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

Tuesday, April 3, 2012

Homage to Tom Stamey, MD


Looking back on my two-plus decades of coexisting with prostate cancer, I see my travels as an odyssey; or perhaps hegira comes closer to the mark, since it has indeed been “a flight to escape danger.” Either way, along the route, at meetings, consults, conferences, I have listened to the opinions and prejudices of eminent healers, men and women I would—all matters of disease aside—be pleased to count as friends.

Among them are a number of urologists and oncologists, all of whom had at least two things in common. First, at some point in their careers they had been either students or colleagues of Thomas Stamey, MD, a leading expert on prostate cancer and godfather and midwife to the PSA blood test. And second, a recognition of the modesty and humility with which Stamey regards his own achievement.

The literature of prostate cancer is hardly known for quotable remarks. Like a few lines you come away with after seeing a good play. But then the only “theatrical” aspect of prostate cancer is the OR. And while a compelling case can be made for too many urologists (aka surgeons) appearing far too frequently in those theaters, I have only one memorable quote.

It is something Dr. Stamey said, his terse prophecy that is pinned to the shelf above the desk where I work, and that has appeared on more than one occasion in my writing. It is this: “When the final chapter of this disease is written, it will prove that never in the history of oncology will so many men have been so over-treated for one disease.”

According to Stamey, prostate cancer is a disease all men get if we live long enough, so given an excuse to carry out a biopsy, doctors will likely find cancer.  “Our job now,” said Stamey, “is to stop removing every man’s prostate who has prostate cancer. We originally thought we were doing the right thing, but we are now figuring out how we went wrong. Some men need prostate treatment but certainly not all of them."

Stamey also reminds us that almost all men over 50 years of age start to develop benign prostatic hyperplasia, and that PSA is related today to the harmless enlargement of the prostate and not to cancer. Although the PSA test is still useful in monitoring patients after surgery, as an indicator of residual cancer, it is not a reliable predictor of the amount or severity of prostate cancer.  Stamey recommends a yearly digital rectal exam for all men over 50, and his group at Stanford is currently working on finding a blood marker that could indicate the more aggressive forms of cancer.

The most significant question is how to combat the fear factor. Many urologists will likely continue to perform biopsies based on PSA results, find early stage cancer, and recommend immediate—and as it turns out,  in most cases, unnecessary— treatment. So in what Stamey calls “this heavily screened country” it is up to each of us not to let fear dictate our decision making, not to yield to the emotional appeal of “cutting it out.”  If we decided to choose a Patron Saint of prostate cancer, you know who my candidate would be.

Consider that prior to the advent of PSA testing back in 1987, 1 of 41 men in the United States died of prostate cancer.  In 2009, with almost universal PSA screening and early treatment, the risk of dying from prostate cancer has improved, but not as much as you might think.  Presently the risk is 1 out of 53.

The cost of this progress is substantial: Prior to PSA testing 90,000 men were diagnosed with prostate cancer annually.  Now 200,000 men are told they have prostate cancer every year.  And, an additional 800,000 men undergo a prostate biopsy without being diagnosed with the disease.

So if your PSA is elevated, before you commit to irreversible and unpredictable bodily invasion, take a minute to consider the odds, and mull over Tom Stamey’s prophecy: “When the final chapter of this disease is written . . .”


Anonymous said...

Ralph and Mark -

We're on that roller coaster ride of every 3 months PSA testing. First test after a 6 year gap was a 6.6. Husband was immediately referred to a urologist for a biopsy and a hex session presentation.

I know now that we should have waited three months and had a second PSA test done. Instead, we signed up for surgery and continued to do research.

Thank the heavens above that one of the items I was reading was Dana Jennings blog at the New York Times. His review of your book shed enough doubt on the hexing done by the surgeon that we canceled the surgery.

We found an oncologist who is working with us in Active Surveillance. We are in the re-testing mode, excited 3 months ago because the score was down to 6.3, nervous this time because it was back up at 6.7, but your book gives us courage to not rush into a decision that would surely change husband's quality of life.

Thank you for telling your story, and continuing to rail against the over-treatment of this condition.

BB said...

I wish I found your site and book sooner. I'm awaiting biopsy test results next week but here's my story.

I had a serious prostatitis flare-up 6 years ago about the time I turned 50. Was left with the impression it was BPH. Symptoms cleared up, but frequently had urgency issues.

Late April of this year severe prostatitis symptoms. Urgent care doctor finds nothing on DRE (had 5 since all negative). On Cipro. Orders a PSA test which came back at 101.6. I think I have metastatic cancer for several days.

Finally, into see a uro who told me that prostatisis could lead to a PSA that high and that the test should not have been ordered.

Three-week course in antibiotics PSA decline to 19.6. Another 4 weeks of Cipro and decline to 9.8.

That urologist moved out of town and I saw another one who wanted to do an immediate biopsy. Still feeling prostatis symptoms, I suggested another course of anti-biotics which led to a decline to 7.5. But free PSA was only 12%. I agreed to the biopsy.

Uro measured my prostate through the TRUS which came in at a whopping 100cc's. He gave me the option of discontinuing the biopsy because I should be giving off PSA that high with a prostate that large. But recommended against it due to the low free PSA %. I told him that prostatis can also cause low free PSA and that the enlarged prostate could be both that and BPH. He didn't disagree but downplayed the impact of prostatis. I agreed to biopsy. But in learning more about it, I wish I hadn't. He said there is a 25% of cancer but apparently it would pretty likely be low grade from what I'm reading because of the low PSAD means prostatis probably involved in the low free PSA.