What If the “N of One” Is Me?

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. 

 
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.

Andrew Symons

Buffalo, New York 

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