May, 2012
Oraculotherapy
By Michael J. Katin, MD
"Never ask a barber if you need a haircut" Warren Buffett, 2007
"Sometimes you need to ask the right barber" MJK, 2012It seems like only yesterday (or March, to be more exact) that there was controversy regarding the morality of paying for former Vice President Dick Cheney to undergo heart transplantation considering that he was at the advanced age of 71 . This occurrence was valuable both because it revived the discussion regarding restriction of health care resources, but particularly since it provided material for last month's column Only a few weeks later, the announcement was made by multi-billionaire Warren Buffett, the Oracle of Omaha, director of Berkshire Hathaway (owners of GEICO , Johns Manville , Fruit of the Loom , and See's Candies , among others), that he had been diagnosed with "stage I prostate cancer," and that he was going to be treated with radiation therapy His statement also included the details that he had received the diagnosis on Wednesday (April 12) and had a CAT (sic) scan and bone scan Thursday (April 13) and an MRI that day (Monday, April 17). It would be hoped this delay in obtaining his imaging studies has not impacted his chance of cure.
Presumably the analysts were well apprised of the effectiveness of radiation therapy for this condition, since an economic meltdown did not occur. But maybe there should be consideration of shorting Berkshire Hathaway stock after all. Mr. Buffett's statement that "I've been told by my doctors that my condition is not remotely life-threatening or even debilitating in any meaningful way" is obviously a smokescreen. First, the use of the adverb " remotely " is suspicious. Prostate cancer can produce serious problems by local-regional effects, certainly not just by remote spread.. Second, why did he choose to throw in the phrase, "in any meaningful way?" Time does not allow me to address the significance of what is " meaningful " and what is not .Was this a subliminal reference to " meaningful use ?" Third, should not there be concern that he underwent a CAT (sic) scan, bone scan, and MRI for "stage I prostate cancer?" The American Society of Clinical Oncology's Cost of Cancer Care Task Force has identified the top five "Opportunities to Improve Quality and Value In Cancer Care ." Presumably the Task Force did not consist entirely of Medical Oncologists, since abolishment of Radiation Oncology was not one of the five items. However, Number Two of the Top Five was: Do not use PET, CT, and radionuclide bone scans in the staging of early prostate cancer at low risk for metastasis (or is it, thou shalt not?).
Is there reason to be concerned that Mr. Buffett, who not only had a CAT (sic) scan and bone scan but even had an MRI, has a far more advanced problem than he has announced. It would be difficult to imagine that Mr. Buffett, who has shared, with his President and with his fellow citizens, his private agony that his secretary pays a higher tax rate than he does, would want to participate in excessive staging studies when ASCO itself, in seeking to comply with the government's health care program directives regarding quality measure assessment , has encouraged that such studies not be performed in the interest of both quality and cost? This would seem extremely unlikely.
Fourth, and of far greater concern, is that he will be undergoing treatment. There may be divided opinions in the medical community, but the business sector has already decided. An article in Forbes, from 2009, titled "The Dark Side of Prostate Cancer Screening," concluded that the paper by Welch and Andersen from the Journal of the National Cancer Institute indicated that PSA screening resulted in diagnosis of many cases of prostate cancer that would "grow slowly" and " never do harm ." Judging from the title of the article, and ignoring the fact that " dark " should not keep being used to denote something negative, isn't it obvious that Big Business would like to promote the idea that prostate cancer does not need to be diagnosed, probably since it interferes with productivity and runs up expenses. Mr. Buffett stated that his prostate cancer was diagnosed because his "PSA level (an indicator my doctors had regularly checked for many years) recently jumped beyond its normal elevation." If Mr. Buffett were being socioeconomically and bureaucratically correct, he would not have been having his PSA value checked, and this further increases suspicion as to the severity of his disease.
We can only hope, for his sake, that he indeed has early stage prostate cancer and, for reasons that are known only to him and his inner circle, he decided to go for treatment rather than active surveillance. Granted, Mr. Buffett will probably not be paying for treatment himself. Although he could afford to put in a dedicated carbon ion facility for his own personal treatment, or purchase a new IMRT/IGRT unit for each one of his fractions of treatment, he will probably have his treatment covered by Medicare and then haggle about the co-pay, unless his secondary coverage (does GEICO have a health insurance division?) kicks in.
It is to be noted that, on the other end of the political spectrum, all four Koch brothers have been treated for prostate cancer. David H. Koch donated $100 million to the Massachusetts Institute of Technology for a cancer research facility, and we should expect Mr. Buffett to make a similar contribution to oncology research and treatment.. Perhaps he would be willing to match the amount of tax ($366.3 million) that he is contesting his companies do not owe the United States Government.
Getting past all this, the most important thing is that Mr. Buffett has selected to be treated with radiation therapy. An ultra-successful businessman who is a personal friend of the President of the United States and who has been considered by some to be the most famous and intelligent investor in our history has selected to be treated with radiation therapy. Warren Buffett, who said "Risk comes from not knowing what you're doing," has decided in favor of radiation therapy. For at least the next several years, whenever one of us sees in consultation someone who is trying to decide on the best treatment for prostate cancer, we simply need to say two words: "Warren Buffett ." Whenever an insurance program or government panel starts propagandizing about promoting active surveillance rather than treatment in older men, we simply need to say two words: "Warren Buffett." The keynote speech at ASTRO's 54th Annual Meeting in October should consist of only two words: "Warren Buffett."
