29. PSA Screening for Prostate Cancer, the Failed Medical Experiment
Jim Smith is a 55 year old athlete and outdoors man,
who runs marathons and camps outdoors. He was not worried about prostate cancer
until he saw the Larry King Show endorsing PSA screening for prostate
cancer. Larry King showed celebrity
endorsements from Colin Powell, Charlton Heston, Jerry Lewis, Arnold Palmer, Rudy Giuliani,
John Kerry, Bob Dole, Norman Schwarzkopf, John McEnroe and Michael Milken all
relating personal prostate cancer stories.
Watching all these celebrities urging PSA testing on the Larry King show
lured Jim into a local Miami hospital offering free screening for prostate cancer. Jim's PSA test showed an elevated PSA of 4.7
(normal is less than 4), so Jim was sent over to a local urologist office all
set for a needle biopsy of his prostate.
Ultrasound Guided Biopsy
Working as an interventional radiologist in the
early days, I actually pioneered ultrasound guided prostate biopsies, and
taught many urologists how to do the procedure.
This procedure involves placing an ultrasound probe into the patient to
image the prostate, and advance a long needle into the prostate gland for the
tissue sample. Usually 6 samples are
obtained. As uncomfortable as it sounds,
it's really all not that bad.
a Second Opinion
Thinking the rush to biopsy a bit hasty, Jim
declined, and instead came to my office seeking a second opinion. After a brief chat, Jim complained of recent
urinary symptoms. Sure enough, his urine
test indicated a simple infection of the prostate gland which is quite common.
The Miracle Drug
Inflammation and prostate infection is a common
cause of PSA elevation.(27-31) The plan
was to treat Jim with antibiotics for his prostate infection and repeat the PSA
test. After a few weeks of daily antibiotic
called Ciprofloxin™, Jim was smiling ear-to-ear because his repeat PSA was back
down to 3.8 and his doctors no longer advised prostate biopsy.
Screening, A 20 Year Failed Medical Experiment
PSA is Prostate Specific Antigen, a protein
discovered in 1986, and a marker for prostate cancer and inflammation. This
article will show you that PSA screening for prostate cancer is, in fact, a 20
year failed medical experiment which provides little or no benefit in saving
Studies Oppose PSA Screening
Gina Kolata of the New York Times wrote a scathing
indictment of PSA screening citing two studies published from March 2009 New
England Journal of Medicine, considered the most important studies in the
history of men's health. (1) The large US study, the PLCO, showed no mortality
benefit from PSA screening. The
European Study, on the other hand, did much better. Their ERSPC study provided a 20% mortality
reduction from PSA screening. However,
this came at a high cost of significant over-diagnosis. Fifty men were treated for prostate cancer
unnecessarily for every life saved. This treatment of surgery, radiation and
hormonal castration is associated with erectile dysfunction (ED) and incontinence.(9-12)
Million Male Victims – Over Diagnosed and Over Treated Since 1986
Dr. Welch reported a very unpleasant finding in the
August 2009 issue of the Journal of the National Cancer Institute.(2) Since the invention of the PSA test in 1986,
one million men have been treated for a clinically insignificant prostate
cancer that did not require treatment. (3-7) These are 1 million male victims,
many suffering from side effects of treatment, such as erectile dysfunction and
2009 BMJ and Archives of Internal Med Papers
Another series of papers just released in the
British Medical Journal Sept. 24 2009, again criticizes mass PSA screening,
advising against it. (13-16) Another highly critical article from the 2009 Archives
of Internal Medicine, by Dr Kirsten Howard from the University of Sydney's
School of Public Health, showed that PSA Testing is not a major factor in
prostate cancer mortality. Dr Howard
says “men with PSA-detected cancer may often undergo therapies for clinically
insignificant cancers " which does not affect mortality rates from
testing the population as a screening test for prostate cancer is no longer
recommended because it results in unnecessary treatment of many clinically insignificant
Why Doesn't It Work? Where Did We Go Wrong with PSA Screening?
We have known since 1935 with the publication of
Arnold Rich's autopsy study that there is a large pool of latent, clinically
insignificant prostate cancer in the male population which increases with age.(47)
By the age of fifty, 30-40 per cent of
males will harbor a clinically insignificant focus of prostate cancer. The vast majority succumb to old age before
the prostate cancer bothers them. These
prostate cancers are the incidental findings at post mortem exam.
Prostate cancer is a slow growing indolent disease
with a 99 per cent 5 year survival after diagnosis. The incidence of latent prostate cancer is
estimated to be one half of the male population 65 and over (7 million of the
14 million males), yet there are only 30,000 deaths per year. This means the average male has a 0.5% chance
of dying from prostate cancer, (or a 99.5 chance of dying from other causes,
not prostate cancer).
PSA screening programs send the screened patients to
trans-rectal ultrasound guided biopsy which finds these latent prostate
cancers, many of which should not be treated.
Mainstream conventional treatment involves radical prostatectomy,
radiation therapy, and hormonal castration.
The first two are associated with adverse effects of incontinence, and
erectile dysfunction. Treatment with androgen blockade, (a form of chemical
castration) is associated with increased mortality and osteoporosis.(117)
Buffalo Hunt Factor - Advanced Prostate Cancer Hunted to Extinction
One impact of wide scale PSA screening for prostate
cancer is the eradication of advanced cases of prostate cancer over the past
two decades. During my training years in
the nuclear medicine department at Rush Medical School in Chicago in the
1970's, the doctors followed dozens of patients with metastatic prostate cancer
on serial bone scans. This is rarely
seen today. The advanced prostate cancer
case is a rare bird driven to extinction, now seen only occasionally.
Stephen Strum, MD, an oncologist from Oregon writes in the comment section of a
March 2009 NEJM article, "The nature
of the patient diagnosed with Prostate Cancer has dramatically changed since
the introduction of PSA in 1987. Almost
gone are men presenting with advanced local or distant Prostate Cancer." (20)
Like the vanishing American Buffalo, these advanced metastatic prostate cancer
cases have been hunted to the point of near extinction by the PSA Screening
Vanishing Buffalo- Hunted to Extinction
Stanford's Dr. Thomas Stamey, the first to advocate
PSA screening in 1987, has come full circle, and no longer recommends PSA
screening. Stamey found the abundance of advanced cases from the early years of
PSA Screening are gone, and the PSA test has become useless. Stamey declares,
"The prostate specific antigen era
in the United States is over for prostate cancer". Stamey's data shows there was a substantial
decrease in correlation between PSA levels and the amount of prostate cancer -
from 43 percent predictive ability in the first five-year group down to 2
percent in the most recent one. "Our job now is to stop removing every man’s
prostate who has prostate cancer," said Stamey. "We originally
thought we were doing the right thing, but we are now figuring out how we went
Opposed to Routine PSA Screening
In 1997, the American Cancer Society changed its
position and no longer recommends screening.
Their chief Medical Officer, Otis Brawley MD declined PSA screening for
himself. Otis Brawley, MD says in a Jan
2000 interview, "twenty-three
organizations of experts from the Canadian Urology Association to the American
College of Physicians to the U.S. Preventive Services Task Force recommend against
screening...the predominance of professional expert opinion is that (PSA
screening) is unproven and should not be done." (119)
is the Clinical Utility of PSA Test?
According Dr Bicker in an article in the August 2009
Anticancer Research, the PSA test is now commonly regarded as an indicator of
prostate volume, and is not independently diagnostic or prognostic of prostate
cancer. (34) Even though mass screening
of asymptomatic men with the PSA test is no longer recommended, the PSA tests
remains a very useful tool in the diagnosis and follow up of prostate cancer.
For example, the PSA is useful as a cancer marker to follow cancer recurrence,
progression or regression after treatment.(45)
We Tell Dangerous Prostate Cancers Apart from Insignificant Ones?
What is the Gleason Score? Gleason Score can help
separate the aggressive cancers from the non-aggressive cancers. Gleason Score
is a histology grading pattern used to grade the biopsy sample. Lower scores (one and two) are associated with
better prognosis. Higher scores (4 and
5) are associated with worse prognosis with more aggressive behavior of the
to Treat the Aggressive Cancers and Ignore the Others - Watchful Waiting vs.
One of the major
problems with prostate cancer screening with PSA, is the inability of this test
to differentiate the clinically insignificant cancers that don't require
treatment from the dangerous cancers that do.
Various authors have suggested refinements by using parameters such as
PSA velocity(23-24)(33)(65-67), Free PSA ratio (21), and of course, the Gleason score (74-76), a
form of histology grading, applied to prostate biopsy sample to provide this
discrimination. Using these refinements,
some doctors such as Laurence Klotz have advocated Active Surveillance based on
PSA velocity.(120) Dr Klotz offers
treatment for cases having a PSA Doubling Time of 3 years or less (based on a
minimum of three determinations over 6 months).
Others, such as Mark Soloway MD, feel that Gleason score upgrade or histological
evidence of tumor aggression is the most important parameter, and have offered
radical treatment if this is found at repeat biopsy. (98-99) The obvious goal
is to identify and treat aggressive tumors before they invade the prostatic
capsule and beyond. This is not so
simple and may require discovery of new biomarkers.
A new bio-marker in prostate cancer cells called
Hsp-27 protein indicates an aggressive type of prostate cancer that requires
treatment. The absence of the Hsp-27
protein suggests a silent type of cancer that does not require immediate
treatment. (35) Do these new protocols and tools work any better than the old
ones? We don't know yet. It may take
another ten years to find out.
Prostate Cancer -Diet and LifeStyle Modification
Given the reality that PSA screening for early
detection for prostate cancer is a misguided adventure which leads to overdiagnosis
and does more harm than good, perhaps another approach to prevention is
warranted. Such an approach is suggested by urologist Ronald Wheeler at the
Sarosota Prostate Center. (105) Dr
Wheeler advocates a nutritional program for prostate cancer prevention with
Vitamins C, B6, E, zinc, selenium, Saw palmetto, Pygeum africanum, stinging
nettle, pumpkin seed, Echinacea purpurea, garlic, ginkgo biloba, Amino
acids–L-glycine, L-alanine, L-glutamic acid and Modified Mediterranean Diet.(105)
Point: How to Reduce PSA With Nutritional Supplements
may be reduced by a nutritional program with Vitamins C, B6, E, zinc,
selenium, Saw Palmetto, Pygeum africanum, stinging nettle, pumpkin seed,
Echinacea purpurea, garlic, ginkgo biloba, Amino acids–L-glycine, L-alanine,
L-glutamic acid and Modified Mediterranean Diet.(105)
Results of Diet and Nutrition Program on
In 20 patients with biopsy proven prostate cancer
who had declined radical treatment, Dr Wheeler's herbal-nutritional supplement
program reduced mean PSA from 6.8 ng/ml to 3.4 ng/ml over three years of
follow-up.(105) (121) I would also add
digestive enzymes, and optimizing vitamin D level with testing and
supplementation, as well as optimizing Iodine levels with Iodoral would also be
included in a typical prostate cancer prevention program.
conclusion, PSA screening for prostate cancer has
been a failed medical experiment leaving behind 1 million male victims
unnecessarily treated for a type of prostate cancer that was clinically
insignificant, providing little or no benefit in terms of lives saved. Leaders in the field are now alerting us to
the pitfalls, harms and limitations involved in PSA cancer screening. Recognizing that there are 30,000 prostate
cancer deaths per year, the urgent challenge is to identify and treat the aggressive
cancers destined to kill the host, and avoid harming the other 7 million men
representing a silent reservoir of biologically insignificant disease. Hopefully, this will be the subject of future
NIH funded research, so that another one million men in the future will be
spared needless over diagnosis and overtreatment.
For references and links, see my web site: www.bioidenticalhormones101.com
References for Chapter 29. PSA
Screening for Cancer, the Failed Medical Experiment
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