Marc B. Garnick, M.D.

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.

Comments:

  1. JoeFranklin@sportshopsusa.com

    Wow this is a very informative article. I never realized what trouble can arise from this type of prostrate cancer testing. It’s amazing how even the rich and powerful can be given the wrong advise.

    Joe

  2. Danny

    Its seems hard for some people to understand that money isn’t everything. Though it makes life much easier in many ways, things such as cancer are more destructive than any kind of “power” people have made the last centuries.
    Cancer is something that is almost impossible to avoid for many people. Those who have died on this terrible disease, R.I.P.

    Kind Regards,

    Danny

  3. Dan

    Doctors are too eager to medicate or radiate. This is a great example. It also proves that Knowledge is much better then money. If he took the time to research his health as much as he does a business he is considering buying there would be no radiation and he would be just as healthy as ever. Buffet needs to re-think his decision. At 81 I think radiation therapy will probably start depleting his health.

  4. HealthyAlister

    Good read. I have to wonder what’s going through Buffet’s mind and how confident he is. Surely a man with that much wealth would have access to medical expertise and facilities that most of us can only dream of?

    Keen to see how the following years roll out for him…

    Alister McWilling

  5. uriahh

    At 81, Mr. Buffet may be exposing himself to unecessay treatment. As good as some reported RT results may be, he is still exposing himself to ionizing radiation .

    If he didn’t consult other CaP authorities, which he could do with no effort at all, then he is relying on one MD’s opinion. In CaP that is hardly the best way to proceed.
    Perhaps he is the kind of gentleman who hears the BIG C word and immediately panics!

  6. Gooddoc.

    What none of these physicians or patients or worried men say ( or perhaps even know) is that there is no viable treatment for prostate cancer.Well under 1% of men undergoing “treatment” have an improved quality of life, while most men who die at 65 or later , have prostate cancer and did not expire because of it . Only the small percentage of men who suffer the most aggressive forms of the disease may benefit in some small degree from surgery or radiation therapy.

  7. George MacDonald

    Pretty much everything expressed in this article is a matter of opinion and up for debate.

    So, it befuddles me that a medical professional would be telling people NOT to have a test (such as PSA) that carries no risk.

    The problem is NOT with the test — it is with what other physicians do with the results. If Buffet was informed of all his options and the consequences and/or benefits associated with each — HE was making an informed choice. HIS choice.

    The choice should not lie with a physician. It is Buffet’s prostate not the physician’s. It is Buffet’s choice.

    True, when somebody else is paying a test, it can be argued that the cost of the test outweigh any likely benefits from the test. But, Buffet could afford to pay for a PSA test for pretty much evey man in the country — so that was not a factor in this case.

  8. Fred Evans

    I know that the current medical advice is that PSA tests are unnecessary in older men. As Dr. Garnick states, “the vast majority of older men would die of something else in the 10 to 20 years.”

    As a soon to be “older man” my concern is what if my doctor declines to ask for a PSA as part of my normal blood panel and my cancer turns out not to be part of the “vast majority”? Frankly, I just don’t see the downside risk of a PSA test. It’s non-invasive and cheap. If the levels are elevated my doctor and I can decide what to do. If I don’t have the test I do nothing and potentially put myself at risk. What is rational for the “vast majority” may be irrational for the individual.

  9. Joe

    The article is right on point. Even before I saw this article, I thought about calling Buffett. I am 67 and have had a high PSA for 15 years. Five(5) biopsies during that time. Most recent one showed small volume, slow growing cancer. Hasn’t grown at all in the past year. No treatment warranted at this time.
    Dr. Garnick: why don’t you try to reach Buffett. If your ethics code precludes that, I may try to reach him.

    • JSodusta

      A simple supplement of Vitamin D3, increased exposure to sunlight to synthesize Vitamin D3 and calcium have been reported to reduce tumor by as much as 50%, even for men who had metastatic prostate cancer. There is overwhelming scientific evidence that those who have deficiency in Vitamin D3 have increased risk in prostate cancer, colorectal cancer, breast cancer etc. (Here are some of the studies: Clinical J of the American Society of Nephrology by M F Holick, Sept 2008, vol3; The New England J of Medicine by M C Chapuy, et al Dec 3/1992; J of Clinical Endocrinology and Metabolism by P Lips et al; Arch Pediatric Adoles Medicine by C M Gordon et al June 2004, vol 158.There are many more references or cross-references as you read some of the articles.)

  10. PBL8LY

    I do hope that with all of Mr. Buffets wisdom and money he is considering all of his options, second opinions, and not worrying about the financial costs. Proton therapy treatment for Prostrate Cancer may do less damage. The richest men don’t always make the best choices ie. Steve Jobs.

  11. TMRN8R

    The general sentiment that prostate cancer is over-treated in the US is likely correct, but we don’t have the details of Mr. Buffett’s disease. Even a high-risk, Gleason 8, T3 prostate cancer could accurately be called “not remotely life-threatening or even debilitating in any meaningful way” as Mr. Buffett has been quoted as describing his cancer. With effective radiotherapy and hormonal manipulation, men with such disease can live for years without significant affects on their quality of life and an otherwise healthy 81 yo white male has an average additional life expectancy of 7 years which is plenty enough time for an intermediate or high-risk prostate cancer to adversely affect his quality or quantity of life without treatment.

    Moreover, it is true that radiotherapy is not without risk, but this article seems to exaggerate them. Sure men get a bit tired and might have a bit of bowel irritation at the end of treatment but I have yet to have one man who is working take time off from work during or immediately after a course of RT and older men do just as well. Rates of chronic rectal bleeding are now ONLY 3% or less and erectile function is PRESERVED in 60-70% of men who are potent before RT and who are not taking hormones.

  12. jojolendir

    great article…i have to admit

  13. 101str8media

    Great post, thanks for the advice. I was not aware of these options. You would think with the money Mr Buffett has in his nest egg, he would at least surround himself with more knowledgeable medical advisers.