On April 17th, 81-year-old Warren Buffett told investors that he had very early prostate cancer. The Washington Post headline read: “Warren Buffett Has Prostate Cancer that is ”Not Remotely Life Threatening.'” Within hours, news accounts said that the story unfolded after discovering a high PSA in a routine appointment. Next, he had a prostate biopsy. A few hours later, news accounts said that Buffett decided to get radiation therapy for prostate cancer. What’s wrong with this picture?
10. He’s an icon who other men will follow, and there is limited (or no) evidence of benefit of aggressive treatment in men as old as Buffett. At 81, his life expectancy is 7.41 years, shy of the 10-year life expectancy mark doctors look for when they recommend aggressive treatment for prostate cancer.
9. Although Buffett can afford whatever care he so desires, it would cost a fortune if tons of men in his age group went for active treatment and there would be little yield and plenty of side effects.
8. For several years, many physician organizations, including those representing the radiologists and urologists (ASTRO and AUA) who stand to gain income from treating older men, have expressed skepticism about the value of treating and screening men as old as Buffett. That’s because prostate cancer is slow-growing. Buffett is more likely to die from something else.
7. There are far better health care investments that would yield better, long-lasting outcomes. Limited healthcare dollars could be spent on things that actually help people.
6. In some circles, the evidence movement is flourishing and medicine is moving towards more of a scientific base. Yet despite years of intensified effort to base medicine on proof of benefit, or evidence, seemingly has not reached one of America’s smartest men.
5.The war on cancer seems very much alive, no matter what the evidence. Even powerful men, possibly more secure, cannot say no.
4. Buffett may well have side effects from the radiation, namely bowel, urinary incontinence, and impotence.
3. Besides being wasteful, it is not going to save his life.
2. The search for an active surveillance icon continues. I was kind of hoping Buffett could have assumed that role. Surgery has its heroic icons: General Norman Schwarzkopf and Senator Bob Dole. Mayor Rudolph Giuliani went with seeds.
1.If the tide shifts and many more older men choose treatment, it will be a step away from science-based medicine.
A previous version of this post had a different point #1.
I couldn’t have said this better myself. Buffett is setting a terrible, illogical example that may influence men to take unnecessary risks. Prostate cancer, like all cancers, is not a one-size-fits-all diagnosis, but for many men, aggressive treatment is more risky than active surveillance with treatment only with signs of disease progression. I do not know the details of his case, but I suspect that without a PSA, he might never have known about the cancer.
On your last point, I assume you mean that orchiectomy is preferable to radiation (not preferable to active surveillance or watchful waiting)? Can you explain why? I don’t know anything about it.
Prostate cancer was a fad among Fortune 500 executives at one time. Michael Milken, Andrew Grove, Rudy Giuliani, etc. all had it done.
Maybe they’re used to delegating important decisions to others, they went to the top doctors, and they followed their doctors’ advice. Sometimes the most fashionable doctors aren’t the best doctors.
I could not agree more. The fact that Mr. Buffett was having his PSA even tested is already going against any conventional wisdom for a man his age.
In an era where we have just had some solid recommendations of medical tests that we ought not be overusing (see: Choosing Wisely: http://choosingwisely.org/?page_id=13) and http://choosingwisely.org/wp-content/uploads/2012/04/5things_12_factsheet_Amer_Soc_Clin_Onc.pdf ) the fact that Mr. Buffet had an MRI, PET and/or CT scans etc as well as PSA screening at the age of 81 is setting a very poor example indeed.
So, like you, this bugs me and I do not condone his actions.
Having said that, there is one extraordinary circumstance here that surely MUST have come into play, and it has nothing to do with medicine, evidence or health policy. It is all about business and economics.
In Mr. Buffett’s position, there is no way a prostate cancer diagnosis could have remained a secret. As one of the world’s richest men, and leader of an investment giant that is perhaps unparalleled in influence, I suspect that this was a business decision to preempt any notion that he was not gong to be just fine, he was “taking care of business” in his usual direct way, and that Berkshire Hathaway was going to be just fine.
So, ironically, the very things that might have given him a golden opportunity to be a powerful role model for doing the right thing according to medical and health practice are the very reasons, I suspect, why he felt he could not do so.
I was thinking along the same lines, once the test came back what choice did he have.
Investors are a shaky group. Almost anything will set them into a panic.
That non treatment wouldn’t shorten Mr. Buffet’s life isn’t what Wall Street would hear, all investors would hear is Warren Buffet has a cancer that isn’t being treated, or isn’t treatable.
And I can imagine the hysteria at the breaking news had he tried keeping it quiet.
Au contraire…How long did Steve Jobs lie about his cancer? He let some information be known, but not the whole truth…
No reason Buffett couldn’t have disclosed AND decided watchful waiting.
I looked at UpToDate, and androgen deprivation therapy is not recommended for localized prostate cancer. Apparently studies show that results of ADT in localized PC were not favorable.
Unfortunately people like evidence based medicine to be used with others not themselves. Expensive treatments with poor outcomes will no longer be reimbursed; we cannot afford to waste limited healthcare dollars on high ticket procedures which have no chance of success.
Very astute analysis Laura. I agree with your conclusions. Buffett is setting a terrible example, one that might cost lives. Recently a church friend underwent a similar operation for an enlarged prostrate (BPH). Tragically he was the victim a nosocomial hospital acquired strain of STAPH and died suddenly.
Some men with BPH have surgery in an attempt to restore their “vigor.” They must not be TV watchers. The effectiveness of supplemental testosterone as a “vigor” restorer has long been ballyhooed. Furthermore, all TV channels seem to be deluged with ads which either end with a man and women in (separate!) bathtubs (LOL) or with a man who competently fixes his car…or sailboat. The subliminal message being, if you take this pill you’ll be competent in bed. I suspect there are many women who would testify that that isn’t necessarily the literal truth.
Less invasive treatments for BPH include forms of heat to destroy excess prostate tissue. Such heat treatments include transurethral needle ablation, a treatment using radio frequency waves; microwave thermothereapy, therapy with electrical currents known as transurethral electrovaporization; photoselective vaporization, treatment with laser beams (Interstitial laser coagulation) and with hot water — hot water-induced thermotherapy All these treatments are superior to BPH surgery in that they have fewer adverse effects.
As I understand it, about half of patients had impotence problems after radical prostatectomy.
Quality of Life and Satisfaction with Outcome among Prostate-Cancer Survivors
Martin G. Sanda, M.D., Rodney L. Dunn, M.S.,
N Engl J Med 2008; 358:1250-1261 March 20, 2008
Distress that was related to the patient’s erectile dysfunction was reported by 44% of partners in the prostatectomy group, 22% of those in the radiotherapy group, and 13% of those in the brachytherapy group
While I’m in the urology collection of the NEJM, here’s the 11 year followup of Fritz Schröder’s European trial.
The significant point is that all-cause mortality is the same whether the men had a PSA test or not, so it merely shifts the deaths from prostate cancer to something else.
How many men do you know who get up in the morning and say, “I wouldn’t mind dying of a heart attack or stroke, but I wouldn’t want to die of prostate cancer. And I wouldn’t mind a 50% risk of being impotent to avoid it.”?
Prostate-Cancer Mortality at 11 Years of Follow-up
Fritz H. Schröder, M.D., Jonas Hugosson, M.D., Monique J. Roobol, et al.
N Engl J Med 2012; 366:981-990 March 15, 2012
Conclusions: Analyses after 2 additional years of follow-up consolidated our previous finding that PSA-based screening significantly reduced mortality from prostate cancer but did not affect all-cause mortality.
Great post, Laura.
It’s so easy to confuse care that is least likely to result in the doctor being faulted with care that is best for the patient or care that is part of a policy that’s best for the population at large. If I were Buffet’s doctors, I’m betting I’d be tempted to protect myself, too. But it’s the wrong decision.
My father was diagnosed with prostate cancer at age 81. He was still fit for his age to the point where he still cut his own firewood (with chainsaw, etc). He was told by his doctors (inEurope) that he would die from another cause and not to worry about the mass. Later, when he developed problems with his urinary system at age 82, it was discovered that he had developed a large mass that was so big that surgery was no longer recommended. He died from prostate cancer when he turned age 83 after several months of severe pain. So, I think Mr. Buffet should make the decision what treatment he prefers. He may be able to extend his life one decade or more!
Working in heathcare IT and having worked in the NHS in the UK I find it so outrageous that with the US spending 3 times to UK per person the excuse that certain treatments cannot be provide such as contraception, treating the poor etc is an issue. It is the “for profit” businesses that are stopping people from getting the care they need. Jesus Christ would not be proud that so many claim to speak in his name.
As a 50 year old who faced hearing the diagnosis of Prostate Cancer, I think we need to be clear about a few items: each case is different, so the treatment should take into account ALL items of the person’s health.
I am 3 years post robotic assisted surgery. I am not living with cancer, I am cancer free. I had no nerve damage and am fully functional without any assistance. My cancer was found via a routine PSA screening. I’m not aware of any other cancer that is treated by the thought of “not knowing is better than treatment”
I am interested, have of the above, (or our blogging host) ever been told they have cancer?
In the interview on Science Friday, you said more once that it is likely that men continue to choose unwarranted or unwise active treatments because the doctors who advise them have a financial interest in performing the surgery or managing the radiation treatments. I was disappointed that this point affected Mr. Flatow no more than water off a duck’s back. Searching your blog, I can find little more about this problem.
Perhaps you have written elsewhere about doctors’ sometimes financial incentives to recommend the use of less than prudent treatment courses?
Thanks in advance.
I listened to today’s discussion about the 0verutilization of surgery to address possible
prostate cancer. The claim of overutilization of surgery was an overly broad based criticism. My case is an example that debunks the validity of this broad based analysis. Starting about age of 55 or 56 my PSA values began to trend up from an initial value of about 2.8 when the value rose to about 4.3 in the next annual evaluation biopsies began. Over the next 3 years the values continued to rise to 6.3 At that time biopsies began the biopsies were negative. The next two years they continued as the values raised to 7.6 when they were able to detect the cancer, it was very close to my seminal vessicles. The surgery was done with the Da Vinci procedure and after 8 years I am cancer free. Here is my point,because the site of that cancer was near the seminal vessicles that put me at a high risk for the cancer to spread into my system. I had zero side effects in part due to the precision of that technique. The persistance of biopsies caught it early and probably saved my life. I am also an African American in which there is a statistically much higher rate of prostate cancer, Lastly I also live in Colorado which has the highest prostate cancer rate for all men in the Country. In summary I was disappointed with y0ur program’s overly broad and surprisingly superficial treatment of a very prevalent and serious disease for men. You should have had a guest to rebut the opinion of your featured guest because her conclusion is not universally accepted in the medical community. I suspect that the impetus was the publication of her work but that fact should not have trump good journalism by having an informed expert to address the shortcomings of her presentation.
I appreciate your point of view. The best journalism is often multisource. However, I would like to point you to the infinite number of news shows that showcase physician experts singing the praises of their technique, with no countervailing opinion, caveats, etc. Thus far, the voice of someone outside of the medical arena has been made invisible. BTW, I have covered urology, specifically prostate cancer for decades. Within the field, there is considerable diversity of opinion.
Eleven years ago, at age fifty one, I was tested and had a PSA of about 6.0. A biopsy indicated a “moderately” aggressive tumor. I monitored for a while, but the more I read, the more I realized that I should do nothing. And that’s what I have done.
The biggest problem is that as a self employed person, I now have a preexisting condition. Because I am otherwise healthy, this has upped my medical insurance by thousands a year and, of course, tens of thousands over ten years.
I sleep though the night and have none of the effects of treatment. Wish I had never been tested.
At age 71, I am a near ten year survivor of prostate cancer dealt with appropriately with a radical prostatectomy.
I have watched men die of too late diagnosed prostate cancer and I wish it on no one.
We should allow Mr. Buffet the liberty of the land in whatever treatment he can access. If we want to deny public funding of legitimate medical procedures based on statistical data as a means of rationing scarce health care dollars, let that be fine. But we shouldn’t criticize Mr. Buffett or constrain his taking personal access to whatever treatment he can afford in the private sector any more than we should constrain the foolishness of a tattoo or the vanity of much cosmetic surgery. We all were born to die, but we have a right and should be at liberty to try to control what we can even as we try to be graceful in accepting that which we can’t.
All many of the above posts have really said is that we ought, in part, to constrain the public cost of health care by rationing the public outlay of funds to the procedures of most probable value, i.e. do a cost benefit analysis of the gross health care offering and offer service as far as the allocated dollars will go. To say it another way, we ought to make a Pareto’s Law analysis of the health care business and seek to take care of 80% of the need with 20% of the expense, and cut off funding for the 20% of the service that racks up 80% of the cost.
But we shouldn’t ever try to deny an individual the personal opportunity to go wherever he wants, for whatever lawful treatment he wants, at his own expense.
As Shakespeare said: “Costly thine apparel as thy purse can afford…” Let it be…
Sorry to come late to the conversation.
Laura has done a great job of summarizing the problems with the current approach to prostate cancer. This problem is an example of a much larger problem in the US healthcare system, which is wasting limited healthcare dollars!
For example, think about how much money Medicare is wasting on both ineffective screening and diagnostic procedures, plus treatment regimens that don’t prolong life, and that probably decrease the quality of life for many men!
Warren Buffet can afford to waste his money, but there are many elders not getting the care they REALLY need, while we waste money on things that don’t really help!
“Medicare wastes dollars” is a platitude of great truth, but it is not much helpful in assessing or solving the problem. Nor is socialized in lieu of capatalistic medicine necessarily a wonderful platitudinous answer. The fundamental objective has to be to make quality health care, at minimized cost, universally available, and then provide a financially subsidized support of the service according to need, and as far as the available monies will go.
We learn in engineering school that we cannot reasonably assess that which we have not (or cannot) quantified. And there is so much “art” in medicine that attempts to “quantify” still are subjective.
Much of the cost of medical service could be reduced if delivery of care could be reduced to a commodity, to be accessed on an open market, run on an optimized assembly line, with cost based price of service instead of the “whatever the market will bear” approach now in place. Right now, every health provider seems to have several prices, high to low, for the same effort. When a person can walk into a doctor’s office, or into a hospital, and pay in cash no more than the favored provider rate, even handed across the country, we will have one issue taken care of.
When the medical and nursing schools and resident training environments cease to ration the number of doctors and nurses in the market place and when service is encouraged to migrate towards an evaluated (quality/price/convenience) provider, there will be a reduction in cost. If a block of service in a given community is put in a place of competetive pricing, the prices will tend towards a minimum.
When the costs of development of truly efficacious “Blockbuster” drugs are made whole to the inventor and thereafter the drugs are available as a commodity, prices will tend towards a minimum.
When we back off of the “save the life at any cost” attitude, defective babies allowed to pass gracefully on, to “die on the mothers breast” as it used to be, or terminally sick or injured individuals triaged against long term life support in intensive care, we will have made progress. But this problem requires subjective assessment and we probably don’t have the “national will” to address it.
In all, we must retain the ability of whoever to access care of their own choosing with use of their own resources. And it is no fair to criticize anyone for accessing the currently available public offering if they play according to the rules. Don’t criticize Mr. Buffett, work to straighten up and level the rules.
It is the elderly who represent the bulk of Medicare expense. Take the 1/3 of the national budget represented by that block of funds and draw us a clear path as to how to both allocate and improve the service while reducing and limiting the cost of the effort.