What If the "N of One" Is Me?
- Andrew Symons
I am a 54-year old academic, family doctor. Last May, after the US Preventive Services Task Force issued a draft recommendation that physicians talk with patients about PSA (prostate-specific antigen) testing at age 55, I was updating my clerkship presentation about preventive screening. At the time, I was experiencing some palpitations (sensations of an abnormal heart beat), so I decided to check my TSH (thyroid stimulating hormone) and CBC (complete blood count).
Not having checked my PSA since age 48 (it was 0.9 then), I decided, on a whim, to add a PSA to my blood tests. It came back 10.8, which means there was a possibility of cancer.
(The fact that I order my own bloodwork, as opposed to going to my doctor and letting him do it, is a whole other discussion!)
The next step was to have a prostate biopsy. Mine showed that I had prostate cancer and, moreover, an aggressive type. (My Gleason score was 8.)
The MRI showed a mass in the prostate. It also showed a possible extra-capsular extension (a mass extending beyond the prostate). This latter finding turned out not to be present after all.
There was also a bone scan, which showed a likely metastatic lesion to my SI joint. The bone biopsy showed this to be a benign area of inflamation from running.
But the aggressive cancer was real, so I had a robotic, radical prostatectomy. I went home the following day. The first ten days post op, with the catheter, were uncomfortable, but into the third week, I felt ready to go back to work.
I am now one year out, and my PSA is still undetectable. Urine leakage is scant, if at all: nothing a thin pad can't handle. Let's say erectile function is reasonable.
When we teach about PSA screening, we present this flowchart which shows that for every 1000 men screened with a PSA, there are lots of false positives, which lead to procedures which, in retrospect, are deemed "unnecessary." And ... just one person out of the one thousand is saved from dying from prostate cancer. The obvious question is, what if that person is me? Had I not bucked the USPSTF recommendations and checked my PSA on a whim, I am pretty sure I would not have lived very far into my sixties.
Buffalo, New York
I realize it is not a great idea to base one's clinical practice on an "n of one," especially if the physcian is the "n of one," but I cannot, in good conscience, recommend against screening. I advise patients that PSA testing may expose them to further testing and procedures, but I also tell them that if their PSA is indeed elevated, we will work with a sensible urologist to guide us through the work-up.
Buffalo, New York