The two subjects of the above title seem to have little in common. But they are both examples of action unmoored from knowledge. If the scientific foundation of medicine is compared to that of economics, specifically the actions of the world’s central banks, the practitioners of the former are certainly closer to the dictates of evidence than are those engaged in the dismal science. My belief in this statement persists despite the gap (sometimes a chasm) that sometimes separates medical practice from medical science. That both medicine and economics are enmeshed in politics makes a search for truth a game of blind man’s buff.
The diagnosis and treatment of prostate cancer has been plagued with controversy and confusion ever since the PSA (prostate-specific antigen) test came into widespread use almost four decades ago. The problem is that while some prostate cancers are aggressive and associated with high mortality rates, most are not and may never cause death. Thus, many men die with prostate cancer, but not from it. Widespread PSA screening led to the diagnosis of many non lethal tumors that nevertheless were aggressively treated with surgery or radiation, therapy associated with high rates of complications like urinary incontinence, impotence, or radiation bowel injury – but with limited or no effect on mortality.
Right from the start of this screening a few physicians, including this one, questioned the widespread use of PSA screening arguing that is was causing more harm than good. There are a number of articles on this site discussing this problem. After increasing medical commentary that PSA screening was more harmful than not, in 2012, the US Preventive Services Task Force advised against routine PSA screening, a recommendation that was modified in 2018 to include shared decision making by patients and their physicians. PSA testing was contraindicated in men over 75.
The second recommendation was mostly formulated to pacify some urologists and oncologists who wanted PSA screening to continue. The fiction of shared decision making is a fig leaf invented by epidemiologists who don’t see patients. That doctors should be told to talk to their patients before doing an important and potentially life altering test assumes they slept through all four years of medical school and the three or more years of postgraduate training that followed. They know they should talk to their patients, but still don’t do it because they don’t have the time. A meaningful discussion of the pros and cons of screening for prostate cancer takes about half an hour and is not reimbursable.
What typically happens is that the test is included with all the routine blood work done annually and the issue is not discussed unless the PSA comes back high. This is when I start to get phone calls from relatives or friends asking what they should do. I spend a lot of time discussing the issue with them which they typically disregard. They eventually end up with a biopsy which if positive is followed by treatment that is of dubious value.
Fifteen-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Prostate Cancer is a paper in the New England Journal of Medicine. Between 1999 and 2009 in the United Kingdom, 82,429 men between 50 and 69 years of age received a prostate-specific antigen (PSA) test. Localized prostate cancer was diagnosed in 2664 men. Of these men, 1643 were enrolled in a trial to evaluate the effectiveness of treatments, with 545 randomly assigned to receive active monitoring, 553 to undergo prostatectomy, and 545 to undergo radiotherapy.
The study concludes that at a median follow-up of 15 years, mortality from PSA-detected prostate cancer remained very low regardless of whether men had been assigned to receive active monitoring, prostatectomy, or radiotherapy. Radical treatment resulted in a lower risk of disease progression than active monitoring but did not lower prostate cancer mortality. All cause mortality was also the same in the three groups.
Telling a patient he has cancer, but that he’d likely do just as well with no treatment as compared to active intervention is not an easy sell. Life for all concerned would be far more tolerable if the PSA test were not done in the first place. The NEJM also published an editorial by an oncologist who advised a more targeted intervention in place of watchful waiting. The management of this disease is not settled. Primary care physicians are apt to be as confused about its diagnosis and treatment as their patients.
Two final observations. The age adjusted mortality from prostate cancer today is exactly what it was in 1930. Thus, it’s impossible to rationally claim that we’ve made a lot of progress in its treatment. Second, no man over 75 should have a routine PSA. Those younger should try to find a physician willing to discuss the test before administering it.
Despite vast increases in our understanding of cancer, the practitioner of medicine often finds himself at a fork in the clinical road. Unlike the fork that led to Yogi Berra’s house regardless of which one you chose, he can often take the wrong one no matter how informed he is.
Pity the poor central banker who almost always goes the wrong way. He’s doubtless familiar with the work of Frederich Hayek the most important economist of the last century. But he’s accepted an assignment that requires he act as if the Nobel Prize winning economist, philosopher, and sociologist had not written a word.
Hayek essentially discovered chaos theory before it was so named. His most important contribution to economics was the postulate that the economy was so complex that no one person or group could fully understand its workings sufficiently to predict its future behavior or successfully intervene in its action such that a better outcome could be achieved. It worked best if left alone to operate under general rules which applied, in almost all instances, to all. This view contradicts everything expected of a central banker. They all know Hayek’s work and in the quiet of their solitude must muse on the folly of their mandate and actions. They are appointed and controlled by politicians assuring that even in the unlikely event that they choose to be rational, they will be overruled.
The world’s central bankers are a fiscal version of Sportin’ Life dispensing happy dust to the world’s economies. The world’s cumulative debt is so high that no one really knows what it is. The politicians and their lackeys (the central bankers) have made so many promises that cannot be honored and created so much artificial wealth that will inevitably be worthless that the only response north of self immolation is denial. The chart below is the International Monetary Fund’s estimate of global debt.
In dollars, global debt is estimated by the IMF to be $235 trillion – a number beyond human comprehension. It’s almost certainly a lot more. But once you’ve exceeded 100% of a lethal dose of anything, any excess doesn’t matter. Having created inflation, spreading moral hazard as if it were a contagious disease, and then charged with magically curing a patient you’ve poisoned the politicians are rescuing banks that unwisely bought long term treasury bonds under the delusion that interest rates would never rise. At the same time, the central bankers are trying to simultaneously raise and lower interest rates.
While all this funny business is going on ask your financial advisor how you should invest your savings and you’ll be told to stay calm and think of the long term. Of course, as Lord Keynes famously quipped, in the long term we’re all dead. While you’re at it, ask him to explain the relationship of fractional reserve banking to bank runs.
The politicians treat their voters as if they were brain dead. The voters oblige by acting as if they were brain dead. Don’t fix social security or medicare. They’ll get better on their own. Everything is hunky-dorry in Cloud Cuckoo Land.
Unlike prostate cancer, which we’ll eventually figure out, our financial woes have reached the river of no return. The economy needs hospice care. There is no way out save the one that the late economist Mancur Olson prescribed for the reform of a giant system off the rails – collapse, followed by starting again from scratch. It’s a good time to be very old.