New York Times writer Dana Jennings, who's been publicly sharing his own story of prostate cancer, writes about a new book about someone else's prostate cancer story.

It's "Invasion of the Prostate Snatchers," by Ralph H. Blum and Dr. Mark Scholz.

Jennings writes:

"(The book) is a provocative and frank look at the bewildering world of prostate cancer, from the current state of the multibillion-dollar industry to the range of available treatments.

About 200,000 cases of prostate cancer are diagnosed each year in the United States, and the authors say nearly all of them are overtreated. Most men, they persuasively argue, would be better served having their cancer managed as a chronic condition.

Why? Because most prostate cancers are lackadaisical -- the fourth-class mail of their kind. The authors say "active surveillance" is an effective initial treatment for most men.

They add that only about 1 in 7 men with newly diagnosed prostate cancer are at risk for a serious form of the disease. "Out of 50,000 radical prostatectomies performed every year in the United States alone," Dr. Scholz writes, "more than 40,000 are unnecessary. In other words, the vast majority of men with prostate cancer would have lived just as long without any operation at all. Most did not need to have their sexuality

Yet radical prostatectomy is still the treatment recommended most often, even though a recent study in The New England Journal of Medicine suggested that it extended the lives of just 1 patient in 48.

And surgery, of course, is most often recommended by surgeons and urologists -- who are also surgeons. Mr. Blum writes: "As one seasoned observer of the prostate cancer industry told me, 'Your prostate is worth what Ted Turner would call serious cash money.' " As for patients, their rational thinking has been short-circuited by the word "cancer." Scared, frantic and vulnerable -- relying on a doctor's insight -- they are ripe to being sold on surgery as their best option. Just get it out.

Every urologist I met with after my diagnosis recommended surgery, even though it was believed then that I had a low-risk Stage 1 cancer. The best advice came from my personal urologist, who declined to do my operation because it was beyond him: "Avoid the community hospital guys who do a volume business in prostates."

I did, but I'm still maimed. In my experience, doctors play down punishing side effects like incontinence, impotence and shrinking of the penis. Those are just words when you hear them, but beyond language when you go through them."

Read Jennings' full column. And you may want to pick up your own copy of "Invasion of the Prostate Snatchers." I'm getting mine.

This is a very important story.

"Unfortunately," as a Mayo Clinic physician says in the story, "this is something that isn't well understood, not just by the public - but by physicians who order the tests."

Special focus was placed on the nuclear technologies of breast-specific gamma imaging and positron emission mammography. The story says a single exam with one of these tests "exposes patients to a risk of radiation-induced cancer that is comparable to the risk from an entire lifetime of yearly mammograms starting at 40."

And the story goes on to discuss a concern that these tests will "become more widespread and casual...now being considered and even being used in some cases as screening tests, and this is not appropriate" - according to the Mayo physician quoted.

I've spoken and written about the imbalance in the news coverage about the U.S. Preventive Service Task Force's new guidelines on mammography last November.

If stories and communications are going to use anecdotes, then for every anecdote about a woman who claims her life was saved by a mammogram in her 40s (something that can't be proven), there should be a countering anecdote with a woman who had a mammogram in her 40s and got a diagnosis of DCIS or ductal carcinoma in situ.

Well the New York Times nailed that story this week, under the headline, "Prone to Error: Earliest Steps to Find Cancer."

I'll only offer the link and will post only this one excerpt:

"Diagnosing D.C.I.S. "is a 30-year history of confusion, differences of opinion and under- and overtreatment."

Everyone should read this story in its entirety.

It covers what was missing too often in the discussion about mammography screening last November. There are tradeoffs of harms and benefits. There is a need for fully informed shared decision-making in the face of this diagnosis. This story makes that clear. Much of our public discussion has not.

From today's latest addition to this excellent series:

"Americans increasingly are treated to death, spending more time in hospitals in their final days, trying last-ditch treatments that often buy only weeks of time, and racking up bills that have made medical care a leading cause of bankruptcies.

More than 80 percent of people who die in the United States have a long, progressive illness such as cancer, heart failure or Alzheimer's disease.

More than 80 percent of such patients say they want to avoid hospitalization and intensive care when they are dying, according to the Dartmouth Atlas Project, which tracks health care trends.

Yet the numbers show that's not what is happening."

AP's six-part series on overtreatment in U.S. health care turns to back pain and spine surgery with a great lead line, "Why did they cut on you?" It was a question a spine surgeon asked a man who came to him still in severe pain after an earlier back operation. Except:

"Even though only a fraction of people with back pain are good candidates for surgery, complicated spine operations are on the rise.

So is the hunt for any relief.

By one recent estimate, Americans are spending a staggering $86 billion a year in care for aching backs -- from MRIs to pain pills to nerve blocks to acupuncture. That research found little evidence that the population got better as the bill soared over the past decade."

The Associated Press, which sometimes may be viewed as only reacting to breaking news of the day, today published a timely and timeless feature explaining:

"Anywhere from one-fifth to nearly one-third of the tests and treatments we get are estimated to be unnecessary, and avoidable care is costly in more ways than the bill: It may lead to dangerous side effects."

It's timely because, on the heels of the New York Times' criticism of Dartmouth Atlas methodology, it refers to Atlas data that shows that:

".. in parts of the country, Medicare pays double or triple the price to treat people with the same illnesses. The differences are not fully explained by big cities' higher cost of living or populations that are poorer, older or sicker. How much care someone gets is a main reason, yet Dartmouth's data shows people in pricier areas don't necessarily fare better."

It's also timely because, on the heels of a study published in Health Affairs that showed that many people surveyed thought more care meant higher-quality, better care, this story led with:

"More medical care won't necessarily make you healthier -- it may make you sicker. It's an idea that technology-loving Americans find hard to believe."

Nice team effort by AP with contributions from Lauran Neergaard, Ricardo Alonso-Zaldivar, Lindsey Tanner and Marilynn Marchione.

(Disclosure: the story quotes Dr. Michael Barry, president of the Foundation for Informed Medical Decision Making, which supports my HealthNewsReview.org project.)

Yale's Harlan Krumholz blogs on the Forbes site today, making a strong case for shared decision-making even though he doesn't use that term in his post. Excerpt:

"A few weeks ago I made a modest proposal to the medical profession in the pages of the Journal of the American Medical Association. I suggested that we make informed consent meaningful and provide patients with the critical information that should be available to anyone contemplating a major test or procedure.

I suggested that in non-urgent situations, when there is time for deliberation, patients be told their options, given realistic estimates of risks and benefits, informed about the track record of the institution and physicians who will provide the service, and provided an estimate of the costs to them.

My proposal was to standardize the information to patients who are considering some of the most common elective tests and procedures. Assemble panels of expert doctors and determine where there is consensus about the minimum information that all patients should know. Work with educators and psychologists to determine how to convey the information fairly and impartially. Inform patients that the best decision will be aligned with their values and preferences and that no one decision is right for everyone.

This solution to rising health care costs does not involve rationing care. It does not shift payments to patients or reduce payments to doctors. It does not require complicated legislation or regulation. The solution simply ensures that patients are making an informed decision."

Glyn Elwyn of Cardiff University, along with a team of colleagues, has a paper in the current Journal of Medical Internet Research about their attempt to examine men's use of an online decision aid for prostate cancer screening. They conclude:

"There is evidence that Prosdex (the decision aid) promotes informed decision making in men, and we highlight factors that should inform the future design of decision aids. First, for the population using Prosdex, 20 minutes seems to be a critical time window in which we can realistically expect information to be accessed. This finding is significant as there has been a recent trend towards developing more sophisticated decision aids that take longer to use, which could be seen as over engineering. We demonstrated, however, that participants did not use the interactive features, and that the window of opportunity for information transfer to support decision making is narrow. Second, users of decision aids are not a homogenous population: there are different types of users characterized by their level of interaction with the decision aid. Therefore, developers need to design tools that sufficiently support and facilitate informed decision making among the different types of users, and should move away from designing one intervention for all."

As one who produced some of the very early shared decision-making programs of the Foundation for Informed Medical Decision Making back in the '90s, I find this interesting but not surprising. We, too, found way back then that users were often turned off by forced interactivity. And, interestingly, the first non-interactive decision aid we produced was on prostate cancer screening and it ran for 20 minutes.

You can take a look at the Prosdex decision aid here. Here's a screen shot of the entry page:

Nice piece on the New York Times' "New Old Age Blog" about old patients getting new joints.

The piece includes messages about shared decision-making and the importance of understanding both potential harms and benefits; about realistic expectations that joint replacement is not a fountain of youth; and about "a caution about so-called minimally invasive joint replacement surgery: the American Academy warns that there's insufficient evidence that this approach, the subject of much media attention, produces quicker recoveries or better results."

Gil Welch and Bill Black of Dartmouth address cancer overdiagnosis in a new review article in the Journal of the National Cancer Institute. Excerpt from the abstract:

"We estimated the magnitude of overdiagnosis from randomized trials: about 25% of mammographically detected breast cancers, 50% of chest x-ray and/or sputum-detected lung cancers, and 60% of prostate-specific antigen-detected prostate cancers. We also review data from observational studies and population-based cancer statistics suggesting overdiagnosis in computed tomography-detected lung cancer, neuroblastoma, thyroid cancer, melanoma, and kidney cancer. To address the problem, patients must be adequately informed of the nature and the magnitude of the trade-off involved with early cancer detection."

That's the title of an op-ed piece by Dr. Gilbert Welch of the Dartmouth Institute of Health Policy & Clinical Practice. Excerpts:

"Here's a question that's not being asked in the healthcare debate: How much medical care do we want in our lives? It's something we should be discussing.

Start with the two life events we all experience, birth and death.

My profession has gotten pretty good at terrifying (and operating on) pregnant women during what should be one of the greatest experiences in life. And we are equally proficient at dragging the elderly through all sorts of misery on the road to death.
...
So the most fundamental life events -- birth and death -- increasingly involve more and more medical care. Why should you care about this increasing medicalization of birth and death?

Simple. Because it exemplifies the medicalization of life. Everyday experiences get turned into diseases, the definitions of what (and who) is normal get narrowed, and our ability to affect the course of normal aging get exaggerated. And we doctors feel increasingly compelled to look hard for things to be wrong in those who feel well.

Medicalization is the process of turning more people into patients. It encourages more of us to be anxious about our health and undermines our confidence in our own bodies. It leads people to have too much treatment -- and some of them are harmed by it.

And it's big part of the reason why medical care costs so much.

There are many areas in which medical care has a great deal to offer. But it has now gone well beyond them. There may have been a time when the words "Do everything possible" were indeed the right approach to medical care. But today, with so many more possibilities for intervention, that's a strategy that is increasingly incompatible with a good life. We all need to be a little more skeptical and -- to really be healthy -- willing to ask "Why?"

Don't just settle for my excerpts. Read the entire article.

I was struck by the recurring themes in this week's health news and planned to blog about it today. But Lindsey Tanner of AP beat me to it with her story, "Experts say US doctors overtesting, overtreating."

She begins:

"Too much cancer screening, too many heart tests, too many cesarean sections. A spate of recent reports suggest that too many Americans - maybe even President Barack Obama - are being overtreated.

Is it doctors practicing defensive medicine? Or are patients so accustomed to a culture of medical technology that they insist on extensive tests and treatments?

A combination of both is at work, but now new evidence and guidelines are recommending a step back and more thorough doctor-patient conversations about risks and benefits."

I had picked up on that same theme in this week's news:

• An independent panel convened this week by the National Institutes of Health confronted a troubling fact that pregnant women currently have limited access to clinicians and facilities able and willing to offer a trial of labor after previous cesarean delivery.

• A troublingly high number of U.S. patients who are given angiograms to check for heart disease turn out not to have a significant problem, according to the latest study to suggest Americans get an excess of medical tests.

• CT scans may pose cancer risk, new research indicates: Doctors, patients should weigh risks vs. rewards of medical imaging. (Chicago Tribune story.)

• Controversy over "value-based insurance design" that tries to address the problem of underuse of proven treatments and overuse of certain surgeries and diagnostic tests that may be less valuable. (Kaiser Health News story.)

• Expensive prostate cancer treatments are winning out over the old standards, driving up the cost of treatment before there's clear evidence that they improve outcomes. (MedPageToday.com story.)

• Dr. Richard Ablin's op-ed in the New York Times, "The Great Prostate Mistake." Excerpt:

"Testing should absolutely not be deployed to screen the entire population of men over the age of 50, the outcome pushed by those who stand to profit."

• And the letter to the editor that followed:

To the Editor:

I can only wish that Richard J. Ablin's article had appeared years ago and spared me and probably many others needless pain and anxiety.

In 1997, at the urging of a couple of friends, I walked into a clinic feeling great and a bit foolish. P.S.A., 9-plus. Biopsy, of course (ouch), and I was told of a "little suspicious gray area" on a film. Lab test result, positive. Doctor recommendation: surgery or radiation.
I decided against both and never looked back, and have lived happily and healthfully ever after.

By the way, the 10 or 15 percent chance of bad side effects (I asked) from surgery is really far higher, from what I've read and heard. Watchful waiting is still the best suggestion any doctor can offer.

Robert S. Corya
Indianapolis, March 10, 2010

• CBS' Harry Smith's live colonoscopy coverage that never touched on any questions about evidence for colonoscopy and some of the questions that have been raised about the overselling of colonoscopy - perhaps resulting in the decline in use of a $20 blood stool slide test.

While Smith's colonoscopy was being televised, I was attending a meeting entitled, "First, Do No Harm," hosted by the US Agency for Healthcare Research & Quality. The purpose of the meeting was to guide future AHRQ research on how to get doctors and patients to stop pursuing approaches for which there is net harm - not benefit. Clearly, health care in the US struggles even with the clearcut issues of cutting back in the face of net harm - much less in grey areas where there is uncertainty about harms vs. benefits.

But kudos to Lindsey Tanner of AP for trying to tie together the week's news in the way she did. We could have stories like that every week. And if we did, we'd have a lot smarter health care consumer population.

Here's another problem with the practice of TV networks using physician "contributors" to comment on health care news. They may have a clear conflict of interest that is not addressed.

When the American Cancer Society released its updated guidelines on prostate cancer screening today, Fox News reported:

"Dr. David Samadi, a Fox News contributor and chief of Robotics and Minimally Invasive Surgery at Mount Sinai School of Medicine in New York City, said he thinks the new guidelines could cause unnecessary deaths.

"In my practice, we find men in their 30s and 40s that are at high-risk and develop prostate cancer," Samadi said.

"Knowing your PSA is power, it is educational; you follow it all the time. You can find a silent prostate cancer that will not affect you, and there is a possibility to over-diagnose, but that's a risk the patient needs to take. You could also find cancer that could lead to death."

The number of prostate cancer deaths continues to decline because of regular screening, Samadi added.

"I really recommend (the age) of 40 as a baseline age," Samadi said."

Doesn't Fox see that he has a blatant conflict of interest on this topic as one who runs a robotic surgery center? There are countless ways to counter these short quotes from Dr. Samadi, but I'm not going to run through them here. Read the Cancer Society report and you'll find all of them there - in dispassionate, non-conflicted, evidence-based depth.

Look at how Katie Hobson of US News & World Report included an expert urologist's input, and one with a much more open-minded and balanced perspective.

"... the gist of all this is a firm end to the notion, still held by some clinicians, that screening for prostate cancer is "the same as colorectal cancer screening or cholesterol screening," says Durado Brooks, director of prostate and colorectal cancers for the ACS and coauthor of the report.

"There has to be a conversation," says John Davis, assistant professor in the department of urology at the M. D. Anderson Cancer Center in Houston. "And these guidelines give some very nice bulleted points and Web links you could build into an information sheet and give to patients."

The American Cancer Society has just released updated guidelines on prostate cancer screening.

Because of the uncertainties of benefits vs. harms of such screening, the ACS puts a new emphasis on shared decision-making and on the use of patient decision aids to help men.

Excerpts from ACS statements released today:

"As it has since 1997, the American Cancer Society advises against a general recommendation for men to undergo screening, instead saying testing should only occur when a man is provided the opportunity to learn about the limitations and potential benefits of screening and treatment.

...The guidelines now outline the uncertainties regarding the balance of benefits and harms associated with screening. They clearly state that every man should be told of the uncertainties, risks and potential benefits of screening, and that no man should be tested without receiving this information."

On the problems with big community screening events:

"The American Cancer Society discourages participation in community-based prostate cancer screening programs unless those can adequately provide for an informed decision-making process and appropriate follow-up. For men who have limited or no access to other sources of care, community-based screening programs may provide the only opportunity to make an informed decision about testing. Men who are contemplating screening through these programs should first receive high-quality objective informed decision-making, either through interaction with trained personnel, or through the use of validated, high-quality decision aids, appropriate to the target population. Since virtually all men age 65 years and older have health insurance through Medicare, they should be discouraged from participating in community-based screening programs, and should be referred to a primary care provider."

The Foundation for Informed Medical Decision Making (disclosure: they support this HealthNewsReview.org project) posted a video clip with its president, Dr. Michael Barry, reinforcing the shared decision-making message.

For now, the Foundation's shared decision-making program on prostate cancer screening can be seen online. Check it out.