As a newly graduated, idealistic physician assistant in 1991, I enthusiastically took to heart all recommendations for health promotion and disease prevention screening. The PSA test was encouraged for all men at that time, and when I found out my father had not been offered what I had been taught was a life-saving test, I beseeched him to have it done. He did and it turned out his PSA was elevated, initiating a medical journey that I am still processing over twenty years later.
His biopsy showed cancerous cells adjacent to the internal capsule of his prostate. “Out of an abundance of caution,” as he put it, the urologist suggested my dad’s limiting metastatic potential with testosterone blocking agents–even though the cancer hadn’t breached the capsule itself. Out of an abundance of caution, my dad agreed. The sequelae of this decision were significant. As a resident of a state without ready access to leuprolide in the 1990s, we had to arrange flights to an adjacent state for treatment. Each injection cost over $2,000, and my dad struggled with the expected side effect of impotence. I will never forget conversations about his treatment and its effect on his libido–conversations not meant to be had between father and daughter.
My father credited me proudly with saving his life. He died just a few years later of right-sided heart failure and a fatal arrhythmia at the young age of 65–not of prostate cancer. Did I mention that I grew up in a household with an ashtray in the shower? His lifetime nicotine addiction was his nemesis.
Did I save my dad’s life? No, I did not. I agonize over the burdens he faced in the last years of his life, burdens initiated by my recommendation, by the diagnosis of a disease unlikely to cause him harm in his lifetime. Treatment of that cancer changed the time he had left, and not for the better. I will take that guilt to the end of my days.
PSA guidelines and treatment recommendations have changed. What hasn’t changed is the challenge of screening for a cancer that most men will die with rather than die of. Today, there is no clear single PSA screening recommendation for most patients. The lesson of my father’s experience is that screening has an important role in health, but with screening comes the potential for significant harm. Don’t forget the harm.