SURVIVING HEALTHCARE chapter 25 THE PROSTATE CANCER MEAT GRINDER
Every great cause begins as a movement, becomes a business, and eventually degenerates into a racket.
Eric Hoffer
Urology’s approach to this disease has undergone an embarrassing outing. The specialty traditionally recommends that the surgeon draw blood for prostate-specific antigen (PSA). The urologists also insert their finger into the patient's rectum to feel for prostate lumps.
If the blood test is high, or the surgeon feels nodules, they stick a large needle repeatedly through the rectum into the prostate to get tissue samples. If the biopsy shows cancer, urologists recommend perilous surgeries or other alarming therapies. This system has been discredited because it never improved survival rates for early disease.
The cancer is present but inactive in most men over 50. Only about twelve percent of men will be diagnosed with prostate cancer during their lives, and their five-year relative survival rate for this cancer after it is diagnosed (the percent with the disease who are alive compared to matched controls) is 97.8 percent. Ignoring it in the early stages produces the same results as treatment, but without the horrific surgical complications. The commonly performed operation, a radical prostatectomy, causes death in 1/200. Compromised or ruined sexuality and uncontrollable urination requiring diapers are common, often for the rest of a man’s life.
Some patients already have metastatic cancer before surgery. In these cases, it kills the patient even though he has suffered through the grisly procedure and recovery.
The PSA test is unreliable. It increases with any irritation of the gland due to factors such as infection or even bicycle riding. Antibiotics or anti-inflammatories are the treatments, not surgery. The vast majority of these tumors grow so slowly that death occurs from something else before the disease becomes an issue. PSA is little help to identify aggressive cancers that would be fatal.
Here is a little math: The USPSTF (US Preventive Services Task Force) did a large-scale analysis of the research literature. They concluded that for every 1,000 men ages 55 to 69 who had their PSA checked every one to four years for a decade, it would save one man from prostate cancer. The number needed to test is 1000, over 10,000 patient-years, and who knows how many tests, possibly 50,000.
Even if you believe these small numbers are meaningful, the cost-benefit ratio is terrible. False-positive PSAs lead to biopsies, which have complications just like the true positives. Men with biopsies that show cancer get surgery or other treatments. The harms resulting from these interventions include erectile dysfunction, urinary incontinence, serious cardiovascular events, deep vein thrombosis, pulmonary embolism, and occasionally death. Checking PSA in asymptomatic men produces no improvement in survival.
The American Veterans Administration “PIVOT” trial compared surgery versus observation for localized prostate cancer over 13 years. There was no statistically or clinically significant difference in either all-cause (absolute survival) or even disease-specific mortality (relative survival). Prostate removal surgery is a net harm.
A Scandinavian study looked at 695 men with prostate cancer. They were divided into two groups. One had radical prostatectomy surgery, the other “watchful waiting.” With the surgery, the men were half as likely to die of the cancer (relative death rate). Their overall death rates from all causes (absolute deaths) at five and ten years were identical to those who did not