When most doctors discover a cancerous lump of some sort, they usually suggest an aggressive treatment to rid the patient of the tumor as quickly as possible. Usually an “aggressive treatment” means a removal of the cancerous growth and sometimes radiation therapy if the tumor is especially dangerous. The theory behind the more proactive approaches of removal and radiation therapy is that cancerous tumors grow quickly and can eventually kill a person if left untreated. However, new research on prostate cancer seems to suggest otherwise—at least for lower-risk tumors.
According to a recent study by Dr. Martin Sanda, director of the Prostate Cancer Center at Beth Israel Deaconess Medical Center, in men with low-risk types of tumors there was no significant difference between those who sought immediate treatment versus those who opted for the “watchful waiting” approach. Specifically, Sanda and his colleagues looked at 51,000 men nationwide diagnosed with prostate cancer. Over a 15-20 year time period, the researchers found that about 10% of the men chose the “watchful wait” approach, or delaying any treatment for at least a year or more. At 10-15 years later, the men who chose this approach still required no treatment, revealing the fact that some tumors don’t require immediate treatment because they are of a slower-growing variety.
For years, doctors have relied on a test called the PSA blood test that indicates whether a male patient has prostate cancer. Primarily, all men over 50 are instructed to have a prostate exam and the PSA blood test. However, Dr. Sanda believes that the test is a “double-edged sword”: while the test can catch serious tumors in a few, it can also cause needless worry and expense for the majority of men with tumors that grow too slowly to cause any real harm. Furthermore, according to Dr. H. Gilbert Welch of the VA Outcomes Group, an estimated 1.3 million additional men have been diagnosed with prostate cancer since the PSA test was first introduced in 1986. Of those 1.3 million, 1 million underwent surgery and other aggressive treatments. Granted, prostate cancer deaths have decreased since the introduction of PSA testing, however, Welch states that about 20 men had to be diagnosed and unnecessarily treated for every one man who actually benefited from an aggressive treatment approach.
Aggressive treatments include surgery, radiation, and/or hormone therapy and can result in impotence and incontinence in about a third of patients. Moreover, simply telling a patient that they have cancer can do harm—resulting in anxiety and feelings of vulnerability. Worst of all, having a cancer diagnosis can mean some men can’t get health insurance coverage. Currently, I have the “low-risk” cancer and have surgery scheduled in a month. But, after reading the results of this study, I am now seriously considering the “watchful waiting” approach.
recently named in the 2009 edition of Best Lawyer's In America, David Mittleman has been representing seriously injured people since 1985. A partner with Church Wyble PC—a division of Grewal Law PLLC—Mr. Mittleman and his partners focus on medical malpractice, wrongful death, car accidents, slip and falls, nursing home injury, pharmacy/pharmacist negligence and disability claims.
34 Comments
Ed Dwulet
Google: "The great American pseudo- epidemic of cancer of the prostate" and read the best article ever written on the subject from 1996. 1996!!! Everything in that article has only been reinforced by study after study since then. People in some other countries saw the PSA era for what it was a long time ago.
Follow that by Googling: "An elusive tumor in a man who has evidence of prostate cancer metastasis" the article is about imaging techniques but the interesting thing is the patient's case history: A radical prostatectomy 11 years ago at 54, PSA only 3.0, Gleason only 6, he was told his "disease was organ-confined with no lymph nodes involved and now he's suffering from metastatic prostate cancer in his lung. All of the latest studies released in 2009 followed men for 10 years. Metastasis of slow growing prostate tumors caused by all these unnecessary surgeries can take a long time to show up. The supposed benefits of aggressively treating all prostate cancers to possibly save a few lives may disappear when longer term studies become available.
Google: "A biopsy can stimulate the inflammation that helps the cancer," and You can read about the guy who developed the theory that biopsies can cause inflammation that may lead to metastasis. Its highly technical but if you read it through to the end you'll get to the point (pun intended) in plain language. This isn't wacko "alternative" medicine --this is cutting edge research at a reputable medical research institute. "Of course, the primary culprit in all these cancers remains inflammation, which is looming ever larger as cancer's all around helpmate, potentially even when it comes to something as routine as a biopsy, a procedure long associated with cancer treatment." In that case study of the guy with lung metastasis, it came from somewhere -- was it the biopsy or his surgery. I say he might have been just fine and lived a full life had he never had a PSA test and never been told he had cancer.
Sometimes you see studies trying to knock "watchful waiting" by citing the number of participants who eventually decide to seek treatment. Other than the simple fact that its difficult for most people to live with a "cancer" diagnosis (however bogus that may be) ... it could also be because the "watchful" part is not benign observation. It consists of repeated biopsies every so often to monitor a cancer progression that may well be accelerated by the repeated biopsies in the first place. A good analogy may be the observer effect in quantum physics (it refers to changes that the act of observing will make on the phenomenon being observed). Take two identical twins with identical prostate tumors -- one is unobserved (not biopsied) and the observed (biopsied). The current medical establishment still considers both tumors identical -- but this research suggests that the biopsied one may be forever changed with respect to metastatic potential -- having being affected by the inflammation caused by the biopsy.
Screening, "early detection" and treatment of a "disease" that 100% of men will have if they live to be 100 is big business in this country. It has been commercialized by the widespread introduction and persistent use of an unproven test (PSA) to create a whole class of new bogus "cancer" patients. The medical industrial complex's exploitation of prostate "cancer" fears rivals that of Bush's terrorism fear campaign. Fear sells ... and hospitals and doctors are getting rich pandering to it.
Capitalism is great at marketing and creating demand. Cancer fears, "free" prostate screenings (but curiously, not free treatments); [and don't forget to get your "free brake inspection" at Midas -- they really care about your safety ...there's no real difference]; Its all a part of the "ask your doctor if ______ is right for you" philosophy of medical care. Get people in the door -- more patients = more profits for all involved ... its as simple as that. PSA testing has been a boon for our "for profit" medical system and a travesty of unnecessary mutilation and death for many American men.
In a different world, what all men will get if they live long enough, and will die with rather than from, would be called "Age-related prostate degeneration" (how about ARPD) -- something that has no relation at all to the real aggressive prostate cancer that kills relatively few -- and for which, as of today, there is no scientifically proven screen or test or cure.
In the end the change will come slowly and a lot of special interests will fight it all the way. After the two big studies last March showing no benefit to PSA screening, the AUA went and changed its recommendations, LOWERING the age from 50 to 40! Unbelievable! But smart ... they are well aware that sometimes the best defense is a good offense. But more likely its that over the past 20 years they have just depleted the 50 and 60 year old patient pool. There has to be a class action here somewhere!
Lee Smith
Dr. Welch, quoted above, is an opponent of all sorts of screening including mammography. However screening isn't the problem it's what one does with the results. In this area progress continues to be made, and when detailed PSA analysis, followed by biopsy, can help predict whether and when one's cancer is likely to spread out the prostate in which case you transition from from a curable cancer to an incurable cancer. Based on the odds facing you as an individual, as uncovered beginning by screening, you can decide what course to pursue (assumming that you have credible medical advice). Then you can decide what sort of Russian Roulette you prefer to play. Would you play if there was one bullet in 20? 1 in 10? one in 3? Because doing nothing, avoiding screening, is a decision -- it doesn't take away a potential cancer, it only increases the chances that by the time you learn about it will be too late.
anon
HIFU is one of the few alternatives to traditional prostate cancer treatment and should be looked upon as such. Its currently in phase III trials in the states and is already available in other countries.
http://www.leadingedgeurology.com
http://www.nyhifucenter.com
http://www.indianahifu.com
are a few physicians that diagnose and treat PCA.
Lee Smith
Ed: If you read the posts, have you found anyone recommending "agressively treating all prostate cancers" -- you have set this up as a straw man? The goals is to get enough information to be resonably selective re who is treated and how. I also tried googling some of the quotes, and all I get are your posts giving the quotes. What are the data on biopsies causing harm? Please give me a study involving at least hundreds of men. You should google "ignorance is bliss" -- it works until the diagnosis of invasive prostate cancer. What is your advice to such men --- sorry you are a minority and have to be sacrificed for the greater good according to Ed. If you want to be constructive, fight for education, and watchful waiting, not your imaginary battle with Capitalism.
Ed Dwulet
There are studies involving 100's of thousands of men who were told they have "cancer" then aggressively treated ... they show 1 million men treated unnecessarily.
Tell a man he has cancer and his visceral reaction is "cut it out" and that's what happens most of the time. My battle is not with capitalism, capitalism is what it is. My battle is with imaginary "cancer" -- and calling a condition that will affect 100% of men if they live long enough "cancer." Its simply a misnomer -- age related prostate degeneration (ARPD)is a normal derivative of aging and not "cancer." Truly aggressive cancer is a totally differnt disease -- and unfortunately there is no effective screen or treatment.
If you google: "An elusive tumor in a man who has evidence of prostate cancer metastasis" the top article is about a man who followed all your advice. PSA's at 54, (only 3.0) biopsies (only Gleason 6) and radical surgery ("cut it out"). Told it was "caught early" "organ confined" ... and 11 years later his PSA is 9 and he is found to have metastatic prostate cancer in his lungs. He is far from the only one. I personally know many men this has happened to. How did it happen? The biopsies or the surgery? Take your pick. The longest prostate cancer studies to date have only followed men for 10 years. Not long enough to detect metastasis of slow growing prostate cells.
It that article it says -- in the interim years the patient was "lost to follow up." Many of these cases of metastatic spread due to biopsy or surgery eventually wrongly attribute the cause of death to something other than prostate cancer. This guy's death certificate will probably say "lung cancer." It will take a long time before there are long term follow up studies to prove the danger of biopsies. The danger of surgery is already documented.
The scientific nature of studies is to attempt to reduce variables. Prostate cancer studies comparing surgery and watchful waiting for example want to compare the death rate for "prostate cancer" ONLY between the two groups. When someone dies of "lung cancer" he is out of the study. The more well done studies also include "all cause mortality." And although studies do show some very slight benefit to surgery over watchful waiting for PROSTATE CANCER ONLY -- THERE IS NO DIFFERENCE IN "ALL CAUSE MORTALITY." Meaning that people who choose surgery die more often of other causes. The PSA era has been a fiasco any way you look at it, capitalism notwithstanding -- it simply provided addition unneeded momentum for an unproven testing and treatment regime.
Ed Dwulet
These are just a few examples I've found from the recent news. If you Google: "Robert Novak's battle with 4 cancers highlights importance of making informed treatment choices" the first search return will be a news article that says his initial "battle" was with prostate cancer in the 1990's. Of course this 100% speculation but I've just seen it happen too many times with friends and relatives and I'm saying that that Mr. Novak may have made a poor choice to battle prostate cancer to begin with (or in 2009, you can now say that he made a poor choice to get a PSA test). Did he die of primary brain cancer or metastatic prostate cancer? Only his doctor knows for sure. Did Paul Newman die of primary lung cancer or metastatic prostate cancer? Author Dominick Dunne just passed away. Read most obituaries and you'll find the cause of death: bladder cancer. Look a little closer and in one article it states that "he recovered from prostate cancer in 2003" -- whatever that means -- most probably that he recovered from the operation to remove his prostate or more likely radiation which often leads to bladder cancer. But only his doctor knows for sure. Causes of death are notoriously inaccurate -- and require rarely performed autopsies to validate -- these mis-classifications may be the the real source of the statistical reduction in deaths from pc since the introduction of PSA testing -- . Most prostate cancer is benign, mess with it and you risk spreading it. Aggressively treating every pc may be saving some lives but it also may be promoting metastasis and eventual deaths that end up being recorded as being from other causes. No one really knows yet -- when the long term data are in the net gain in lives saved may in fact be negative.
Lee Smith
I think I may actually agree with Ed on one thing. We are all too ignorant when it comes to cancer. The word it too frightening for many of us to think rationally when we learn we have it. Our first response == get it out. That may or may not be the best thing for a given situation. We need more education re the various kinds of cancers, diagnostic techniques, available treatments. That being said, I believe a good urologist (actually several good urologists) is the person to speak to if you are unfortunate enough to have prostate cancer. Being afraid to get a PSA test is the other side of the coin of jumping immediately to overtreatment based on a single PSA reading. As with many things in life there is a golden mean --- routine PSA and DRE testing (starting with a baseline at age 40 makes sense to me), biopsy if necessary, further education in likely outcomes for someone with your characteristics based on all the specific data in your situation, and decision based on the medical evidence and your personal values re what risks you want to take. I say this as a PhD in Biomedical Science with a fairly broad background in many areas, fairly broad reading of the literature, some smidgen of common sense, and personal experience in my family and community.
Ed Dwulet
Why weren't the injury trial lawyers on this case: In the 1990's, in those early days of PSA, my father was first diagnosed with prostate cancer at 85 years of age based upon a PSA test and nothing else! At 85! As he was happily going about enjoying the last years of his life a urologist, an m.d. who took a do no harm oath, sat him down and told him he had "incurable" cancer. But not to worry, the doctor said, we have a great treatment that will probably hold the cancer at bay -- and it involved regular painful injections at the doctor's office. That "big C" diagnosis psychologically devastated my Dad for all his remaining days.
A few years after my father died at age 89 (of congestive heart failure) this story hit the national news: "Pharmaceutical Companies to Pay $1.2B in Medicare Fraud" "Prosecutors also indicted six current and former employees of TAP -- including Alan MacKenzie, now the president of Takeda Pharmaceuticals North America -- charging them with conspiracy to pay kickbacks to doctors if they prescribed Lupron. The kickbacks included trips to resorts, medical equipment and money offered to the doctors as ''educational grants,'' prosecutors said."
The drug company got fined -- a few of the worst offending doctors also paid fines - but none lost their licenses -- instead they got to continue on with their unethical practices. Maybe one of them went on to remove Lee's prostate?
I seriously considered looking up my dad's urologist and trying to arrange a meeting with him and a baseball bat -- to my father, a doctor's word was God's -- what a violation of trust! Instead I became determined to learn as much as I could about prostate cancer and to help as many men as I could to avoid becoming an AUA and AMA sanctioned victim of prostate cancer for profit.
As with many drugs foisted on the public without proper study it wasn't until many years later these that these stories began surfacing in the mainstream press: "Hormonal therapy for prostate cancer may cause heart problems (2009)." (my Dad's eventual cause of death) -- "Primary androgen deprivation therapy (PADT) is not associated with improved survival for elderly men with localised prostate cancer, compared to conservative management of the disease (doing nothing), according to a study in the July 9 issue of JAMA(2008)." (so his painful injections were for nothing) -- "Androgen-deprivation therapy for prostate cancer increases the risk of fracture among elderly men (2005)." (my Dad did only slightly trip and broke his leg shortly before he died). So he was a guinea pig for the medical industrial complex -- as was everyone else who got an "experimental" PSA test before its efficacy was proven and went on to be unnecessarily treated.
Has the statute of limitations expired?
Lee Smith
Ed; You do have my sincere sympathy for the horrible treatment of your father. I can see why you feel the way you do and why it clouds your judgement. Everything was done wrong but that's really not what the PSA testing debate is about. As opposed to elderly men such as your father, for younger men from 40 to 80 our goal remains to avoid having to suffer the side effects of metasticizing cancer or of temporarily slowing down a spreading prostate cancer through such things as hormonal treatments. Hence the PSA series of tests, along with biopsy when indicated to allow us to make an informed decision re our attempts to control our future. Folks you have to decide in whom to seek advice - Ed or a credible urologist. The choice is yours. (And incidentally, my urologist also had prostate cancer, and had his prostate removed -- I suppose to help him increase his profit).
Ed Dwulet
True studies on the effectiveness of cancer treatments are difficult if not impossible because no one wants to be in the control group. Just about everyone told they have cancer wants to do something, anything to treat it -- proven or unproven. The closest thing we have to a control group for prostate cancer is watchful waiting. I submit that all of those watchful waiting controls have been contaminated by biopsy. In 2009, studies are finally available showing little to no difference between watchful waiting and treatment groups. But "no difference" could actually mean a HIGHER death rate for both groups than would occur in an unscreened, unbiopsied, untreated group (in other words -- men just left alone).
Of course as I said earlier -- studies are designed to minimize variables. So none include: men who die on the operating table, men who die from other complications of surgery or hospitalization or medication errors, or those who might contract antibiotic resistant staph infections, or even subsequent suicides due to post operative depression -- all of which would make the treatment group statistics much worse. On the other hand many of those same factors could affect men receiving biopsies as part of watchful waiting. I really don't like testimonials but sometimes they are useful to illustrate a point. Incidents like the following are also never recorded in the various prostate studies: my neighbor, just who turned 50, went for his "50 year physical," blood test PSA=7, they tell him to come back in 2 months, PSA = 10, then biopsy, 2 days later a 104 fever, ER in the middle of the night, e coli infection into his blood from the biposy despite pre/post antibiotics, all his organs affected, double pneumonia, 3 & 1/2 weeks in the hospital, mostly the ICU, touch and go for a while, nearly died. And what about his biopsy? All cores negative! I am as certain that some people are killed by prostate biopsies as they are by the complications of surgeries. How many times it happens is a little more difficult to ascertain. They are lost to the statistics of hospital mistakes and errors (aka complications). This immediate risk is added to the long term risk that biopsies may cause inflammation which is linked to the development of aggressive prostate cancer and metastasis. Biopsies may be a great diagnostic tool for many medical conditions, but prostate cancer isn't one of them. One doctor I spoke with likened it to walking in the jungle and poking a sleeping tiger with a stick.
Autopsy surveys of men who die of trauma find prostate cancer in 8% of 20 year olds. That percentage continues to increase with every decade of life until it reaches 100% of men who live to be 100. For the most part PSA testing and biopsies are detecting this normal component of aging. Since there is no way to predict the future course of cancer in any individual, telling these men they have "cancer" leads to "cut it out" surgeries in almost every instance. For the most part these are surgeries of pseudo-cancers that would have never threatened their lives.
This year the risks of PSA testing are finally being exposed for all to see. As the 1996 article I first referenced foretold, men being subjected to PSA screeing were subjects of an experiment -- without being informed of that fact. In 2009 we can finally say that the overwhelming data clearly shows that the harms of PSA testing far outweigh the benefits.
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