The Hypothetical Rabbit

Michael W. Kattan,

Front Oncol. 2016; 6: 123.

Published online

This common analogy for describing newly diagnosed prostate cancer patients appears to be attributable to Hinman,* who borrowed from Crile when applied to breast cancer.

·      Turtles are patients with very slow growing disease. Their disease grows so slowly that they need not be diagnosed, for the disease will never spread to the point of causing problems within the patient’s lifetime. A turtle will die of another cause, not prostate cancer.

·      The bird has been diagnosed too late to have impact on the disease. It has already spread and cannot be meaningfully slowed down, to the point where the patient is likely to die of his prostate cancer. The bird is similarly not helped much by a diagnosis of prostate cancer since it is already too late to stop the disease.

·      The rabbit sits in the sweet spot. The rabbit is the man with prostate cancer who needs to be diagnosed (his disease spreads faster than that of the turtle and indeed poses a threat to his life), yet the disease is still curable (unlike the disease borne of the bird).

This model holds for many other cancers, perhaps most. It can be helpful when patients or physicians think about screening and treatment.

*The value of screening for prostatic carcinoma: a commentary.

Hinman F Jr.  Urol Int. 1991;46(3):275-8.

Abstract

Can routine digital rectal examinations, transrectal ultrasound studies, and prostate-specific antigen determinations reduce deaths from prostatic carcinoma? The evidence is that the benefits of early diagnosis and treatment are at least neutralized by the limited reliability and high monetary and human costs of the test and by the lack of proof that treatment is effective for those tumors detected. One must conclude that universal screening is not now warranted and will await demonstration of effectiveness by controlled studies.

Out of the Straightjacket

Michael S. Weinstein, M.D., M.B.E.

N Engl J Med 2018; 378:793-795

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This is the narrative of a trauma surgeon who has a history of major depressive illness.  He tells it as it was; including his psychiatric hospitalization, electroconvulsive therapy, and recovery.  In some ways, this is a restitution story.

Dr. Weinstein addresses important areas we’d rather not face.

“We often make decisions in the face of uncertainty that deeply affect our patients’ lives. When things went wrong, I frequently blamed myself. I learned that doubt, ignorance, and lack of confidence were my own failings.”

“Though I had mental illness, I still saw it as a weakness, a personal fault. I remember early in my career hearing of a colleague who took a leave of absence for a “nervous breakdown.” I joked about it, said he was weak. Now it was my turn.”

“I wanted out, out of work and out of life. I wished I would get hit by a car, and sometimes took steps to increase my risk. I felt trapped in my work and worried that I would expose my shortcomings if I sought a leave or disclosed my feelings. I’ve subsequently learned that my colleagues were quite concerned about me but found me unreceptive to attempts to help. I was trying to get help in many ways, but nothing seemed to work.”

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This is an important topic.  We’d rather not acknowledge it.  The best-selling author, Sherwin Nuland, was a surgeon who similarly was hospitalized for major depression.  He chronicled that in his autobiography, “Lost in America.”