Prostate Cancer Diagnosis and Treatment — Good Medicine or Business as Usual?

//Prostate Cancer Diagnosis and Treatment — Good Medicine or Business as Usual?

This is a follow-up to a post I wrote called, “PSA Testing: The Good, the Bad and the Ugly”.   http://prostatecancerblog.net/wp-admin/post.php?action=edit&post=2120.  Please read that before you read this.

Dr. Richard Ablin, father of the PSA test, argued in a New York Times op-ed piece recently that the widespread, routine use of the test to screen for prostate cancer (PC, my abbr.)  has been nothing short of a “costly, profit-driven public health disaster”. 

While I agree with much of what Dr. Ablin says, I think he overstates his case.  Take for example the argument that widespread, routine PSA screening is not worthwhile because only 3% of men with prostate cancer (PC) actually die of the disease. I find this point of view myopic .  It ignores the suffering and disability endured by the many men who live with prostate cancer for years and may endure harsh treatments, even though they may be “lucky enough” to eventually die with PC, not of it.  (Keep in mind that there are about four million men in this country who have been diagnosed with PC. ) And let’s not forget the 30,000 men who do die of PC each year.

So I say it’s not just quantity but quality.

And the PSA test is not quite as useless as Dr. Ablin makes it out to be.  If that were so, then why would the doc recommend that high-risk patients be tested?  The value of the PSA test is much greater when combined with other patient risk factors such as age, Gleason score, stage, PSA density, etc.  And the new PCA3 test, which is more “specific” for PC (no false positives), can also give the PSA test a boost when the two are combined.  (The test is not yet FDA-approved but used by some clinicians.)   

Also, PSA levels in the lower range may not mean much, but if you have a PSA over 10, as my husband did, you may have an aggressive PC and at least you get a chance to treat it.  I don’t want to go back to the day when a diagnosis of PC was a death sentence.

Misuse of the PSA Test

On the other side are the legions of men (many in their 40s and 50s) who leak or who have to run to the bathroom all the time or who haven’t had sex in 10 years because they were aggressively treated for a disease that would not have harmed them.  And the women are the collateral damage.  I’ve lost track of how many alienated wives I’ve spoken to who’ve been pushed away by depressed husbands.  (I think women suffer more from the effects of PC than men, and studies have borne this out. That’s why I have a post on this blog called, “Resources for Desperate Women.”)

For years now we have been discussing the problem of the overdiagnosis and overtreatment of PC.  Doctors have been advised to exercise restraint in prescribing invasive treatments, but this just hasn’t happened.  For example, the number of robotic prostatectomies performed has jumped if not skyrocketed in recent years. 

Anecdotal evidence is not the best, but what I’m going to share with you is supported by research.   I have been following the conversation of a large  group of newly diagnosed men with PC in  a popular online forum.  What I see is guys who have what the National Comprehensive Cancer Center (nccn.org, a consortium of the top cancer hospitals in the country) calls “very low-grade cancer,” which they recommend be managed by watchful waiting.  Instead these people are herded into surgery.   I have seen men operated on who did not even have cancer in the first place (although they may have had pre-cancerous cells).

And the American Urological Association just made things worse by lowering the recommended age for a first PSA test from 50 to 40.  While there’s a rationale for this, I’m afraid a lot of young men with “insignificant” PC’s are going to caught in this trap. 

I believe we should abolish mass, population-based PC screening.  A man should not be given vital information about his health at a baseball game or county fair.  The PSA test should be done in a doctor’s office, with proper guidance.  And I will tell you from experience that the best thing you can do for your health is to develop a relationship with a good primary doctor whom you trust.

The PSA Test and Vested Interests

The PSA test is not a bad thing in itself:  You can compare it to a medicinal herb: when taken properly it can heal, but when used improperly it can poison.  PSA testing has become “toxic” to society because it has been so widely misused by doctors, drug companies, device makers and others with vested interests.  Did you know that “Prostate Cancer Awareness Week,” which is usually accompanied by mass screening events, was thought up by a drug company?  Or that the tennis star John McEnroe, who many of us saw on the Larry King show urging men to be tested for PC at age 40 (supposedly on behalf of a charity), is a paid spokeman for Glaxo-Smithkline?

I had to scratch my head a bit to figure out what Glaxo has to gain by pushing mass PC screening.  But I think I figured it out.  PSA testing brings lots of men to the doctor’s office.  Most of these guys will NOT be diagnosed with PC, but they may well have an enlarged prostate.  So Glaxo stands ready with Avodart, a drug that shrinks the prostate.

Last month I got a press release from a large radiotherapy practice based in Georgia, advising me to tell the world that February was “Love Month.”  And the message was that for Valentine’s Day, instead of bonbons, you should give your amour a PSA test.

So I asked myself, “What’s love got to do with this?”  Seems to me it’s about money.  I personally would not want to have a PSA test done by anybody who has a financial motive to treat me.

And there’s more: academics and policy wonks say that doctors are “incentivized” to perform invasive procedures  because our fee for service healthcare system rewards them for doing things, not spending time with patients.

PC Screening and Treatment in the Real World

Best practices now recommend that, before ordering a PSA test, a doctor give the patient a detailed lecture about the  pros and cons of PC screening.  You don’t have to be a genius to know that this just doesn’t happen in the real world — for one thing there are time constraints.  One doctor wrote, “Give me a weekend with the patient and I’ll explain everything to him”.  Best practices also require doctors to discuss the pros and cons of all available treatments with newly diagnosed patients.  But this is a pipe dream.

A recent study found that doctors are heavily biased toward their own specialties.  So if a newly diagnosed man with even a speck of cancer sees a urologist, he will probably end up having a radical prostatectomy.  And a patient who visits a radiation oncologist will likely end up having radiation.  According to this study, only patients who saw a medical oncologist (3%) or a primary care doctor (22%)  were given conservative treatments such as watchful waiting.

Technology has come to play a major role in PC treatment: doctors and hospitals now spend millions of dollars on high tech equipment like the da Vinci surgical robot, which costs about $1.5 million to purchase and $150,000 a year to maintain.  Setting up a proton beam accelerator costs a staggering $100-200 million and requires a space the size of a football field.  The only way to offset these costs is to keep the machines running, i.e. using them to treat as many patients as possible.

It’s noteworthy that neither robotic surgery nor proton beam therapy has been shown to be superior (in preservation of continence, potency and cancer control) to the old methods, but the government picks up the tab for these procedures anyway through Medicare and Medicaid.

Men who are diagnosed with prostate cancer just do not have the tools with which to make informed decisions about treatment.  This is because there is very little good information available about PC, and much of what is available is biased.  More important, a newly diagnosed man is very unlikely to be able to see the forest for the trees.  A man can have a Ph.D. and do his homework,  but most likely he still won’t realize that in the examining room with him, figuratively speaking, there may be not just his doctor but a government accountant, a drug company rep and an insurance company executive.   And these “invisible presences” may well influence the course of his treatment and his life.

A Bright Future

In the mission statement of this blog that I have been writing for almost four years, I stated that it was my wish to play a role in bringing about the more humane treatment of PC patients and their families.  (And I mean the word “treatment” in both senses of the word.)   I wasn’t seeing much progress to be honest with you.  But now I’m feeling hopeful (ecstatic might be a better word), because we are finally discussing, hotly debating issues that are very important to us, the PC community.  And the world is paying attention.  Sometimes I feel like the academics, pundits, researchers and others who comment on PC (often  disparagingly) publicly should just go to hell and mind their own business because they’re not in the trenches like we are.  But in spite of this occasional pique I believe that more discussion will lead to better care for prostate cancer patients, not vice versa. 

What makes me happiest is that we as a society are finally starting to realize that more medicine is not always better medicine. (This is a quote from an article in this week’s New Yorker magazine by Dr. Atul Gawande, a well-known doctor and medical writer.)  We have to realize this, because we’re going to go broke otherwise.

You might say that with prostate cancer, frequently less is more.

By | 2017-10-19T10:54:06+00:00 March 31st, 2010|Postings|21 Comments

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21 Comments

  1. Does treatment for prostate cancer affect ability to have sex? March 31, 2010 at 6:12 pm

    […] The PSA Test: Monster or Lifesaver? :: Living with Prostate Cancer […]

  2. Rabbi Ed Weinsberg, Ed.D., D.D. March 31, 2010 at 10:16 pm

    Hi, Leah,

    Thanks for your thoughtful article.

    Just a brief thought in reference to your concluding with Dr. Atul Gawande that more medicine is not necessarily better medicine, and your concluding that with prostate cancer, less medical (PSA) screening and treatment might be more.

    This is a beautiful sentiment but rather ambiguous. Medicine is all of what you’ve implied, namely, skilled doctors who know how to use diagnostic tools like PSA screening, as well as proper application of advancing technology and improved pharmaceuticals, but it is a lot more too.

    Medicine is also about compassionate physicians who know how to listen to their patients and act in their patients’ best interests, – not always doing what their patients want, but need. More medicine means knowing that prescribed drugs can help or hinder, and therefore need to be administered cautiously.

    More medicine means treating a patient holistically, not only with the help of Western medicine. It’s relying on meditation, appropriate nutrition, and looking not just for cures but for ways to prevent disease and dis-ease.

    In short, more medicine in the broadest sense of the word (meaning, not just more drugs or more surgery) is ALWAYS beneficial, when practiced by knowledgeable, capable, attentive and caring doctors.

    In that respect more medicine is ALWAYS better, not worse. It’s up to scientists to develop methods for better assessing patients’ needs, while providing improved antidotes to resolve patients’ problems. And it’s up to clinicians to use more advanced science judiciously while adhering to the highest medical standards,

    The problem with modern medicine is as much a matter of how science has or has not progressed as it is in how practitioners practice.

  3. Katie May 7, 2010 at 9:15 am

    This is a great post, but there is a factor I would say that you have missed, and that a lot of doctors miss, and that is serious patient education. When my uncle was diagnosed he was only getting vague descriptions, and no in depth information. We had to get him a book, To Pee Or Not To Pee, to do what the do what the doctor should have done. I would strongly suggest this for anyone with a new diagnosis, or a family member with one.

  4. Michael Glode May 25, 2010 at 12:25 am

    An excellent and thoughtful post Leah. I had a chance to spend 5-10 minutes each with some patients in a screening clinic last weekend and a few of the men chose not to be screened after hearing about the controversy in more detail. This is what I think we need to do – provide enough time for truly informed decision making. It is not what we have been doing in our mass screening efforts. It also takes more time that primary care physicians usually have, unfortunately, so maybe the blogosphere will make up for some of our deficiencies.

  5. Richard Chowning August 23, 2010 at 11:48 am

    Thanks Leah,
    You stated that the mission of your blog is to “play a role in bringing about the more humane treatment of PC patients and their families.” I am sure that you have already done that many times over during these past four years.
    It seems to me the chemo therapy is so painful mentally and physically that it could be almost seen as inhumane. The side effects are so severe.

    ….Richard Chowning

  6. Ken August 25, 2010 at 9:09 pm

    I think the PSA is a good first screening tool, as both my dad and brother have enlarged prostate, which was identified from a PSA test. Both are using saw palmetto based supplements to control the issues, and it has actually helped my dad shrink the size of his prostate.

    I do agree that too many men are having radical surgeries, that are not only unnecessary, but impacting their ability to have a normal, healthy sex life.

    While I am not a supporter of Obamacare, I think a positive will be more alternative treatment options being discussed to reduce overall healthcare costs.

  7. S. Thomas November 24, 2010 at 5:02 pm

    Dear Leah,

    Your article is thoughtful and timely. Thanks so much for speaking for wives and sharing a perspective that is so often not discussed. May we have your permission to reprint your article to share with families in North Mississippi? If so, do let us know how you wish your permissions and credit information to appear.

    Sandra H. Burke
    Executive Director
    American Prostate Cancer Research Fund, Inc.
    7852 New Craft Road
    Olive Branch, MS 38654

    Olive Branch, MS

  8. Leah December 20, 2010 at 11:39 am

    You can use any material as long as you credit it.

  9. gabriel black January 9, 2011 at 5:43 am

    30,000 is a huge number. I just really knew this statistic and i’m quite alarmed. Thank you for sharing. I’m so glad to have found this web page. My pal mentioned it to me before, yet never got around to checking it out until now. I also found this interesting article about prostate cancer you may wanna check out at http://jessicabyrne.com/facts-about-prostate-cancer.html

  10. Colleen March 13, 2011 at 6:13 pm

    I am so thankful for routine PSA tests. My husband had one and his PSA came back at 9! It had been 1.5 for ages. His biopsy showed all quadrants were cancerous with Gleason 7 and 8. Without that PSA, he would not have been diagnosed until too late. His prostate is normal size so a digital exam would not have shown a problem. We see the surgeon on Wed and are praying it’s contained in the prostate now.

  11. Gary April 5, 2011 at 11:46 pm

    I had a high PSA which resulted in a biopsy with a Gleason of 8. I had a robotic prostatectomy performed resulting in a radical prostatectomy sparing the nerves on Oct. 7, 2009. Now 18 months out I am being told that I will need an implant because function has not returned and will not return. I have tried the pills which did not work. I have also tried the injections which worked to a degree but cannot bring myself to inject myself. I am 57 and do not want to give my sex life up. I have not made up my mind to go ahead with the implant yet, which is scheduled for May 20. It is a struggle to keep from being depressed and I was never a person that got depressed over life situations, and I have been through quite a few “major” bad times. My wife has been an “angel” and terrific support through this but I “feel” the stress it has caused us both. I cannot get enough “solid” info from men who have had an implant to determine for myself how I really feel about having one or not. I would not try to influence anyone as to the path they may choose to take in treating their prostate cancer, however, I’m not so sure that I would have had the surgery after what I have experienced. I do not have a death wish but maybe quality over quantity, and I do so enjoy a beautiful Texas day with a great wife, and watching the grandsons……..

  12. michael April 16, 2011 at 11:16 am

    I am 51 years old, about two months ago I applied for life insurance. Little did I know that my life would change forever. I of course had to have a blood test done, besides being 100% healthy my PSA 5.83. I had my family doctor give me another blood test last month. His resilts came back 4.58 .
    He then referred me to a urologist who examined me and recommended that I have a digital exam, which he found nothing but was concerned about my PSA results. He then recommened that I have a biopsy which I had two weeks ago . The resuts came back with me having cancer on one of my prostate. Next week my wife and I are having a meeting with him to discuss surgery. I am so mentally drained and confused. Any advice would be appreciated.

  13. michael April 16, 2011 at 1:49 pm

    Colleen, I hope everything turned out for the best for you and your husband.

  14. Bob August 5, 2011 at 11:38 pm

    In this post you report on a watchful waiting approach that is now more often referred to as active surveillance of close monitoring of low-risk, low-grade cancer. Good to read that.

  15. Prostate Cancer December 14, 2011 at 2:50 am

    If the cancer is in its early states, treatment may not be required. The doctor will advice you to wait and watch for the symptoms. If the cancer is still progressing, then you may consider either surgery or radiation treatment. Initially radiation therapy is recommended, if there is not any improvement in your conditions, surgery can be considered as a last option.

  16. Glenn February 7, 2012 at 2:44 pm

    Leah,

    First, thank you for this work; for this passion.

    You state “It ignores the suffering and disability endured by the many men who live with prostate cancer for years and may endure harsh treatments, even though they may be “lucky enough” to eventually die with PC, not of it.”

    This is the first I have read anything about this. Most articles describe living with [the results/surguries of] prostate cancer. Is there a source that describes the untreated symptoms, results of the ‘slow growing’ prostate cancer? What are the harsh treatments you mention that are not p-ctomy, rad, cryo etc.?

  17. steve carpenter February 9, 2012 at 9:42 pm

    For those who have not made a decision about which type of therapy for prostate cancer, no class I evidence exists to show any difference between surgery and radiation. For favorable and intermediate risk cancer, the success rate between surgery and radiation is identical The most accurate radiation is with cyberknife since it utilizes continuous real time tracking of the prostate movement and delivers the radiation with submillimeter accuracy.

  18. Dr. James Meschino September 21, 2012 at 2:48 am

    Cancer patients will be Inspired from this blog post and the help provided here is really great. This post covers cancer-related topics, including undergoing treatment and being newly diagnosed. It’s really good to know that you can help people out that much. I also provide natural health solutions for Cancer patients.

    Thank you
    Dr. James Meschino

  19. Steve Ward November 8, 2012 at 1:58 pm

    Excellent and thought-out post, thank you!

    While everyone else is commenting on the medical aspect of treating Prostate Cancer, I’d like to note the importance of being mentally sound while enduring treatment. (Please don’t take this as me not appreciating your comments… they’re all wonderfully informative)

    When I enduring treatment, I tried my hardest to stay positive for the simple fact that if you’re minds not in the fight, your body won’t be either. So, aside from all the medical knowledge you must educate yourself on while dealing with your diagnosis, I find it invaluable to be strong in your mind. It will take you far.

  20. Dr. James Meschino November 19, 2012 at 5:18 am

    This blog is a great source of information for me. Thank you very much for giving me such important information.
    I also provides natural health solution.
    Thanks
    Dr. James Meschino

  21. greg March 13, 2013 at 12:53 am

    We all can help ourseves taking steps to prevent and cure cancer through diet, lifestyle and lower stress levels on the body. Also, a holistic approach using natural, herbal medicine can be a powerful combination for long-term health and well-being that can attempt to cleanse the body. We are all living longer and owe to ourselves to better enjoy these ‘golden” years.

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