Treating or Ignoring Prostate Cancer
http://thedianerehmshow.org/shows/2011-10-11/treating-or-ignoring-prostate-cancer
A new report coming out on Tuesday says a routine prostate cancer test could do more harm than good. It recommends that healthy men should not get the prostate-specific antigen, or P.S.A., exam. Some physicians argue that the test can reduce a man’s chances of dying of prostate cancer, plain and simple. But others argue that on balance, scientific studies do not support the claim that screening healthy men saves lives and in fact may cause them to have unnecessary surgery which could leave them incontinent, impotent or even death. Evaluating the risks and benefits of prostate cancer screening.
Guests
Dr. Gerald Andriole
Chief of Urology at Barnes-Jewish Hospital and Washington University School of Medicine in St. Louis
Shannon Brownlee
acting director of the New America Foundation Health Policy Program and co-author of the New York Time Magazine article, "Can Cancer Ever Be Ignored."
Dr. Patrick Walsh
University Distinguished Service Professor, The James Buchanan Brady Urological Institute, Johns Hopkins University and author of "The Patrick C. Walsh Guide to Surviving Prostate Cancer."
Dr. Chiledum Ahaghotu
Associate Professor of Surgery and Chief of Urology at Howard University Hospital.
Comments
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Hello Ms Rehm-
My name is Bruce Williams from Bangor, Maine. I am 57 and a 7 year prostate cancer survivor. Because of a PSA test my cancer was detected early and I have had no lingering effecrts or treatments post surgery. I find all the buzz lately about PSA testing being unnecessary disturbing. I know many prostate cancer survivors through support groups. I know of NO prostate cancer survivors who did not have a PSA test. The PSA test is a simple blood test which requires a very small amount of blood to be drawn from the patient. It seems the issue is once the test results are presented to the patient, the medical staff-doctors, nurses and lab staff-do not properly counsel the patient on what the results represent. The PSA test is 1/3 of what should determine the next step toward a biopsy. The other 2/3 are family history-the closer the relative, the higher the risk of prostate cancer-and the infamous DRE (Digital Rectal Exam). I would like to hear comments from your guest(s) whose view it is that PSA does more harm than good concerning alternative methods of early detection.
Thanks much for your time.
I am a 69 year old survivor of prostate cancer. I was diagnosed at age 60 when my PSA went up but was still in the normal range. Following diagnosis through a biopsy, I chose radiation treatment over surgery. And yes, I still suffer from some side effects, but they are minor considering that I can live an active life.
My grandfather lived to age 95 and had and was treated for prostate cancer. Whether he would still have lived to 95 if not treated, I cannot say. My father lived to age 98, and although he was never treated for prostate cancer, his PSA was so high that he undoubtedly had the disease. Both developed it much later in life than I did.
When I was diagnosed, I was told that if the cancer was not treated, I could expect to go about 10 years without symptoms. But since I hope to live well into my 90s, I knew that it was important to get treatment, and I have never regretted it.
So I believe that it is important that men have an annual PSA test and digital rectal exam. It is an inexpensive part of an annual physical exam. If the results come back as indicating possible prostate cancer, one should than get a biopsy, and one can decide from there how to proceed. But as life spans increase, and as we hope to live longer and longer, men my age should consider treatment as life prolonging and worthwhile.
Good Morning Diane,
I am a prostate cancer survivor. I was diagnosed in '07 (at the age of 57) with a Gleason Score of 7. But for the PSA my cancer would likely be "out of sight-out of mind," although at this point I could possibly be dying of cancer and still not know it. I received proton radiation therapy with hormone therapy (MD Anderson in Houston) and experienced only minimal side effects. From my perspective, the PSA (and the confirming biopsy) was pretty damned cost-effective. I urge those who advocate dropping prostate cancer screening to go back and reconsider what you are doing! Is this the practice of medicine by physicians or bean-counters? To me it seems to be the latter!
I love your show, keep up the good work!
I am 70 years old. I had biopsies for about 5 years starting 6 years ago, after my PSA exceed the threshold of "4". Nothing was found until about a year ago when a biopsy showed a small region of low grade cancer. I went to a major cancer center where another biopsy produced the same results. I enrolled in a "watchful waiting" study, expecting never to have to do anything else.
To enroll in the "watchful waiting" study, I had to have *another* entry biopsy, six months ago. It showed substantially larger and substantially more dangerous cancer. I had surgery which apparently removed all the cancer. I had incontinence symptoms for about 2 months. I am still trying to overcome the impotence associated with the operation. My surgeon continues to see me and to prescribe for the impotence. My history shows how complicated it is to understand what is going on in the prostate without "going in" to look.
Walter Benjamin - Orlando, Florida: 54, diagnosed 2/4/2011, robotic prostatectomy performed 4/5/2011. Gleasons 8-8-8 (very aggressive). Both parents still alive. Father is 86 and healthy. Digital exams were always negative for me. Routine PSA tests showed slowly rising PSA. GP suggested I see urologist who suggested biopsy which revealed cancer in prostate. Surgical margins were good, but cancer very close to bladder and had spread to and occupied most of both seminal vessicles. Post surgical PSA < .1 so far.
I'm not out of the woods yet, but without the PSA, according to urologist, my life would definitely have been significantly shortened. PSA test at minimum gave me a chance to live a full length life. It possibly extended my life significantly.
Since when is knowing whether you have cancer too much information? What's the harm in knowing enough to make an informed decision about whether to treat ? The test costs next to nothing. It's a simple blood test. Clearly, it does save lives. The government should not be recommending that doctors keep their patients in the dark. It should give the patients the option to know and trust the physicians to advise them on the significance of the findings. It's a matter of what to do with the information, not whether to have it. If there's a more reliable test, I'm all for it.
7 years ago, at age 49, I was scheduled for a hernia surgery and my blood work included, unbeknownst to me, a PSA.
It came back medium high. Turned out I had cancer which was cured through surgery, performed by Dr. Walsh.
I believe and the facts indicate that the PSA test done, without my prior knowledge, saved my life. (period)
It may not always work, in my case, thank God it did.
John
Michigan
Cutting back on tests for prostate cancer closely resembles the earlier policy disseminated about cutting back on mammograms and on practitioners providing manual breast exams. It serves the insurance industry.
Maybe our country is in a condition where we can't face the truths about our situation, even our health: Can't discuss the updraft of wealth even when it costs lives.
I'm sure though that there are many older men with slowly progressing prostate malignancies who would have a higher quality of life if left untreated, as long as they can urinate and are not in pain.
But that would require medical evaluation to determine their choice.
And it would require follow-up.
What we have here is a blanket statement saying less diagnosis and treatment are better than knowing. This is banal evil in such a wealthy technologically sophisticated society. Again, why can we not have universal health care like other advanced countries, and even Cuba? You can bet that Rick Perry and Mitt Romney and Herman Cain see a urologist regularly, and take their PSAs seriously.
My husband underwent a radical prostatectomy at UPenn almost 4 years ago. A month or so later he began bleeding from the colon, which eventually stopped on its own. He had another bleeding incident several months later. In January 2009 he was diagnosed with amyloidodsis and passed away April 18, 2009. Affected were his GI tract, kidneys and autonomic nervious system. Is it possible that the original procedure may have started the downward spiral leading to amyloidosis?
Please explain free PSA and it's relveance to PSA testing.
Dick, Bethlehem,NC
One of the factors that no one has mentioned is that a high PSA number, even though it is not necessarily an indicator of cancer, can cause the insurance companies to not insure you without exclusions (prostate related), or to raise your already high rates to the stratosphere. This, after 2 biopsies indicated no cancer.
I am 67 years old, never had any problems, but now my PSA test showed an elevated level. The urologist said he found something during the digital examination, and recommends a biopsy. With all this new information, I really have a dilemma. Shall I go ahead with the biopsy.
A family member was diagnosed with prostate cancer about 20 years ago, in his early 50's. There was no tumor, just cancer cells. He opted for no treatment. Now in his eary 70's, he recently underwent another biopsy, based on current PSA testing. Again, no tumor, just cancer cells. I have never seen or heard this particular issue covered. Do the experts have an opinion on what to do in such a situation?
Hello. My name is Lou Rabbia. At the age of 52, an elavated psa test led to a biopsy which showed I had prostate cancer that was labeled a stage 3. If not for the psa, some heads up attention from my pcp and urologist, I would not be writing this at this time.
I had no symptoms. Leave well enough alone.
Aggressive followup of a relatively low PSA test provided detection of both prostate and kidney cancer and saved my life. At age 53 a routine physical indicated a PSA level of 3.3. I have a conservative primary care physician who teaches at Eastern Virginia Medical School and has been seeing me for 25 years. He sent me to a urologist, who got a 3.8 reading 6 months later, did a prostate biopsy, and found cancer in 4 of 7 cores. This gave a Gleason score of 7 (3+4). He ordered a bone scan and CT, which discovered kidney cancer but no bone or lymph node cancer. We decided treating the kidney cancer should be done first, I had a partial nephrectomy, and the pathology report indicated the age of the tumor at 5 - 6 years. After much research I have decided to have a radical prostatectomy to give me the best option to remove all of the cancerous cells. Without the PSA test and aggressive followup by my physicians I would have had no idea that I had either cancer, since I have no family history of prostate or kidney cancer and no symptoms.
At age 70, my father was diagnosed with prostate cancer after an elevated PSA led to biopsy. I remember very little conversation about WHETHER he should be treated; he was simply given choices between the various aggressive options available.
He chose radiation, and was treated for many weeks. He subsequently developed rectal bleeding which lasted for over two years, and finally was unable to urinate because the radiation had destroyed his urethra.
At the age of 73, he was permanently catheterized. He finally developed a MRSA infection from the catheter, which killed him at age 73.
After so many testimonials from those who believe they were saved by aggressive treatment, I think it's important that people realize that there are another possible outcomes.
As a physicist, I must ask, "How can someone who claims to be a scientist argue in favor of ignorance in preference to knowledge?" Personally, I think people should avail themselves of whatever information is available to help live a more healthy and productive life.
I can see the medical industrial establishment getting up in arms over the loss of revenue if people no longer get unneeded testing.
Please ask your doctors how they feel about the fact that Americans get 5 times more MRI's than the German people do, per capita.
My doctor tells me I shouldn't read the New York Times. I guess an educated consumer is not ideal in the minds of the medical establishment.
When the German people start dropping in the streets because they have fewer MRI's than we do, or when the Americans lessen the wasted number of tests, then I will begin to have more faith in the system, which is rigged for profits.
Ms. Brownlee, lets make a deal, I won't advise you on your screening for breast cancer, please stop spreading misinformation on prostate cancer. You organization is populated by journalists and tv commentators (known more accurately in the UK as 'Presenters').
My father suffered from prostate cancer when in his 60's and died a very painful death.
Your oversimplification of a complex and serious medical condition is built on a flawed and incomplete study. The flaws in the study have been revealed and discussed by medical professionals on this morning's panel.
An excellent show. The elephant in the room is that as our population and the population of the EU and Japan age, healthcare decisions will involve an ever increasing element of cost/benefit analysis. The Scandinavian study showed that with PSA screening, for every 50 patients diagnosed with cancer by this modality, one life is saved. If that life is yours or the life of your father/husband/brother, the benefit associated the cost is obvious. However, bureaucrats in the Department of HHS do not have this luxury. There, the data will be viewed in a wholly dispassionate manner and weighed against the other options available to be served by this same pool of healthcare dollars.
the PSA test caught my dad's prostate cancer early, all three times! I think it's an important screen for men who have a family history of it. My Grandad had it as well.
As a physician I witness every day how perverse incentives lead physicians to make decisions that benefit them instead of decisions that prioritize patient benefit above all else. Most physicians are so caught up in their practice that I believe they don't even realize that they are doing this. Some unfortunately blatantly do it. In the case of PSAs how can we expect all physicians to take the extra time to explain to patients and not recommend surgery, except when it really only benefits the patient, when their livelihood depends on it. They are human and such behavior is fundamentally human.
I was appalled by the show. First, to have a panel composed of only urologists by itself is a terrible decision because they all have conflict of interest. Try to picture a urologist who is at the height of his career after spending several years building his practice. Now try to picture him being objective about the possibility that he has unnecessarily operated on probably thousands of patients, causing many of them serious damage to their quality of life. And try to imagine that he will think nothing of taking a steep cut in his income.
Second, the moderator should have studied very carefully the actual document in question. For example, he did not press the issue of financial involvement when the respondent answered in an offhand manner. He should have asked in several different ways questions that made it perfectly clear that the PSA test is notoriously unreliable and that ANY biopsy is invalid because it can’t identify aggressive cancer. Had he carefully read the report, he would have pressed the issue.
In the interests of full disclosure, I refused to visit any more urologists after spending a year examining the data. I understand that some of these doctors sincerely believe that they sincere, but sincerity has never been considered an indicator of truth. Medical history is full of sincere doctors who continued to recommend procedures proved ineffective or even harmful.
My father was diagnosed with prostate cancer, via DRE, in the early 1990s at age 56. He had surgery two months later and is now a very healthy and active almost-77-year old. The PSA did not exist at that time. The DRE revealed "maybe something, I'm not really sure." The follow-up by the urologist revealed, "well, there might be something, I think it's worth a biopsy." The prostate cancer was very small and very contained and surgery was (obviously) successful. He had some incontinence issues for a year or so, and does have impotence, but as he and my mom have both firmly stated, "we continue to have a very active and satisfying sex life!" My dad also continues to run, hike, swim, ballroom dance, take lifelong learning classes, enjoy his grandchildren, volunteer at a nature preserve, two hospitals, and a food bank, and do a million other things.
On the flip side, my husband nagged his father to have his prostate checked (especially when the PSA became available), but my father-in-law resisted, for quite a few years. Finally, just before he retired, he had a full check-up, including the PSA, which was (if I remember correctly) right at or just above 4. His doctor said it was likely slow-growing and to go off on a long-planned cross-country trip. Sadly, his prostate cancer metastasized in the next year and after eight years of hormone treatments, radiation, and chemotherapy my father-in-law died of prostate cancer.
Impotence and incontinence are not the worst things that can happen to a person. It is far preferable to be alive, with impotence and / or incontinence, than dead. You can ask my dad.
It seems to me there are two problems here: with applied science and with the modern healthcare system.
The problem here is twofold:
(1) Science is notoriously myopic, whereas people are not.
When "science"/doctors/a lobbying group pronounce that something is bad for you only to backpedal or dissemble a few years later, people remember. They learn not to trust (much less understand) the latest pronouncements, their physicians, and the scientific method in general, and so are reduced to quackery, radical diets and other such snake oil.
(2) The profit motive
The fact of the matter is: the healtchcare industry has been making a lot of money off these treatments for years. Now I'll wager health insurance agencies have crunched the numbers and decided it's not profitable - because men with a high PSA tend to require more healthcare. Too bad we don't have some form of socialized medicine to remove the big money bias.
Seems to me that these so-called "treatments" need to be refined, not testing policy. To state it baldly: this is about money.
This recommendation adds up to nothing but doctors and insurance adjusters blaming the victim rather than taking responsibility for their past and future actions. While taking no action is sometimes the wiser course, being ignorant never is. Next time you cover this subject, please invite well-informed prostate cancer survivors. Otherwise, I see no need to listen to another panel of charming experts doing that doubletalk thing.
Excellent yet depressing point.
Charlie Rose conducted an interview with Dr. Patrick Walsh which can be seen free online. Go to CharlieRose.com and search for the good doctor.
Dr. Walsh speaks of the significance of "PSA velocity" and mine has been rising. However, I was told by my primary care doctor that my rise was "statistically insignificant" due to daily catheterizations, colonized bacteria in my urinary tract, chronic infections etc.
I see no less than three urologists --one of which specializes in people with spinal cord injury/ paralysis such as myself, another who's in a cancer clinic and yet another at a university medical center. My paternal grandfather and uncle both had prostate cancer but eventually succumbed to other things. Each lived into their early 80's.
My name is Jose Morales, 57 years old, and I'm an asymptomatic prostate cancer survivor. For no reason at all, in May 2010 I went to my GP and asked him for a complete exam and lab test, unbeknowns to me he included PSA. PSA came back 24. It was repeated immedaitely at another lab and it came back 27. The Urologist did the dreaded DRE and his face said it all. Biopsy confirmed both GP and Urologists suspicions, which was also send to another pathology lab for confirmation. Common adenocarcionoma of the tubular variant type and of rapid growth. A Gleason of 9. As recent as 3 months ago I underwent radical prostectomy. The cancer was not contained, it spread to neighboring lymph nodes and bladder. Post surgerry PSA again returned with a value of 21. Now, I'm under hormone treatment and no sugar diet. I don't have or suffer from any other condition or illness. Still I think the PSA exam is another tool of the many physician have at their disposal. It should be given the diagnostic weight it deserves.
The show was most disappointing. There was no guest to defend and explain the recommendation of the committee, only urologists all of whose practices depend to a significant extent on active intervention in prostate cancer. There was no voice to counter their general position that they knew better than this objective panel. A defender of the panel's conclusion could have pointed out more forcefully the conclusion that only 1 man in 47 who has his prostate removed has had his life saved, and medical science at this point has no way of knowing which one of the 47 it was. They could have pointed out that at least half of the other 46, who wouldn't have died anyway, have serious side effects. Finally, a defender of the study could have pointed out that anecdotal accounts from men who claim to have had their lives saved by the PSA test are just wrong; they have no way of knowing whether they would have died from prostate cancer, and the greatest majority of them would not have.
There is nothing wrong with a man deciding to have the PSA test and have his prostate removed if he wishes, but he should do so with much more objective information than was provided on your show.
I was diagnosed with early prostate cancer late 2009 and was treated with proton radiation. I am blessed with no real side effects. The rate of rise in the PSA reading was the key clue that triggered my urologist to perform a biopsy. I remain a believer in using the PSA as a screening test until a better test is developed. THen family history and biopsy results have to be considered. So if we do not look, we are not likely to find prostate cancer, but think of all the insurance costs to be saved. Reminds me of the recommendation last year to cease testing women for breast cancer in their 40s!!!
Chiloe
Dear Ms. Rehm,
I was diagnosed at age 47. When I was 45 I had a prostate infection and went on some antibiotics. At that time my doctor decided to do a PSA test. The level was 1.7. He decided that going forward we should test just to keep track of the number. At age 46 the number went to 2.2 and at age 47 it jumped again to 2.9. Because of the upward trend he recommended I go see a urologist. We talked about the numbers and decided that it would be a good idea to do a biopsy to level set. We really did not expect to find anything based on the PSA and DRE. Well one of the cores that biopsied was slightly positive. We discussed everything from watching and waiting, to radiation, to surgery. I knew that it would drive me crazy doing watching and waiting and opted for DaVinci surgery. While only one core was slightly positive, over 35% of my gland was cancerous but it was contained. I cannot even imagine what might have happened if I waited till I was 50. So far, my followups have been very good. Yes there are the side effects that you deal with but you learn to live with them. If I am going out to play golf in the morning, I will have decaf coffee instead, or wait until we make the turn. Over time you learn what you body can and can’t handle, and if you are diligent about your kegels, you recover quickly. I struggled the first few weeks, but within a month I was back to work, bowling, doing just about everything I did before the surgery. I would rather the side effects, then finding out at age 50 and possibly not having as many options available. Since that time I have told anyone willing to listen about what happened to me and have recommded to them that even if they are not 50, go get a baseline test done, so that if you doctor wants to wait till 50 to start routine testing, at least they have something to compare it to.
Thank you,
Joe Miller
Randolph NJ