Over-Treating Prostate Cancer

BY MARK SCHOLZ, MD

Prostate cancer treatment is out of control, and the U.S. Preventive Services Task Force* has stepped up with the recommendation to stop PSA screening. The recommendation to ban PSA testing surprises patients and doctors alike. After all, in a trial published in the New England Journal of Medicine PSA screening was shown to lower prostate cancer mortality in a trial published in the New England Journal of Medicine in 180,000 men.

Some have questioned the expertise of the Task Force panel because there was no representation by urologists, radiation therapists or medical oncologists, the types of doctors usually responsible for treating prostate cancer.  Actually, the credentials of the panel members appear entirely appropriate to comment on screening, an area of medicine usually handled by primary care doctors.  The panel members consisted of 12 MD’s and four PhD’s trained in primary care, public health and statistics.

The Task Force has been taking massive criticism for recommending the end of PSA screening.  While conceding that PSA screening may save lives, their judgment was that too few lives are saved to justify the thousands of men getting radical treatment they don’t need. They also point out that at least a hundred thousand men annually are burdened with a diagnosis of CANCER when this particular type of cancer is very rarely life-threatening.  The sad thing is that even though most prostate cancers are harmless, a robust surgical and radiation industry can’t seem to stop treating ill-informed patients who assume that anything called cancer needs immediate treatment.

Invasion of the Prostate Snatchers was written to counter this dangerous ignorance. Throughout the entire book, Ralph Blum and I explained why something termed CANCER, as long as it is preceded by the work PROSTATE, in many cases should be totally harmless.  Ralph himself is a living example, diagnosed more than 20 years ago and still in possession of his prostate. Of course, confusion inevitably arises because certain types of prostate cancer can indeed be dangerous. Not dangerous like lung or pancreas cancer which can kill within months of diagnosis. But, over a decade or two, prostate cancer does indeed kill a minority of men. Demise from cancer certainly qualifies as “dangerous,” even if the death is much postponed.

Because there is so much confusion about the different types of prostate cancer our book pays special attention to the modern methods for distinguishing between the good and bad types.  Suffice to say in this brief blog, as long as there is a modicum of attention to detail, telling the difference between the good and the bad types is usually pretty simple.  Far more difficult is getting the uninitiated to slow down and study the situation before taking irreversible action. In the rushed process leading up to treatment, many fail in their struggle to believe that something termed CANCER really represents no threat at all.  Others, even more sadly, never hear their over-enthusiastic doctors marshal a single argument against immediate treatment.

So the Task Force is shooting PSA, the messenger, when doctors and patients are the real culprits. PSA is not the problem. The real problem is rushing to immediate biopsy at the very first sign of a PSA elevation.  A million men have mindless biopsies every year. I call them mindless because most men undergo biopsy before they have any idea of what they are getting into.  They are not pre-informed that most men over 50 have cancer cells in their prostate, and that a biopsy will be positive 20% of the time.  So when bad news comes, usually via a phone call, emotional hell breaks loose.  After all, isn’t CANCER a call to action?   Unfortunately, the urologists the doctors designated to treat prostate cancer are surgeons, who are by definition, men of action.

The Task Force is correct in their view that too many men are being frightened in unnecessary radical treatment.  The problem is a million men undergoing mindless biopsy, not PSA screening.  PSA elevation should precipitate further testing, prostate imaging and most of all, education.  My next Blog will outline the process of how to handle an elevated PSA.

*Previous blog written about this topic can be found here:  http://prostatesnatchers.blogspot.com/2011/10/discontinue-psa-screening.html