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Feature Stories

One doctor on turning 65: Rejoice! (And use screenings wisely)

Hadler Nortin

Nortin M. Hadler, M.D., professor of medicine at the University of North Carolina, believes older folks are "medicalized" – his term for "reframing ordinary life predicaments so they're viewed as diseases." His 2011 book, "Rethinking Aging: Growing Old and Living Well in an Overtreated Society," contends those 65-plus often get unneeded drugs, tests, treatments, and diagnoses.

"Doctors have long taken Hippocrates' 'do no harm' to heart, but in the 21st century we have the science to take his 'do good' to heart as well," says Hadler. "Treatments, procedures, and medicines must really work; they must be prescribed for 'important' diseases, and we must know we can achieve meaningful outcomes. If not, we really achieve very little."

One disease Hadler finds "unimportant" is prostate cancer. "For those few who actually get the worst forms, prostate cancer is very important. But we cannot identify the few among the many men whose cancer is not lethal – that's most men who will die with prostate cancer, but very few from it. They usually die from something else, typically heart disease." So though many men may be diagnosed with prostate cancer, few would have actually died from it if its natural course went untreated.

Hadler cites two large 2009 long-term randomized, controlled trials: the PLCO in America (76,693 men) and the ERSPC in Europe (162,387 men). The studies looked at the effect of cancer screening on mortality. Hadler's conclusion: "Screening 1,400 men for nine years would cause you to treat 48 more men, but avert prostate cancer death in one. That's a lot of over-diagnosis and over-treatment."

Other prostate cancer screening views

There are pros and cons to prostate cancer screening, and experts do not all agree on the best approach. In May 2012, the U.S. Preventive Services Task Force (USPSTF) said it "recommends against prostate-specific antigen (PSA)-based screening for prostate cancer. The USPSTF concludes that there is moderate certainty that the benefits of PSA-based screening for prostate cancer do not outweigh the harms." (Source: http://www.uspreventiveservicestaskforce.org/prostatecancerscreening/prostatefinalrs.htm)

By contrast, the American Cancer Society recommends that, "Men who have at least a 10-year life expectancy should have an opportunity to make an informed decision with their health care provider about whether to be screened for prostate cancer, after receiving information about the potential benefits, risks, and uncertainties associated with prostate cancer screening. Prostate cancer screening should not occur without an informed decision-making process." (Source: http://onlinelibrary.wiley.com/doi/10.3322/caac.20143/pdf)

Hadler's older-age prescription

"I wrote 'Rethinking Aging' (UNC Press, Chapel Hill, 2011) to help signal a change in the parlance of time from 'my time is limited' to 'my time is valuable, too valuable not to capture every moment I can.' Whether robust or frail, make time slow down."

Hadler says, at 65, rejoice for having lived this long and for the fact that you are in the first generation in history that can rationally ask how to productively spend the next 15-20 years. "Aging isn't a disease. Frail elderly persons aren't a burden. Marginalizing this time of life deprives our communities of lifeblood and denies the aged the sense of vitality that is the privilege of longevity in the 21st century. Older people must think of themselves as, and be treated as, people with a future, not only a past."