Buffett’s prostate cancer: poor decisions

Warren Buffett may be the second richest man in America, but he appears to be getting the poorest medical advice.

Buffett announced to Berkshire Hathaway shareholders last week that he has early stage prostate cancer that “is not remotely life-threatening or even debilitating in any meaningful way.” If Buffett’s cancer had been detected because he was having symptoms, such as trouble urinating or bone pain, I wouldn’t be writing this column, and instead would be privately wishing him well and discussing optimal medical treatment.

Instead, at age 81, Buffett reportedly had a blood test for prostate-specific antigen (PSA), a controversial test used to detect hidden prostate cancer. This would be a good thing if prostate cancer was a fast-growing, deadly cancer like lung or pancreatic cancer. But it isn’t. Prostate cancer generally grows slowly and usually doesn’t affect a man’s health or longevity. We are also led to believe that the cancer cells detected in Buffett’s prostate gland were neither highly aggressive nor widespread.

The United States Preventive Services Task Force and other medical organizations urge men over age 75, and their doctors, to avoid the PSA test. Sure, it might detect silent prostate cancer. But the vast majority of older men would die of something else in the 10 to 20 years that it would generally take for the cancer to make itself known. At that point, there would still be time to treat the cancer.

Buffett’s PSA test set off a disastrous chain of events that will probably do the legendary money manager more harm than good. The high PSA result triggered a prostate biopsy. (On Twitter, cancer specialist Benjamin Davies of the University of Pittsburgh School of Medicine said “If one of my residents biopsied an 81yo (with no mets [metastases]) I would fire them on the spot.”) The biopsy showed some cancerous cells in the walnut-sized gland. And that is leading Buffett to a two-month course of radiation therapy.

If Buffett’s PSA level was very high, or had been increasing rapidly, or the biopsy showed highly abnormal, fast-growing cancer cells, radiation therapy is one of several reasonable options. But if his PSA is stable, his Gleason score (a measure of how closely cancer cells resemble normal ones) is low, and he isn’t experiencing any prostate-related symptoms, undergoing radiation therapy right now doesn’t make sense.

Although quite safe, radiation therapy isn’t a risk-free procedure. As we describe in HarvardMedicalSchool’s 2012 Annual Report on Prostate Diseases, it has immediate side effects, such as fatigue and bowel problems. Over the long term, about 50% to 70% of men lose the ability to get or sustain an erection or experience rectal bleeding.

A different approach

For my patients with early-stage prostate cancer and a low Gleason score, I recommend something called active surveillance with delayed intention to treat (once known as watchful waiting). These men have their PSA levels checked three to four times a year and have periodic prostate biopsies. These steps keep tabs on the tumor. If they indicate that the tumor is getting bigger or becoming more aggressive, then it’s time to consider surgery or radiation therapy. A consensus panel of experts convened last year by the National Institutes of Health concluded that active surveillance is a “viable option that should be offered to patients with low-risk prostate cancer.”

Deferring treatment until it’s needed makes more sense than rushing to treatment. Surgery, radiation therapy, and other treatments are still available later on, and the data indicate that the outcome is just as good for those who delay treatment.

I worry that Buffett’s decision to have a PSA test at age 81, and to announce he will undergo radiation therapy to treat his apparently localized, early-stage prostate cancer, sends the message to older men that PSA screening and immediate treatment are the right thing to do. For many men in this situation, it’s the wrong thing to do.