The co-authors of Invasion of the Prostate Snatchers, blog alternate posts weekly. We invite you to post your comments.

Tuesday, November 3, 2015

Biopsy, Not PSA, Leads to Prostate Cancer


Prostate cancer is way over treated, and the problem starts with over diagnosis.  Once men are diagnosed, the fear of cancer naturally drives them toward radical treatment. In 2011 the US Preventive Services Task Force intervened, trying to stop overtreatment, argued that PSA testing causes more harm than good.

Some have questioned the expertise of the panel because of the lack of representation by urologists, radiation therapists or medical oncologists --the types of doctors usually responsible for treating prostate cancer.  Actually, the credentials of the panel constituents appear entirely appropriate to comment on screening, because this is an area of medicine usually handled by primary care doctors.  The panel members consisted of twelve MD’s and four PhD’s trained in primary care, public health and statistics.

The Task Force agrees that PSA screening may save lives. Their judgment, however, was that too few lives are saved to justify thousands of men getting unnecessary radical treatment. One statistic indicates that a thousand men must be screened to save one life within the next 12 years.

Personally, I agree with the panel in regards to over diagnosis is a root cause of over treatment. However, simply discarding PSA is an oversimplification. PSA can detect a variety of problems infection and benign prostate enlargement. Actually, the majority of men with elevated PSA, don’t have prostate cancer.

No, the real problem is after a PSA test rises. Every year, a million men are advised to have a dozen, large-bore needles jabbed into their rectums “Just to be sure there is no cancer.”  Such behavior sounds ridiculous, but really, it is just the survival instinct in action. People will do practically anything when they fear for their lives.

So if not a biopsy to evaluate an elevated PSA, what’s next?

First, the fear must be faced. Ralph Waldo Emerson says “Knowledge is the antidote to fear.” So let’s look at some basic facts:

  • One out of 38 men die of prostate cancer
  • One out of seven men are diagnosed with prostate cancer
  • In men who are “diagnosed”
    • Five-year survival is 100%
    • Ten-year survival is 99%
    • Fifteen-year survival is 94%

Considering it is cancer, survival rates are great! At least these numbers should overcome any urge to rush. Clearly there is plenty of time is to study and learn more. Confusion arises because a minority of prostate cancers can indeed be dangerous. Not as dangerous as lung or pancreas cancer which kill within months. However, demise from prostate cancer certainly qualifies as “dangerous,” even if it is rather infrequent and much postponed.

These statistics reveal something else that is quite useful. Prostate management issues are of long-range nature, like saving for college or for retirement. Just as expert financial planners are limited in the ability to make predictions about economic activity ten years in the future, doctors should be equally humble in their pronouncements about the future of prostate cancer. We don’t know for sure, but we strongly suspect there will be substantial breakthroughs in the diagnosis and treatment of prostate cancer in the next ten years.

For the short term, I think the best way to proceed is with imaging the prostate with a 3Tmulti-parametric MRI or color Doppler ultrasound. Scans are about as accurate as a random biopsy for detecting aggressive cancers and they usually fail to detect the harmless low grade types, which is a good thing. However, if there is a worrisome abnormality, a targeted biopsy with just a couple cores is needed.

Over-diagnosis and over-treatment is not due to PSA. It’s the misguided policy of rushing into an immediate random biopsy whenever there is a slight elevation.  .The random biopsy procedure should be abandoned.  PSA abnormalities should be evaluated with prostate imaging A targeted biopsy can be considered in men who have a distinct abnormality detected by imaging.    

Tuesday, October 20, 2015

Let the Buyer Beware


Its time to change our preconceptions about prostate cancer and “reboot” the way we think about what typically is a non-life-threatening disease. Ever since the FDA first approved PSA testing in 1987, prostate cancer has grown into an aggressive multibillion dollar industry. Marketing hype has created the impression that treatments like Proton therapy and robotic surgery are universally desirable, even though well-informed patients know this is hardly the case.  How did the prostate cancer world deviate so far off the originally intended tract of helping patients? And what can be done to set things straight?

Ten years ago the experts believed that immediate curative treatment was needed for every man with prostate cancer.  Today, after 20 years of vigorously detecting and treating every case of prostate cancer, it has become clear that almost half of the 230,000 men diagnosed every year are undergoing radical treatment for a cancer that is incapable of metastasizing.  Now it’s time for the medical community to come to grips with the fact that over a million men in the United States are living with impotence and incontinence for no justifiable reason. This is a disaster of gargantuan proportions.

Shockingly, even though we can now readily identify these harmless cancers, the problem of rampant overtreatment continues. In 2015 another 50,000 men will undergo unnecessary radical treatment. The medical industrial complex that has been gaining momentum for 25 years refuses to confess its tragic errors.  The huge investments in enormously expensive medical equipment need to be paid off.  No one is willing to accept responsibility, make apologies or confess wrongdoing for all the overtreatment.  The existing system is entrenched and the doctors are too comfortable with the status quo.

Reversing the momentum of twenty-five years of recommending unnecessary radical treatments is going to require the patients to protect themselves.  They need to become far more medically sophisticated consumers.  Five years ago, Ralph Blum and I fired the first salvo by writing Invasion of the Prostate Snatchers: No More Unnecessary Biopsies, Radical Treatment or Loss of Sexual Potency. In our book, we attempted to defang the poisonous and fear-inducing word cancer by renaming the low-risk type that does not metastasize “The UnCancer.”  Our book has been helpful at revamping the gross misconception that every prostate cancer is potentially deadly.  Invasion provides an excellent introduction to men with newly-diagnosed cancer by presenting the important concept that prostate cancer comes in three broad types: low, intermediate and high-risk.  

One of the important themes introduced by Invasion is a healthy mistrust of physician motives. For protection against patients receiving the wrong treatment, Invasion argues strongly for patient empowerment through education. The term, “prostate cancer” is merely an umbrella term for a broad spectrum of illnesses that behave very differently. The book simplifies the treatment decision making process by clearly identifying the three major subtypes of prostate cancer, low, intermediate and high-risk.  Once patients have gained an accurate understanding of where they fit into this individualized schema, an informed treatment decision can be made.  As a medical oncologist, rather than a surgeon, the information provided in the book is unbiased with clear presentation of all the risks and benefits associated with all the different treatments that are available.

In an era now past, physicians were trained to put their patients interests ahead of their own.  Today, patients need to adopt defensive tactics that are realistic about how prostate cancer care has become a highly lucrative business. The patient who assumes that their counseling physician represents his best interests, is on the cusp of making a dangerous mistake. Bluntly, the prostate cancer world has evolved into a sophisticated and well-oiled business and the buyer better be on guard.   

Tuesday, October 6, 2015

A Midlife Crisis Avoided


Building up a medical practice and getting a late start with a family, my midlife crisis was delayed past the usual occurrence for men in their early 40s.  However, by the time I hit 50, self-questioning was starting to surface. My life had meaningful pursuits but it was time to take a deep breath and do the traditional life inventory of the “mid-years,” to reassess my goals for the last third of my existence here on planet earth.

After reflection, I realized that I really didn’t have any great ideas to reinvigorate my passion for the last lap. I couldn’t sell my wife on the idea of buying a Lamborghini (I already owned a small boat).  I didn’t have any specific desire to travel.  I had given up on golf due to a terrible and uncorrectable slice.  I have never been successful playing the stock market.  All these considerations were going through my head about ten years ago.  Now ten years later, I turned 60 and I feel revitalized and reinvigorated.  So what turned things around?  

Many of you have come to know Ralph, my coauthor in the Snatchers Blog. He is as a sensible dispenser of advice and knowledge about life and about prostate cancer.  I first met Ralph almost fifteen years ago, first as a patient, subsequently as a writing teacher and now as a writing partner. As I reflect back over the years that we have worked together I am convinced that its Ralph who spared me from my mid-life crisis.  Don’t get me wrong, I have a lovely family.  My wife Juliet is a bulwark of truth.  My children are delightfully sensible, talented and hard-working. I am also blessed with an amazing medical practice with wonderful coworkers and extra-special patients.

Even so, visiting with a dozen men a day, five days a week, year after year, decade after decade can wear you down.  Getting paid less and less every year while the work load steadily increases is hardly inspiring either.  A midlife crisis was in the wings and I had no idea how my passion for the medical profession could be restored.  So back in 2005, I was looking for a new challenge when Ralph first approached me to write a book . I even agreed after he told me the zany title, “Invasion of the Prostate Snatchers.”

Fortunately, when Ralph invited me to be a cowriter, he didn’t give a second thought to the paucity of writing skills.  (Ralph has so much confidence in his own writing skills he believes he could train a monkey to write). Over the next four years we clashed on many occasions. Considering that English was my worst subject in school I have to give myself some credit for having the courage to accept his proposal.

Back then I had little interest I had in developing the craft of writing.  Writing is hard to do.  In addition, with limited free time in a busy medical practice, it’s no surprise that developing writing skills was a low priority to me.  But I was also starting to get upset about the injustice of so many men’s sexual identities being robbed by unnecessary surgery.  The dawning realization, that men, rather than being helped by surgery are actually being tremendously harmed, is what motivated me to finally confront the painful task of developing some writing skills so I could convey my observations to the na├»ve and unsuspecting patients. Thank God I had Ralph to tutor me along through this long and arduous journey.

Learning to write about topics that matter to me (such as saving men from the loss their sexual identity) has saved me from the “meaningless” philosophical wandering that characterizes a midlife crisis.  And as I get older and further polish my writing skills, I have enjoyed even more satisfaction by helping men to avoid numerous medical pitfalls.  For example, in my next blog I’ll be exposing another incredibly repugnant policy—men on Active Surveillance who have 12 large needles plunged through their rectal wall into the prostate gland every year. Yikes!

In the meantime, let me express my genuine appreciation to Ralph for having the patience and skill to draw me down this totally unexpected pathway.  At this point I am happy to report that I see no hint of an existential crisis looming on the horizon.     

Tuesday, September 29, 2015

Taking Charge of Your Prostate Cancer Recovery: Fast Forward From the Old Model


In the old model of prostate cancer care, you were rushed into radical treatment--usually surgery or radiation--often without fully understanding all your options, or the risks and side effects involved. The entire process was focused on the tumor; minimal attention was given to you as a person, and little effort was made to explore the benefits of healthy lifestyle choices, immune-enhancing treatments, reasonable delays, and emotional support.  

The emerging new model of prostate cancer care recognizes the important role you can, and should, play in your recovery. The emerging model comprehends that simply attacking the cancer is not enough. Greg Anderson, who after surviving "terminal" lung cancer founded the Cancer Recovery Foundation, has said that "Retaining a medical team without doing everything you can to help yourself is like attempting to walk on one stilt."

So what do you need to know in order to take charge of your recovery?

There are three common misperceptions about prostate cancer:

*The assumption that the disease is as dangerous as other cancers.
*The assumption that the urologist who did your biopsy is a prostate cancer expert.
*The assumption that a quick treatment decision is necessary before the cancer spreads.

First of all, prostate cancer is unique among cancers because the mortality rate is so low. Around two hundred thousand men in the U.S. alone are diagnosed with the disease every year, and less than 15% will eventually die from it, usually over a decade down the line, while a majority of men who have the far more common low-risk, slow-growing prostate cancer can anticipate living a normal life span, or dying of something else.

Your local urologist has a busy medical practice that involves treating problems like impotence, infections, incontinence, and kidney stones. He also does biopsies. But the average urologist performs fewer than five prostate removals (prostatectomies) a year--far too few to be considered proficient. He may be a talented doctor, but he is unlikely to be a prostate cancer expert. So once you have your biopsy results, it is best to consult a prostate cancer specialist, either at a major medical center, or at a high-volume prostate cancer clinic.

As for the third misperception, it is essential, before committing to any form of treatment, that you  do your own research, and are convinced the treatment you choose is the right one for you.  Do not let anyone rush you into making a bad decision. Once your category of prostate cancer is identified (Low, Intermediate, or High Risk), get on the Internet and learn about every treatment option--including no treatment whatsoever--for your type of disease.  If you are over 70, and have low-risk disease, my advice to you is to find a doctor who has experience monitoring an active surveillance protocol.

Your role in your recovery, however, doesn't end with choosing your treatment. The emphasis on lifestyle changes has been one of the most significant shifts in cancer care in the last decade. A study at UCSF showed that improving your nutrition, reducing stress and getting more exercise, can lower PSA levels.  And according to a relatively new field of health psychology called "illness representation," your beliefs and expectations also impact the outcome of your disease. So take charge of your recovery, and have faith in your choice of treatment.