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Dr. Kenneth Tokita counters New York Times bad advice on prostate cancer screening

Thursday, March 19, 2009
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HH: I’m starting this hour with Dr. Kenneth Tokita, who is the Cancer Center of Irvine’s founder. Before that, he founded cancer centers at St. John’s Hospital in Santa Monica, Torrance, he has been in the field for more than thirty years. And I’m doing so because tomorrow, you’re going to see in your newspapers, and tonight you’re going to see on TV if you watch it, the report of two studies having to do with prostate cancer screening that I think have the potential to mislead, and maybe even injure people if they are misreported. So Dr. Tokita, welcome, I’m so glad you could spend some time with me this afternoon.

KT: Hi, Hugh.

HH: Now let’s start, how long have you been treating people for prostate cancer?

KT: For about 32 years now.

HH: And so about how many different patients do you think you’ve had over 32 years?

KT: Probably 3,000 or so.

HH: And what kind of treatments at the Cancer Center of Irvine are offered?

KT: Right now, our main focus is on radiation therapy, but our urologists do robotic surgeries and other types of treatment.

HH: And so from before the PSA test was invented, you have been treating prostate cancer.

KT: Correct.

HH: So what do you make of these two studies today? Why don’t you summarize what they say, and how should they be understood.

KT: Well, these studies have been going on ever since I’ve been in medicine. And basically, what they do, they’re national studies or large-scale studies to see about the death rate, or how it effects mortality in a specific disease type. So in doing that, you’ll get a small number of patients who have the disease, and you’ll have a small number that’ll die of the disease. The problem with these big studies is that they’re comparing huge populations that have a lot of different problems, a lot of different diseases, and you’re now trying to decipher out of that that small number of patients that die of prostate cancer. And so it’ll look very small in that series, and that becomes very misleading, because it doesn’t tell you how many of the patients actually went on to die of prostate cancer. That’s the biggest problem.

HH: Now generally speaking, I understand prostate cancer to be the cancer that is most likely to be cured by early intervention. Am I right about that?

KT: That’s correct, in men.

HH: In men, obviously.

KT: Right.

HH: And so the headline here, prostate cancer screening found to save few if any lives, this is a New York Times headline.

KT: Right.

HH: Doesn’t that suggest that you might as well not get tested?

KT: That’s correct, and that’s exactly what we heard in the 60s with heart disease, and then a few years ago, many of you heard that with breast cancer, and now you’re hearing it with prostate cancer.

HH: But it just is so counterintuitive to me. If someone’s driving around right now and they’re 52, and they’ve never been tested and they hear this headline…

KT: Right.

HH: They’re going to say okay, I can go to 55, I can go to 60, I might not ever get tested. Are they playing roulette?

KT: Yes, they really are. The problem is these studies really should look at several hundred patients who have cancer of the prostate with several other hundred patients equally matched who decide not to be treated, versus those who have been treated. Then you can really tell if treatment adds anything to that. And that’s the only real way to study it.

HH: Now one of the, let me read a couple of paragraphs to you. “The reason screening saves so few lives, cancer experts say, is that prostate cancers often grow very slowly, if at all, and most never endanger a man if left alone. But when doctors find an early stage prostate tumor, they cannot tell with confidence whether it will be dangerous, so they usually treat all early cancers as if they were life threatening. As a result, the majority of men whose early stage cancers would not harm them suffer serious effects of cancer therapy, but get no benefit.” Is that misleading?

KT: It’s very misleading.

HH: That’s what I thought.

KT: It basically, whoever wrote that basically does not treat prostate cancer.

HH: It’s a New York Times reporter, so obviously they don’t, but explain why.

KT: And the reason is that we have become fairly sophisticated now in deciphering which patients are at high risk, which patients are at moderate risk, and which patients are at low risk. For example, this last week I saw five patients with prostate cancer. Two of them have very low risk, and they are perfectly comfortable, it would be perfectly comfortable for them to watch this cancer, and be followed at regular intervals with PSAs. And there is a very good chance that indeed they may die of something else before the cancer gets them. Then there’s the moderate ones where we know that if we wait six to seven years, they’ll be in trouble. Then there are ones that are very dangerous, two of whom I saw this week, who if we don’t do something we would have no chance of curing them, and they probably would be dead in five years.

HH: Now is it fair to say, you’ve been doing this a long time, and the Cancer Center of Irvine, one of the cutting edge facilities on the West Coast if not the country, if you’re not a specialist like that, if you’re just going in to see a general practitioner, are they going to be equipped generally to do this? Or do they even attempt to read a PSA test that way?

KT: Well, the PSA is just an indicator. Let me tell you what a PSA…what it is, is a protein that’s made by the prostate. So if something goes wrong with the prostate, the PSA’ll go up. The three most common things are infection, a disease called benign hypertrophy, which makes it harder for guys like me to pee as I get older. And then the third one is cancer. So when the PSA rises, those patients will then be sent to a urologist who’ll make that decision whether to biopsy or not biopsy.

HH: And so how easy is it for you to tell whether it’s one of those patients who needs intervention immediately, that can be in the moderate category, can just go home and check in every few years? How hard is that to do?

KT: It’s very easy now. That’s what’s so frustrating about these articles.

HH: Yeah.

KT: It’s really easy. There’s now, we’ve worked out the parameters, we now know which patients when they walk in with their results, who’s at high risk and should be treated. These two patients this week, they have to be treated. One’s 62 and the other one is 74. They should be treated. They’re healthy, and without treatment, in five years, they’ll probably be close to dying.

HH: But you can, with treatment, prolong their lives as many years as they have in a natural life span left.

KT: There’s a very high cure rate on both of them, because they were picked up early with PSAs.

HH: You see, this is completely different of the media coverage that is going to come out from these studies.

KT: Because what you’re talking about now is a small segment. You’re talking about the patients who actually have the cancer.

HH: Yeah.

KT: And that’s the bottom line. If you have the cancer, are you willing to just look at this study and say I’m not going to do anything? I personally, I’m 66, I want to live to 90 and spend all the money…I’m just teasing. But I would love to live to 90 and be healthy as long as my brain’s working okay.

HH: How many patients, if you see hundreds a year, elect just to watch?

KT: Actually, a fair number do. About 20% do.

HH: Okay.

KT: And the way it works is about half of all the men that come into my group for review have the slower-growing cancer. And those, they can watch if they want to. But it’s kind of a tricky thing for a person to walk in and say I have a cancer, do I not want to be treated. But we’re pretty, we try to be pretty even about that. We say stop, there’s potential side effects to treatment, analyze those, and decide whether you’re willing to take that risk of those side effects if you get treated.

HH: This isn’t related to the study, but I’m curious. If you were to correlate personality type with those who tend to accept the risk, is there a personality type?

KT: There really is. Yeah, it’s interesting.

HH: What is it?

KT: The type A personalities which are doctors and engineers will tend to want to be treated. There’s a cause and effect type of understanding. The more, the real thinkers, a lot of the professors and really smart people, who are not smart, but the really smart people can quite often think it through and make a decision that they’re willing to analyze and weigh the facts, and go through it. So it’s interesting that you asked that question.

HH: So I want to go back now to the key takeaway, and what I want, really, people to hear is that they should get their PSA tested, and then if it is a positive, explore with a professional like you or other colleagues…you’ll be able to tell them whether they’re at high risk, medium risk or low risk. It just doesn’t make any sense not to get tested.

KT: Absolutely. And 90%, 95% of the urologists in the United States are very, very competent, really well trained, and can tell their patients that. It’s really impressive.

HH: I want to ask you about, in the earlier conversation we had today, you mentioned that there’s also a push by some to discourage testing among older people because obviously, if you don’t get tested, you’ll die from prostate cancer. But if you do get tested and you get cured, you’re going to live a lot longer and cost a lot more money to the system. Now that’s subtle. Is that embedded into our system yet? Is that anti-testing ethic embedded in our system yet?

KT: It is, and it’s a government-pushed issue. And you see it in the countries that have socialized medicine, because they worry that it will bankrupt their system if they pick up all these prostate cancers and breast cancers, et cetera. So now that we have a better understanding that we can cure these people, and they can live a longer life, I think that will fall aside the same way it did with heart disease.

HH: And so older people should also get tested, because they’ve got a lot of great years left for them. If they’re 75, they’ve got another quarter century to go.

KT: I think everybody has a right to have a choice. So if you know you have prostate cancer, it should be your choice whether you want to just watch it or go aggressively after it.

HH: Dr. Kenneth Tokita, thanks for coming by. I very much appreciate it, the Cancer Center of Irvine, I’ve linked it over at www.hughhewitt.com if you want to find Dr. Tokita. He’s treated a couple of friends of mine, and they rave about him. He’s friends with Dennis Prager as well, and you can probably hear in his voice why that is. When you read this story tomorrow, just shake you head. I think Gina Kolata in the New York Times has done a very grave disservice to people with those two paragraphs, and I hope the word gets out. Dr. Tokita, thanks, great to have you in studio.

End of interview.

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