In The News: Editorial
The Ghost of Larry Clark
The conversation had ended. Not nicely, but with anger. He had never talked like that before. He must have known that it was over.
My friend Larry died of prostate cancer. It seemed so odd given his work in prostate cancer prevention. The life and death of Larry make a stark point: to reduce the burden of prostate cancer, we have to speak the truth.
I met Larry in 1993. He had come to the Miami VA Medical Center, where I was the chief urological surgeon. Sitting in plaid shirt and suspenders, he looked like Paul Bunyan and he made a seductive suggestion: Prevent cancer with selenium.
Larry was not a lumberjack, but an epidemiologist, a man who finds correlations. Epidemiologists do this to detect the causes of illness. For example, they might notice that certain places, such as intersections, are correlated with certain outcomes, such as accidents. They might suggest solutions, such as telling us to stay out of intersections.
It is not easy to transform epidemiological observations into useful solutions; correlations suggest but do not prove a cause. For example, in the 1980s two things correlated: the rise in the sale of Toyotas and the rise in the incidence of prostate cancer. If correlation proved cause, we could prevent prostate cancer by not selling Toyotas. No-one has made this suggestion.
Larry knew that there is a lot of cancer where the soil is poor in selenium. He designed a study to test his conviction that selenium prevents cancer. After randomizing men to get selenium or placebo, he measured serum PSA, a marker of prostate cancer. My task was to do prostate exams to detect nodules, also markers of prostate cancer. We found that the men who got selenium had 63% fewer prostate cancer diagnoses.
Our report was rejected by The New England Journal of Medicine. One reason: our study did not impose prostate biopsies. This matters because only biopsies – not PSA tests and not prostate exams – can diagnose prostate cancer. In other words, our study had left open the possibility that selenium merely concealed the prostate cancer. How? By affecting prostate cancer markers – PSA and prostate abnormalities – without affecting the actual cancer. Maybe selenium merely swept cancer under the rug.
Our study was published by the Journal of the American Medical Association, which is tracked by the media. In the frenzy that followed, the limits of our study’s design seemed to have no effect on popular opinion: Everyone talked about selenium. It had been the same with zinc. Twenty years ago, while moonlighting at Yonkers Raceway, I wrote a gargantuan yet delightfully esoteric review of prostate zinc. I found no support that zinc mattered. Everyone talks about zinc.
During the course of our work, Larry was diagnosed with prostate cancer. He was young when it killed him.
I thought of him in May, when epidemiologists at the National Cancer Institute reported that selenium supplementation correlates with dramatically increased risk of fatal prostate cancer. I thought about residual data on selenium and vitamin D, which Larry and I had assembled. Sitting unpublished on my hard drive, it remains a fitting symbol of a study prematurely applied and a life so ironically over.
Larry’s ghost is asking some questions. What will inoculate us against the ill effects of half-baked advice, commercial imperative, and our own blinding passions? In our consumerist stew of panaceas du jour, of golden calves cast in pomegranate, who will be the referee? And how will we improve our state of knowledge?
On the morning of Thursday, November 15, the Prostate Cancer Mission opens a conversation and offers some answers. Inspired by the memories of Merv Griffin, Jorge Mas Canosa, my friend Larry and so many others who died of prostate cancer, the PCM convenes a public forum. Local panelists will consider some issues and answer some questions. Visiting experts will speak about risk and hype and erections.
Maybe you know someone who will be there: Merrett Stierheim, Leslie Pantin, Ken Griffey Sr, Meg Green, Barry Johnson. Maybe you don’t. It doesn’t matter. What matters is that someone you love is at risk. What matters is that this is about all of us.
The forum will not be all things to all people. It will be one part of a long conversation. We’d love to have you with us.
The Open Conversation on Prostate Cancer will be held on Thursday, November 15 from 8 AM to 11:30 AM at the Intercontinental Miami Hotel. To register or get information, log on to www.pcmission.org or call 305-854-2568.