Is my doctor telling me the truth? Plus: Advice and resources for prostate cancer patients.
Question: Your book has already changed the way I approach my family's medical issues, but there's one thing I'm not sure about. You say that I should just ask a surgeon I'm interviewing, ‘Doctor, how many of these operations have you done?’ But how can I know if he's telling me the truth?
Leslie Michelson: The same way you know whether someone else is telling you the truth. You look him or her in the eye. You absorb what's going on and how they are treating you. Then you trust your gut.
I think people have tremendous intuition about when someone is lying or leveling with them. If you have concerns about a physician’s candor, and his answer to this question only adds to those concerns, there's only one thing to do: Get dressed and leave his office. Find another physician. It's crucial that you trust the person taking care of you.
Keep in mind that asking your physicians about their volumes and outcomes isn't a trick question! You can just say, "Dr. Smith, I'm worried about this surgery, and I know there's variation in outcomes. This is very important to me and I've got to ask you a couple of questions: How much experience have you had treating this disease? How many of these surgeries have you done with patients who are just like me? And can you give me a sense of what your outcomes have been? I don't want to just go into this blindly, so I really need to know."
And they need to tell you.
Question: When I ask my surgeon how many operations she has done, how do I know what's a good number?
Leslie Michelson: An excellent question, and it depends on the procedure. If it's an aortic valve repair, for example, your surgeon has to have performed a number in the hundreds. If it's prostate-cancer surgery, it should be north of a thousand procedures, or even in the many thousands. The relationship between volume and outcomes has been well established, and it's my position that the more surgeries of your exact type that your doctor has done, the better. After all—practice makes perfect.
In fact, when researchers reviewed the cases of more than 5,100 men with prostate cancer who had undergone radical prostatectomies between 1996 and 2003 at four of the nation’s top hospitals, they discovered that patients who were treated by rookies—doctors with fewer than 50 surgeries under their belts—had a 24% chance of the disease returning within five years. For patients who went to the real pros—surgeons who’d done more than 1,000 procedures—the probability of their prostate cancer returning dropped to about 8%. So if you make the mistake—and it is a mistake—of going to someone who hasn’t done enough prostatectomies to become good at it, you are tripling the odds that your disease will come back.
This kind of information, by the way, can often be found online by searching for "volume-outcome relationships for (your condition) surgery." Sometimes, you'll find illuminating studies on PubMed. Those can often be hard for newly diagnosed patients to absorb, so I'd also suggest visiting the websites of the major philanthropic organizations dedicated to your condition. (If it's cancer you're dealing with, also check out the information at NCCN and NCI.) Many of these organizations have help hotlines answered by caring volunteers who can provide you evidence-based information about your problem.
Question: I'm 71, in good health, with no prostate cancer in my family. But my PSA has risen from around 7 to 10. My urologist did a digital rectal exam, and I now have a choice of more PSA testing, a biopsy, or no action. It just doesn't seem like, from what I've read, that there are any other modern options here for me. But I'm wary of the possible side effects of biopsies and my urologist doesn't see any value in doing what's called free PSA or further PSA testing.
Leslie Michelson: Urology is a very broad field in which physicians are treating so many different illnesses, from bladder infections, to prostatitis, to rectal dysfunction. There are many conditions that urologists can treat, but prostate cancer is a very specific disease. So my first question to you is: Are you seeing a prostate cancer expert? If not, then gather your medical records—your entire PSA history is extremely important—and go see a prostate cancer expert at a major hospital and get their guidance as to what to do.
Also, if you want to do a little more research online, check out the website of the Prostate Cancer Foundation, the world's largest philanthropy for prostate cancer research. Full disclosure: I was privileged for five years to be the CEO of the Prostate Cancer Foundation, and we published the latest research and educational materials for newly diagnosed patients, patients with rising PSAs, and patients with advanced disease. All the literature is lay friendly, evidence-based, and free. Teaching men about this disease is their mission, and I know they have resources that can help you to get the best medical care.