his early seventies. Since Aliber had been getting a prostate-specific antigen (PSA) test every year since 1996, his doctors had a good baseline from which to judge his unusual scores. They recommended that he have a biopsy because his PSA scores were variable and increasing. When one of the 10 snips from the biopsy came back positive for cancer, Aliber was faced with four treatment options—surgery to remove the prostate, external radiation, internal radiation, or watchful waiting—or some combination of the four.

"Economists deal with data, and they often deal with data under uncertainty," says Aliber. To him, choosing a treatment course was similar to making an investment. "I was trying to figure out what the aftereffects were of different treatments—in a sense, that's the cost." The benefit, of course, would be a potentially longer life.

Photo by Chris Milliman

Hanover resident Robert Aliber, an economist, chose "watchful waiting" when he had a positive biopsy after his prostate-specific antigen test results began to rise. He approached the decision as if he were making an investment--weighing the costs against the gains.

"My choice is straightforward," Aliber wrote in a February 2002 memo to his doctors. "I can 'buy' a treatment in the next few months, or I can adopt a policy of watchful waiting and 'buy' a treatment at some future date if the PSA or other data indicate that the cancer has become more aggressive.

"The choice between whether to 'buy' a

Photos by Jon Gilbert Fox

Pathologist Wendy Wells, top, says that deciding if a tissue sample is cancerous or not sometimes isn't clear-cut. But it is clear from the number of paper cups on their conference table, bottom, that meetings of the outcomes group to explore such issues are very collaborative.

prostate-cancer treatment at this time or perhaps at a later time can be modeled like an investment decision," Aliber continued. "The traditional investment decision is 'which investment has the higher present value (or, alternatively, the higher rate of return)?'" In other words, was it more valuable to him to maintain his quality of life in his seventies in exchange for potentially shortening his life? He decided it was.

Four years after the diagnosis, Aliber's PSA levels have stabilized, a sign that the cancer probably isn't growing. "It would have been costly without any benefit if I'd had the treatment three years ago," he says. So Aliber appears to be beating his cancer by doing little more than watching and waiting.

In the end, the decision to be screened, or not screened, for a particular cancer—

as well as what course of treatment, or nontreatment, to pursue if cancer is detected—should be made in the context of each individual's own preferences. Welch and Black and others of like mind hope that most physicians would agree with that premise.

Where much of the controversy centers, however, is on the population and policy-making levels. Should the medical community be enthusiastically endorsing cancer screening? Is saving a few lives worth harming many? There's a bigger question at work here, too. What should be the medical community's philosophy about taking action in the absence of conclusive data?

For physicians, like Aliber's DHMC urologist, John Seigne, M.B., the tendency is to want to do something. "I'm a urologic oncologist," Seigne explains. "Sitting in front of me every day are people who have prostate cancer, people who are dying of prostate cancer, people who I can't cure. . . . So I get a completely different perspective from somebody who is" looking at the big picture. Somebody like Black. Or Welch.

Four years after the diagnosis, Aliber's PSA levels have stabilized, a sign that the cancer probably isn't growing. "It would have been costly without any benefit if I'd had the treatment three years ago," he says. So Aliber appears to be beating his cancer by doing little more than watching and waiting.

Yet Seigne, as does Carney, values the questions that Black, Welch, and others have been raising. "What do you do when you don't know the answer to a question? Do you do nothing?" Seigne reflects. "One of the tenets of the Hippocratic oath is [first] do no harm—primum non nocere. So do you do nothing? Or do you try and synthesize the best available information that you have and do something with it? . . . I don't know enough about philosophy to answer that." Does anyone?