectrum of aggressiveness in prostate cancers. The vast majority detected by screening are not aggressive and screening does more harm than good in these men. The most aggressive forms are not helped (usually) by screening because they are too aggressive and are not asymptomatic long enough to be detected by screening. The moderately aggressive tumors are the only ones that can benefit from screening and the unusual man who has one of these detected by screening may have their life “saved,” but this is offset by the number killed by the treatments and the large number who are left impotent and incontinent.
Here’s an evidence-based infographic from the Harding Center for Risk Literacy that explains the numbers – note that for every thousand men screened, up to 160 false positive tests will occur and up to 20 men will be treated unnecessarily (risking harm from unneeded surgery) with no clear mortality benefit.
Although Stiller dismisses those harms – incontinence, impotence, among others — as being “in the purview of the doctor treating the patient” (whatever that means), the fact is that the treatments themselves can be deadly or cause serious disabling side effects. Even the biopsy resulting from a false-positive PSA can lead to serious infections requiring hospitalization and – rarely – death.
In fact, the treatments can be so grueling that it’s possible they may increase other causes of death – canceling out any reduction in prostate cancer deaths. That’s why Prasad and others argue that overall mortality, and not prostate cancer mortality, should be the benchmark to assess benefits from cancer screening.
Celebrities have a responsibility to use their platform wisely
Another problem with saying the PSA saved his life: He might still die from prostate cancer, in spite of being tested. Sadly – and I very much hope this is not the case – it’s possible that Stiller’s cancer is one of the aggressive ones that will recur despite early detection and treatment – meaning that Stiller’s declaration of having his life “saved” will turn out to be premature. This is a reality that needs to be acknowledged. Everyone needs to choose their words carefully when addressing a topic as deadly serious as cancer.
That’s especially true for celebrities, who in our culture have an outsized platform to express their views. Timothy Caulfield, who studies celebrity health messaging at the University of Alberta, calls Stiller’s post “exactly the kind of celebrity advice that is not needed.”
The message that is conveyed by Stiller’s post is that PSA testing is a benign procedure (“it is a simple, painless blood test”) that only has upsides – that is, if you have the right doctor (how a patient is suppose to know this, isn’t clear). But his personal story is not evidence. This is a well-told anecdote, not good data that demonstrates that PSA testing is worthwhile. It is advice that can only confuse the public discourse surrounding PSA testing. More important, it runs counters to the emerging evidence-informed consensus that, for most, PSA screening is not helpful and may be harmful. But because the advice is coming from a celebrity, it will get pop culture traction and could encourage the utilization of a test that has questionable value. And, alas, we also know that a powerful narrative, like the one in Stiller’s blog, can overwhelm even a mountain of good clinical data. Bottom line: not helpful.”
How much traction is this getting? The Today Show, with its audience of millions, has already had Dr. Mehmet Oz on the show discussing the piece and its implications. It was great to see the sometimes evidence-challenged Dr. Oz pouring some cold water on Stiller’s claims and citing U.S. Preventive Services Task Force data on the very modest benefits — and considerable harms — of PSA screening.
Caulfield gives Stiller points for engaging the controversy around PSA testing and referring to the relevant policy statements. However, I’d note that Stiller’s thesis appears to reflect the views of his urologist, Dr. Edward Schaeffer, who’s helped promote fear-mongering messages about “skyrocketing” rates of prostate cancer due to reduced PSA testing. Those statements aren’t based on sound science as I pointed out in a post a few months ago.
Skewed statistics can certainly stir up fear that would lead to blog posts about the need for more PSA testing. But such posts telling personal stories are no substitute for a comprehensive assessment of the evidence. The choice that was right for Stiller is not right for everyone.
“Frankly, I am sick of celebrities telling anecdotes about cancer screening,” says Prasad. “Screening is too important to too many people, and has too broad public health repercussions.”
Prasad adds: “When celebrities choose to volunteer some, but not all, of their health information they may affect health decisions for many Americans (as was seen with Angelina Jolie). As such, celebrities have a responsibility to do so wisely. I am afraid Ben Stiller’s post does not meet this mark.”
Note: Please see the comments section for additional commentary from Dr. Prasad that was edited from the post for length.