Cut From Steel

This week's hero is the man reading this right now

You are the hero again this week, and this is the fortieth of these letters to land in your inbox.

I want to be specific about why you get this one. Today's letter concerns a test where there is no single right answer that applies to every man, and where the people who write the guidelines have deliberately handed the decision to you personally.

Almost nothing else in medicine works that way. A doctor tells a man he has broken his wrist and then sets it. Nobody asks the man with the wrist to weigh up the evidence first and form a view.

PSA screening is different, and the difference is not an accident. The US Preventive Services Task Force states in plain words that for men aged 55 to 69, the decision to undergo periodic PSA-based screening should be an individual one.

That single sentence puts you in the chair. You are being asked to hold a genuine trade-off in your head, understand that reasonable men land on opposite sides of it, and then come to a view about your own body.

Most men will have that conversation cold, in eleven minutes, with no idea that a trade-off was ever involved. You will not.

Forty issues in, you are better equipped for this than almost anybody else in that waiting room. The guidelines handed you the decision, and you are the one who has to be ready to make it. Read the numbers below twice.

You are being asked to make this call yourself

You are somewhere past 55, and either nobody has raised the prostate with you at all, or somebody mentioned it once and moved straight past it to your blood pressure.

I want to give you the actual figures rather than a slogan. The US Preventive Services Task Force publishes what happens to 1,000 men screened with PSA over about 13 years, and both columns of that ledger deserve your attention.

You will not find a clean answer in them. That absence is exactly why the decision was handed to you.

It's not age. It's these three.

I will give you the Task Force's own figures for 1,000 men screened over roughly 13 years.

01 / What You Stand To Gain

About 1.3 men out of the thousand avoid dying of prostate cancer. Around 3 avoid the cancer spreading to the rest of the body. Both figures are small. They are also entirely real, and for the man who happens to be one of them it is the whole ball game.

02 / What You Stand To Risk

Roughly 240 of the thousand get at least one positive PSA result, and about 220 go on to have a prostate biopsy. Around 2 end up in hospital with a complication from the biopsy itself. About 100 are diagnosed with prostate cancer, and the Task Force estimates that somewhere between 20 and 50 percent of screen-detected cancers are overdiagnosed, meaning they were never going to cause that man any trouble.

03 / What The Treatment Costs

Out of the same thousand men, about 50 develop sexual dysfunction and about 15 develop urinary incontinence as a result of treatment. The Task Force recommends against PSA screening altogether for men aged 70 and over. For men between 55 and 69 it asks you to weigh those columns against one another, with your doctor, and decide.

Take it back today

I owe you the limits of any table. These are averages across a very large population, and they know nothing about your father's history, your ethnicity or your own particular risk. A man with prostate cancer in the family is sitting in a different column from the one printed above.

You should also know that the way this is done has been changing. MRI before biopsy, and active surveillance rather than immediate treatment, have both altered the harm side of that ledger since those numbers were assembled. Ask your doctor what the pathway actually looks like where you live.

I want you to book the conversation rather than the test, at least to begin with. Ask for fifteen minutes, say the words PSA screening when you book it, and take the two columns above in with you on paper. Then make the call yourself, which is precisely what you have been asked to do.

You have been waiting for somebody to tell you whether to have this test. Nobody is going to, because the guidelines handed that decision to you. Book the conversation this week.

— Travis

Insider Member's Corner

6 free habits before the PSA conversation:

Forty letters in, you have earned something with no practical justification at all.

01 / Wheels · Aston Martin DB11

A front-engined grand tourer rather than a supercar, which is the correct shape of fast car for a man over 50. It will cross France in a day without breaking your back, and it looks better parked than most things look moving. Depreciation has been savage, which is dreadful news for the first owner and very good news for the second. Buy the V8 and drive it in the rain.

02 / Smoke · Padrón 1964 Anniversary Series

Nicaraguan, box-pressed, and aged four years before it is rolled. It is the cigar that serious smokers name when they are not showing off, and it does not need an occasion built around it. One after a long walk, outside, with nothing else happening, is the correct use. Buy a five-pack rather than a box the first time.

03 / Trip · A week in the Highlands with no itinerary

A car, a full tank, a rough direction and no bookings past the first night. The west coast of Scotland in autumn does something to a man that a planned holiday cannot. Take a paper map and leave the route open. The point of the week is that nobody, including you, knows where you will sleep on Thursday.