12112017Headline:

Lansing, Michigan

HomeMichiganLansing

Email David Mittleman David Mittleman on LinkedIn David Mittleman on Facebook David Mittleman on Avvo
David Mittleman
David Mittleman
Attorney • (888) 227-4770

"Watch and Wait" Approach to Low-Risk Prostate Cancer is as Effective as Aggressive Treatments

36 comments

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.

36 Comments

Have an opinion about this post? Please consider leaving a comment or subscribing to the feed to have future articles delivered to your feed reader.

  1. Ed Dwulet says:
    up arrow

    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!

  2. Lee Smith says:
    up arrow

    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.

  3. anon says:
    up arrow

    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.

  4. Lee Smith says:
    up arrow

    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.

  5. Ed Dwulet says:
    up arrow

    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.

  6. Ed Dwulet says:
    up arrow

    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.

  7. Ed Dwulet says:
    up arrow

    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.

  8. Lee Smith says:
    up arrow

    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.

  9. Ed Dwulet says:
    up arrow

    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?

  10. Lee Smith says:
    up arrow

    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).

  11. Ed Dwulet says:
    up arrow

    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.

  12. Lee Smith says:
    up arrow

    For someone who doesn’t like anecdotal information — that’s all you have. You have ferreted out exceptions and your conclusions are much more negative than the official stances. All involved now agree that men need to be told the pros and cons of PSA testing — and I agree that education is the key. But no reputable source I have ever seen comes to your conclusions. Give me some creditable sources. I hope your scare tactics do not result in someone’s suffering. Who is the doctor with the tiger analogy — I’d like to ask him the basis for this conclusion. So far as I can tell prostate biopsies have little morbidity and can provide a great deal of important information.
    Readers: please check out legitimate sources
    e.g. Johns Hopkins, Memorial Sloan Kettering, Mayo Clinic, drcatalona.com etc. Please do not buy the hogwash and do not be frightened out of being tested, and do not be frightened into premature treatment.

  13. Ed Dwulet says:
    up arrow

    There is absolutely no way to determine the morbidity of prostate biopsies from any data available today. That would require a study of thousands of men who were given a biopsy, matched with thousands of controls and then followed for a very long time. Most all biopsies result in treatment. Very few younger men can live with a cancer diagnosis. Its the elderly who often choose to watch and wait — and had they been properly informed beforehand — most would never have had a PSA or biopsy to begin with. Biopsies cause inflammation and inflammation has been linked to causing aggressive prostate cancer.

    Biopsies do not reveal a “great deal” of information. They are a snapshot of the particular part of the prostate removed. A Gleason score is a rating of that snapshot. It does not indicate in any way whether or not an individual’s “cancer” will be aggressively progressive. BUT LABORATORY RESEARCH NOW SUGGESTS THAT WHAT IT MIGHT DO IS GUARANTEE THAT YOUR “CANCER” WILL BECOME AGGRESSIVELY PROGRESSIVE. That risk is just not worth it for a pseudo-disease that runs a benign course for almost all men for most of their lives.

  14. Ed Dwulet says:
    up arrow

    Lee says: “All involved NOW agree that men need to be told the pros and cons of PSA testing …”
    NOW? … how very convenient! What about the last 20 years? The only problem is that it looks like there are no “pros” .. only “cons.”

    Yes, indeed … please check credible sources like the Merck Manual for Physicians: this information reflects all the latest studies although its been included in their prostate cancer info for years:

    “Screening is based on the hypothesis that early detection allows treatment of the cancer while it is still localized, thereby reducing mortality. However, the hypothesis that early treatment reduces mortality is unproven. Patients with well-differentiated cancer do just as well with or without treatment, and those with poorly differentiated cancers tend to do poorly with or without treatment.” Case closed!

    Why do any testing? Why have a biopsy? Why have treatment and spend the rest of your life impotent and in diapers for nothing? Why? … Ask Lee?

  15. Ed Dwulet says:
    up arrow

    I don’t ascribe to any vast conspiracy or any even any evil intent by anyone involved in this PSA fiasco. The evil is in that mindless all consuming profit machine called the medical-industrial complex. People can and do rationalize all kinds of things to be able to sleep at night … as I’m sure the guards at Treblinka somehow did — and as I’m am sure many urologists did and still do. They’ve somehow convinced themselves that they are doing the right thing. Before PSA testing urologists didn’t have all that much to do — but since the introduction of PSA, I am certain that incomes of urology as a specialty have skyrocketed. Somebody got paid for those 1 million unnecessary surgeries these last few years. If a study is ambiguous, as most are, they will interpret it to their benefit. Convinced they are saving lives, the fact that they are making lots of money doing it is just a little side benefit — they see the Wall Street wiz kids making billions shuffling money around — its taken them 12 years of hard work to get where they are — if anybody deserves the big money, its someone heroically saving lives — like they are treating prostate cancer (even if its only 1 life in 50 — as a big study from Europe showed this year) (and the fact that those other 49 men are patients for life is just another nice side benefit). In my experience talking to many urologists — they are often perplexed when I ask them about one study or another. Many if not most don’t have the time or interest to keep up with the state of the art and do their own research. They leave all that to their special interest group and cover organization, the AUA (American Urological Association) — maybe one of Lee’s “legitimate” sources. Two weeks after those two big studies last March showing no benefit to PSA screening, the AUA went and changed its guidelines, they completely disregarded the science and LOWERED the recommended age for screening from 50 to 40! Unbelievable! But smart … they are well aware that sometimes the best defense is a good offense. They see the train coming and they want to slow it down … or more likely it could just be that over the past 20 years they have completely depleted the 50 and 60 year old patient pool and there are still lots of swimming pool and McMansion payments their members have to make. The AUA issues “guidelines” and many, if not most urologists blindly follow them. It serves two purposes — first,they don’t have to do any independent thinking — and second, it provides excellent cover in case they get sued for malpractice.

    But eerily “I was just following the guidelines of my profession” does sound a lot like “I was just following the orders of my superiors”

  16. Lee Smith says:
    up arrow

    I’m admittedly far from an expert but my understanding was, and is, that PSA readings, Gleason grade, etc are all predictive of the future progression of one’s cancer. I guess my urologist was not in Ed’s sample, because iIn my case, i was informed of the alternatives for me, watchful waiting, external radiation, seeds, cryosurgery. I spent considerable time with the urologist and was given a number of print outs and recommendations of things to read to get an overview of my situation. I was personally very interested in the predictive power of the Partin Tables and estimated the likelihood that if I had a prostatectomy the cancer would be fully contained. I had a decent chance, but as I recall there was a significant chance it would already be out and invadng the rest of my body. After a couple of months of reading and deliberation in conjunction with my wife and speaking to a number of other fellows who had prostatectomies, I chose to do it, and was extremely thinkful that there was no cancer on the margin. That was 12 years ago and so far, thank God and my surgeon, my PSA is not measurable, indicating that no cells escaped. Meanwhile my erections aren’t what they used to be, but my continence is very close to normal. I am enjoying my life, my wife, my grandchildren, and thank God every day that my wife convinced my to get a PSA test. And I know my story in common — and fotunately have not met anyone who suffered the way Ed describes. Perhaps there are more skilled, more honest surgeons where I live and it just happens to be a oasis where MDs are actually committed to helping folks and have the skills to do so — or maybe it’s a parallel universe to the one Ed lives in. If you go to some of the sites I mentioned you can learn more about this parallel universe where logic and common sense are consistent with medical practice, and getting rid of agressive cancer actually leads to a healthier and more fullfilling life. My world is called “Earth”, Ed what planet are you on?
    In any case, for those interested in some technical details, here is an article on gleason scores which tell you something about the kind of cancer you have:

    http://www.nature.com/modpathol/journal/v17/n3/full/3800054a.html

    From the abstract:

    Long Course Article

    Modern Pathology (2004) 17, 292–306, advance online publication, 13 February 2004; doi:10.1038/modpathol.3800054
    Gleason grading and prognostic factors in carcinoma of the prostate

    Peter A Humphrey1

    1Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, MO, USA

    Correspondence: PA Humphrey, Department of Pathology and Immunology, Box 8118, Washington University Medical Center, 660 South Euclid Avenue, St Louis, MO 63110, USA. E-mail: humphrey@path.wustl.edu

    Received 9 July 2003; Accepted 9 July 2003; Published online 13 February 2004.
    Top of page
    Abstract

    Gleason grade of adenocarcinoma of the prostate is an established prognostic indicator that has stood the test of time. The Gleason grading method was devised in the 1960s and 1970s by Dr Donald F Gleason and members of the Veterans Administration Cooperative Urological Research Group. This grading system is based entirely on the histologic pattern of arrangement of carcinoma cells in H&E-stained sections. Five basic grade patterns are used to generate a histologic score, which can range from 2 to 10. These patterns are illustrated in a standard drawing that can be employed as a guide for recognition of the specific Gleason grades. Increasing Gleason grade is directly related to a number of histopathologic end points, including tumor size, margin status, and pathologic stage. Indeed, models have been developed that allow for pretreatment prediction of pathologic stage based upon needle biopsy Gleason grade, total serum prostate-specific antigen level, and clinical stage. Gleason grade has been linked to a number of clinical end points, including clinical stage, progression to metastatic disease, and survival. Gleason grade is often incorporated into nomograms used to predict response to a specific therapy, such as radiotherapy or surgery.

    Of course this all could be lies — apparently that’s what they do on Ed’s planet, but as far as I can tell researchers are a little more honest in my parallel world.

  17. Ed Dwulet says:
    up arrow

    Poor Lee, Misery must really love company! There must not be a more apt truism to describe the refusal of victims of this fiasco from acknowledging it and moving on.

    This is 2009, PLEASE stop advising people to follow in your 1996 footsteps.
    JUST THIS WEEK TWO MORE NEW more studies attesting to the worthlessness of PSA testing. Science moves forward, unfortunately you’re stuck in the past.

    I’m sure he hasn’t read the article I referred to in my earlier post … but if he were to read it … I can’t honestly believe that before he got to the end he wasn’t wishing he had been a subscriber to the Journal of Medical Ethics in 1996 … BEFORE his first PSA test.

    There you would have seen this: “Should patients who are to be screened by PSA measurement be told that the test is inaccurate? Should they be told that therapies available to treat the disease, if detected, are of no proven benefit? Should they be informed, prior to being screened for PSA, that they are subjects in an experiment?”

    The grand experiment has gone on far too long … at least a million of lives ruined, thanks in large part to “for profit” medicine.

    Right now Lee is not trying to help anyone, he’s trying to justify what he did 13 years ago. It cannot be said that he made a “mistake” back then … any reasonable person might have made the same decision armed with the same information available to him at the time.

    But finally in 2009 …its looking more and more like the jig is up ..the game is over…the fat lady is singing. Thank GOD!

  18. Ed Dwulet says:
    up arrow

    A recent CNN news release carries this statement: ” The germ, a type of parasite, can infect the prostate and may cause inflammation that spurs the growth of prostate cancer later in life, says senior author Lorelei Mucci, Ph.D., an assistant professor of epidemiology at the Harvard School of Public Health. “Our underlying hypothesis is around inflammation and, in particular, we believe that inflammation from a variety of sources is leading to prostate cancer progression,” she says.”

    Hmmm … inflammation! Where have we heard that before? How about?

    “A biopsy can stimulate the inflammation that helps the cancer,” J.L. Luo M.D. Phd. Scripps Researcher when speaking about prostate cancer.

    Inflammation appears not to be a good thing when it comes to prostate cancer. In the case of inflammation caused by this STD “those (men) with a past trichomonas infection were two to three times more likely to develop an aggressive and potentially life-threatening form of prostate cancer.”

    As Lee suggests, you can wait for some impossible to do study about biopsies to never reach the “Annals of the AUA” and never be put into practice … or you can put 2 + 2 together yourself and use that information in your decision-making today.

    The inventor of the PSA test said “all you need is an excuse to biopsy and you’ll find cancer.” (Google quote for source) PSA testing has provided that excuse. A biopsy may very well be a great diagnostic tool for many medical conditions but prostate cancer isn’t one of them. I’ve brought this subject up with many doctors (some who are friends) and while many admitted to privately subscribing to the risk of biopsies — more than one has responded ” well … we can verify your cancer now via biopsy or we can do it later on the autopsy table. Take your pick” (I think its something they must teach them in med school – How to Deal with the Reluctant Patient 101) Fear sells and in so many words they are saying “we have no choice.”

    BUT YOU DO HAVE A CHOICE!

    Ask yourself if it is worth it for a pseudo-disease that has a benign course for almost all men throughout most of their lives.

    Ask yourself if it is worth it for a pseudo-disease for which “no treatment has been PROVEN to be superior to doing nothing at all.” (Google that quote for 2008 NY Times article)

    Ask yourself if it is worth it for a pseudo-disease that the medical-industrial complex insists on calling “cancer” but might better be called “Age-related-prostate degeneration.”

    Ask yourself if its worth for a pseudo-disease that recent research has conclusively proven to be overdiagnosed and overtreated to the tune of 1 million men in this country in just the past few years.

    Repeating over and over the number of men who die from prostate cancer each year is clearly a part of the scare tactics of all the fear-based Prostate Cancer “Awareness” campaigns. The implication always is that all 27,000 of these men could be be somehow saved if they were only made “aware” of prostate cancer early enough. The facts are that many, if not most of these 27,000 have aggressive cancers for which no amount of early detection or treatment will ever help. The facts are that many, if not most of the these 27,000 are elderly who would never ethically be treated and eventually have to die of something. That leaves very very few remaining to be “saved” by an ineffective, massively disproportionate, screening program that has ensnared millions of men and already harmed many of them.

    I rest my case.

  19. Ed Dwulet says:
    up arrow

    P.S. With respect to Lee’s extensive cut and paste on Gleason scores. I have never said that Gleason’s were not a prognostic indicator. While a Gleason 10 (poorly differentiated cancer) might indicate certain and imminent death, a finding of a Gleason 6 does not indicate that there is a certain and imminent Gleason 7, 8 ,9 or 10 in your future …

    The mere fact that there are various methods to their madness does not change this factual truth:

    “… the hypothesis that early treatment reduces mortality is unproven. Patients with well-differentiated cancer do just as well with or without treatment, and those with poorly differentiated cancers tend to do poorly with or without treatment.”

  20. Ed Dwulet says:
    up arrow

    P.P.S. Stated another way, one perceptive urologist has stated, ‘The only patients we can cure are precisely those who will live the longest without intervention.’

  21. Lee Smith says:
    up arrow

    March 23, 2009 (Stockholm, Sweden) — Men with localized prostate cancer who were randomly assigned to receive radical prostatectomy in the Scandinavian Prostate Cancer Group (SPCG)-4 trial not only achieved superior survival, compared with men who were randomized to watchful waiting, they did so without sacrificing quality of life.

    In fact, they scored slightly better in terms of anxiety, depression, well-being, and overall quality of life than men in the watchful-waiting group, said Lars Holmberg, MD, professor of cancer epidemiology at King’s College London School of Medicine, in the United Kingdom, who was one of the SPCG-4 study authors.
    ———————
    June 12, 2009

    Prostate cancer test improves prediction of disease course
    A new prostate cancer risk assessment test, developed by a UCSF team, gives patients and their doctors a better way of gauging long-term risks and pinpointing high risk cases.

    According to UCSF study findings, published this week, the test proved accurate in predicting bone metastasis, prostate cancer-specific mortality, and all-cause mortality when localized prostate cancer is first diagnosed. The test is known as the UCSF Cancer of the Prostate Risk Assessment, or CAPRA.

    The study, involving 10,627 men, is reported in the June 9 online edition of the “Journal of the National Cancer Institute.’’

    “This test should help physicians and their patients predict the likely course of the individual’s disease,” said Matthew R. Cooperberg, MD, MPH, lead investigator of the study. Cooperberg, who helped develop the risk assessment test, is a prostate cancer specialist in the UCSF Department of Urology and the UCSF Helen Diller Family Comprehensive Cancer Center.

    “In this study, we looked at the CAPRA score’s ability to predict mortality across multiple forms of treatment. It should help patients and clinicians decide which tumors need to be treated, and how aggressively. We also hope that in the research setting it can serve as a well-validated and consistent means of classifying men into low, intermediate and high risk groups.”
    ———
    August 10, 2009

    FORT WASHINGTON, PA — Prostate-Specific Antigen (PSA) testing performs optimally when conducted intelligently and combined with prompt, effective, high-quality treatment according to the updated NCCN Clinical Practice Guidelines in Oncology™ for Prostate Cancer Early Detection. In the wake of the recent confusion that ensued after the publication of two PSA screening trials, the European Randomized Study of Screening for Prostate Cancer (ERSPC) and the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial (PLCO) conducted in the United States, the NCCN Guidelines Prostate Cancer Early Detection Panel Members stress that PSA testing is effective and needs to be more rigorous in high-risk populations.

    “PSA testing has saved thousands of lives and continues to be an important tool in the fight against prostate cancer,” says Mark Kawachi, MD, Chair of the NCCN Guidelines for Prostate Early Detection and Associate Professor of Surgery, Urology and Urologic Oncology at City of Hope Comprehensive Cancer Center. “We are most likely to produce further declines in prostate cancer mortality if we focus on younger men who are more likely to die of prostate cancer than other causes and the diagnosing of aggressive prostate cancer in all men.”

  22. Ed Dwulet says:
    up arrow

    I invite anyone to read the report Lee selectively cut and pasted … and decide for themselves.

    http://www.medscape.com/viewarticle/590010

    Headlines often portray a biased picture of the actual story … and I would think that any independent reading of that study could only damage Lee’s own case and help mine.

    The actual statistical differences were SLIGHT, and more importantly, as I argued earlier, the study does not include “all cause mortality” — which I contend would show that those choosing surgery die more often of other causes. Nor does it account for or include: men who died on the operating table, men who died from other complications of surgery or hospitalization or medication errors, or those who might have contracted antibiotic resistant staph infections, or even subsequent suicides due to post operative depression — all of which would make the treatment group statistics much worse and make the slight advantage to treatment shown in this one study completely disappear.

    Here is an actual quote from the report: “In fact, they [the radical p group] scored SLIGHTLY better in terms of anxiety, depression, well-being, and overall quality of life than men in the watchful-waiting group…” Are you kidding? I could have told you that without a study! That people who have done something (i.e. “cut it out” however mistaken that course of action might be) — might have slightly less anxiety and depression then someone who was told they have cancer chose to do nothing!

    Another actual quote: “The finding that there is NO BIG DIFFERENCE between watchful waiting and active treatment reflects the fact that, although there are adverse effects in the sexual and micturition field, these are clearly not experienced as something very bad in the radical-treatment group. “NO VERY BAD” … are you kidding again! Well … if you’ve scared the hell out of someone by telling them they have a “cancer” that might kill them — and they really believe it — its no surprise to me that they might accept all kinds of degradation in their quality of life in return for staying alive!

    Finally, in 2009, as we are hopefully and at long last entering the post PSA era … Lee, in apparent desperation cites a study from the pre-PSA era:

    Actual quote: “Because SPCG-4 was begun before the era of PSA screening, the results may not be entirely generalizeable to the current population of prostate cancer patients. Dr. Holmberg admitted that the trial could not be started today, in the era of PSA testing, noting that the patients in SPCG-4 are not representative of the prostate cancer patients clinicians see today.”

    I respectfully rest my case. Thanks for listening. I hope my posts here might provoke some thought and further research on the part of anyone who might someday find themselves confronted with the complex and conflicting issues of prostate cancer.

  23. Lee Smith says:
    up arrow

    Ed; Thanks for reading the first article. There are actually three.

    One final word — the approach to prostate cancer is indeed changing since 1996 when I was diagnosed. Treatments have been greatly improved, and in addition active surveillance (generally, as I understand it using PSA readings, and biopsies as necessary to monitor the progression of one’s prostate cancer) seems likely to become more and more accepted as men learn about the realities of prostate cancer and seek to avoid both metastatic prostate cancer and overtreatment.

    Here is an interesting site :

    http://prostatecancerinfolink.net/2009/09/01/has-the-pendulum-really-started-to-swing/

    Here is a selected quote:

    AS is utterly dependent on the current and continuing use of the PSA test (for lack of anything better) to identify patients with early stage prostate cancer and monitor them accordingly over time. Do we need a better test that can discriminate the patient with indolent disease for the patient with aggressive Gleason 6 prostate cancer? Of course we do. But in the meantime we need to follow the data published last week by Grace Lu-Yao and her colleagues, which clearly demonstrates that PSA testing has massively reduced the risk of an initial diagnosis of progressive, regionally advanced disease, by which time the patient is quite certainly at high risk for metastatic prostate cancer which might have been avoided.

    It’s your choice– good luck and God bless

  24. Lee Smith says:
    up arrow

    One more common review of the current situation:

    http://www.time.com/time/health/article/0,8599,1886227,00.html

    For now, Andriole recommends a screening approach tailored to the particular patient. “If the man sitting in front of me was an elderly man with a medical condition and he looked like he had a limited life expectancy — say seven to 10 years,” Andriole says, “I think I could have a good conscience in telling him that the PSA test is not necessarily for him.”

    For men with more time left, the smart approach is probably to stick with the exams. A positive test may mean a biopsy, and those results will determine the need for treatment. It’s not precise, but it is science — and for now, that’s the best we’ve got.

  25. Ed Dwulet says:
    up arrow

    Lee’s closing remarks (i.e. “for men with more time”)forces me to respond again to point out the utter fallacy of his final argument.

    Google “STANFORD RESEARCHER DECLARES ‘PSA ERA IS OVER’ IN PREDICTING PROSTATE CANCER RISK” and read what the inventor of the PSA test said about it in 2004! But nobody listened. Too many people were making too much money mutilating too many men. He says: “All you need is an excuse to biopsy the prostate and you are going to find cancer.” He says that researchers examined the prostates of healthy men who died from trauma, finding that 8 percent of those in their 20s already had prostate cancer! Would catching cancer in a 25 year old be “early enough.”

    Lee’s “off the wall” comment “A positive test may mean a biopsy” … as if it were just a nothing thing… is cavalier and dangerous. Look at the extreme, consider this hypothetical: Biopsy a hundred 20 year olds and you would find cancer in 8 of them –(these would be Lee’s “men with more time.” Then what? Watchful waiting/Active surveillance … or whatever Lee wants to call it? Keep asking them to come back every year for the next 40 or 50 or 60 years for more biopsies? How very ridiculous!

    Don’t like hypotheticals? How about real life? Google: “At 32, a Decision: Is Cancer Small Enough to Ignore?” and read a Pulitzer Prize winning article about a poor guy who inadvertently got a PSA test when he was 29 and after numerous biopsies and consultations around the country was facing a radical prostatectomy at 32! Very very sad. I’ve asked the Wall Street Journal for a follow up story many times without a response — I’d really like to know what happened to this poor guy?

    Prostate biopsy now appears to be a real risk and “for profit” medicine has every reason to downplay and minimize that risk. I happened to be working for Dupont Chemical when the first reports of the danger fluorocarbons posed to the upper atmosphere. I saw firsthand how they mobilized their armies of Phd’s to find fault with the studies. Of course, the fact that they were the world’s largest manufacturer of freon had nothing to do with it! It was until 20 years later that they were finally forced to acknowledge the danger and halt production. The influence of money has a bad habit of trumping heath — individually or of the planet.

    I contend that no one really knows what these biopsies may be doing to indolent prostate cancer. It could be that men choosing “cut it out” surgeries may have been unknowingly “doing the right thing” for the wrong reason. Not for what the cancer might have done to them … but because of what the biopsy might have done to their cancer!

  26. Ed Dwulet says:
    up arrow

    Of course Lee might counter that no one is recommending testing 20 year old’s (not yet anyway). To which I might respond: Why not? Its as good a random number as any.

    What is the actual science behind the new 40?

    What was the actual science behind the past recommendation to screen 50 year olds?

    THERE WAS NONE! They are arbitrary numbers chosen out of thin air.

    As is the “annual” requirement [for PSA tests] — if there was some science behind that, maybe based upon known rates of prostate cancer progression, it might be 3 years or 5 years or 18 months or you name it — and traceable to a real scientific standard of evidence.

    There is nothing more arbitrary than “annual” anything as a screening requirement. Incomes are measured on an annual basis — and money not science is usually found behind such recommendations.

    Someone has to send this case to a jury!

  27. Lee Smith says:
    up arrow

    I guess we are going to keep going forever on this.
    Here is a very recent article

    http://www.medscape.com/viewarticle/709798

    PSA Test Is Imperfect Screening Tool: What to Do?

    I’ll give you the final words — I’m sure that Ed will fill in the middle in his own selective way:

    “I don’t want people to walk away from PSA and say it’s useless,” he remarked. “We believe we are still saving lives with the test.”

  28. Ed Dwulet says:
    up arrow

    Again one of Lee’s references bolsters my case and harms his. Talk about selective quotes! Lee must be blind! Rather than chose a quote about what somebdy “believes,” how about one that has been verified by science: “PSA screening cannot differentiate between indolent and lethal prostate cancer,” they write. The test sends many men down a path of diagnostic biopsies and treatment with no certainty of mortality benefit but with much anxiety and overtreatment, she said.”

    This is a fact. This has been proven by science. 1.3 million men overtreated when the recommended age for screening was 50!

    And Lee has no problem with lowering the PSA screening age to 40 … even though the science says that there can only be one result of such an arbitrary move: that even millions more will join him among the ranks of the overtreated.

    Misery loves company … and love really is blind.

  29. Ed Dwulet says:
    up arrow

    Lee can selectively find articles to support his position just as he selectively chose quotes from that last article. Many so-called internet “news” items are planted by special interests looking to benefit from getting their particular point of view across. Google “free prostate screening” and you’ll find hundreds of “news” articles touting “save your life” PSA testing with no mention at all of the the risks and uncertainties. This isn’t “news” this is a search for new customers. I don’t know and I really don’t care what he wants you to read. Consider the source.

    Even if it might be a legitimate medical news outlet — like Medscape, the article he referenced — too many news outlets these days feel that in the interest of appearing “fair and balanced” … or to not alienate certain groups they depend upon for their own advertising revenue … they must present two sides to every story even when overwhelming scientific evidence supports one side. So they find somebody, anybody, most probably an AUA member to quote that he “believes” PSA testing is valuable. Yes … valuable to his bottom line! Just who is really going to benefit from all those additional biopsies and surgeries with the arbitrary lowering of the PSA screening age to 40. Consider the source.

    Like a believer of religion who finds validation in the fact that apparently sensible and sane people share similar beliefs, Lee is trying to lead as many people as he possibly can down an irreversable path to a radical prostatectomy … for no other reason than to validate his own decision to travel that path. He’s already invoked his own urologist and many of his “intelligent” friends. As my Dad often said to me when I was a kid, having asked him to allow me to go somewhere just because one of my friends was going … “If your friend decides to go jump off a cliff … are you going to follow him?” … and that’s exactly what you’ll be doing if you listen to anything Lee has to say. Consider the source.

  30. Lee Smith says:
    up arrow

    Prostate cancer testing and treatment in US has led to much steeper decline in death rate compared to other countries
    October 5, 2009 by Jim Tucker

    http://prostablog.wordpress.com/2009/10/05/prostate-death-rates/

  31. Lee Smith says:
    up arrow

    Don’t know if anyone is reading this any more, but thought I’d give one more reference. They keep coming out.

    http://prostablog.wordpress.com/2009/10/06/prostate-exaggeration/

    “The common claim that PSA testing leads to high and unacceptable levels of prostate cancer over-detection – and therefore over-treatment – is an exaggeration, according to a presentation at the 107th annual meeting of the New York Section of the American Urology Association.”

  32. jeffrey dach says:
    up arrow

    Although PSA screening eradicated advanced prostate cancer from the population, there was a downside.

    According to Welch’s report in August JNCI, one million men were overdiagnosed and overtreated for prostate cancer over the last twenty years.

    Why was PSA Screening for Prostate Cancer, a 20 year failed Medical Experiment ? Get the whole story here…

    http://jeffreydach.com/2009/10/01/psa-testing-the-failed-medical-experiment-by-jeffrey-dach-md.aspx

  33. Ed Dwulet says:
    up arrow

    From the New York Times, October 21, 2009:

    “It is impossible to distinguish between harmless prostate cancers and deadly ones. As a result, many of the 200,000 men who receive prostate cancer diagnoses annually are subjected to aggressive treatments that render them incontinent and impotent.”

    It is IMPOSSIBLE …

    It is IMPOSSIBLE to distinguish ….

    It is IMPOSSIBLE to distinguish between HARMLESS … and DEADLY …

    IMPOSSIBLE!

    HOW MANY MEN WERE TOLD THIS BEFORE THEIR PSA TESTS?

    HOW MANY MEN WERE TOLD THIS BEFORE OR AFTER THEIR DOCTOR INFORMED THEM: “I’m sorry to tell you that your biopsy found cancer.”

    IMPOSSIBLE to tell harmless from deadly prostate cancer.

    I knew this 13 years ago.

    I knew it … and any doctor should have known it.

    If this isn’t malpractice of the first order I don’t know what is.