Current Research Confirms Dr. Devra Davis Was Right: Prostate Cancer Testing Needs To Be Limited

 

                                                            Dr. Devra Davis

Dr. Devra Davis in her 'Secret History of the War on Cancer'  was critical in blowing away the nonsense about cancer testing and treatments that for decades has caused endless grief. Especially loss of quality of life – say after a P.S.A. test or even a mammogram.  With regard to the first, we now know- thanks to rigorous recent research and data - that most prostate tumors are deemed “indolent,” meaning that they don’t spread or cause bothersome symptoms. Davis argued, however, that too many men panicked if the P.S.A.  even hit 'threshold' level - say of 4.0 or above, followed by a biopsy showing Gleason score 6.0.  (An elevated P.S.A. reading can prompt a cascade of subsequent tests and treatments, because “‘cancer’ is an emotionally charged term that send brains off the rails.)

In the relevant chapter, she examined the extreme consequences of responding to higher P.S.A. levels, which included trans rectal prostate biopsy - carrying the risk of sepsis, urinary blockage or other trauma. 

See e.g.:  Side Effects of a TRUS Biopsy (news-medical.net)

 And:

• Notes on a Prostate Biopsy: Don’t Fear and Don’t Hyper Google...

Then also rushing to any invasive treatment, whether surgery (prostatectomy) or high dose radiation such as I had in 2012, e.g.

• The Longest Day...And Then Some... 
• Only later did I realize (after reading a book by oncologist John P. Mulhall) the extent of damage done, e.g.

""Radiation therapy works by killing cells. It kills not just cancer cells but normal cells. However, those cells that are the most rapidly dividing are the most sensitive to radiation (as is true for chemotherapy). Fortunately, most cancers have cells that are dividing more rapidly than normal cells.

Radiation attacks the DNA in our cells. It causes breakages in the DNA, and when this occurs, the cells commit suicide, a process known as apoptosis. Normal cells have better repair machinery to fix some radiation damage while cancer cells do not.  As well as killing off the actual prostate cancer cells, radiation causes injury to the blood vessels that supply the cancer."   

             The extent of blood vessel damage became evident to me in the weeks and months following when I realized no erection was possible without taking Viagra - recommended by my urologist to "keep blood flowing".  And as Mulhall also adds:

   "The amount of radiation needed to cause endothelial damage is tiny, ranging from 0.1 to 1 Gy. It is estimated that between 15 to 20 Gy is required to injure large blood vessels (when given in a single dose).  This damage to blood vessels is known as endartertitis obliterans and may take up to a decade to manifest itself maximally."

       

          The effects of prostate surgery are even more traumatic as Devra Davis noted, and can include severe damage to ancillary nerves, dysorgasmia, and urinary leakage requiring constant use of pads or adult diapers, and more recently the use of the Space Oar, a surgically implanted biodegradable gel to separate rectum from urethra, e.g.  

       Space Oar - Urologist | UC Irvine Department of Urology (uciurology.com)

Despite all these issues about half of men over 70 continue P.S.A. screening, according to a new study in JAMA Network Open. Though testing declined with age, “they really shouldn’t be getting screened at this rate,” said the lead author Sandhya Kalavacherla. Devra Davis in her book would definitely agree and regard the choice to get tested - given the advanced age - an absurd risk to quality of life.  

 True, doing mothing can carry risks (doing watchful waiting or active surveillance) but treatment involves significant side effects, which often ease after the first year or two but may persist or even intensify.  This is what I have found but also why I have refused further "invasive" treatments - like more radiation - because of the risk to quality of life. British data showed, for instance, that six months after treatment, urinary leakage requiring pads affected roughly half of the men who’d had a prostatectomy, compared to 5 percent of those who underwent radiation and 4 percent of those under active surveillance.

After six years, 17 percent of the prostatectomy group still needed pads; among those under active surveillance, it was 8 percent, and 4 percent in the radiation group.   By contrast, men under active surveillance were more likely to retain the ability to have erections, though all three groups reported decreased sexual function with age. After 12 years, men in the radiation group were twice as likely, at 12 percent, to report fecal leakage as men in the other groups.

The financial costs of unnecessary testing and treatment also run high, as an analysis of claims from a large Medicare Advantage program demonstrate. The study, recently published in JAMA Network Open, looked at payments for regular P.S.A. screening and related services for men over 70 with no pre-existing prostate problems. According to David Kim, a health economist at the University of Chicago and lead author of the study.

“The initial screening, which is unnecessary, triggers these follow-up services, a series of events catalyzed by anxiety. The further it progresses, the harder it is to stop.”

This is one reason I have delayed any further (e.g. chemical. hormone therapy) interventions, despite a rising P.S.A.  e.g.

 Why My Own Recent PSA Result Led Me To Question That "Decline In Testing Begets More Undiagnosed Metastatic Cancer"

To fix ideas, from 2016 to 2018, each dollar spent on a P.S.A. test on men over 70 generated another $6 spent for additional P.S.A. tests, imaging, radiation and surgery. Extrapolated to traditional Medicare beneficiaries, Medicare could have spent $46 million on P.S.A. tests alone for men over 70 and $275 million in follow-up care.   

One way out of this morass of cascading cost is to change how providers get paid. Kim has suggested that refusing to reimburse them for procedures that receive low recommendations from the U.S. Preventive Services Task Force could mean fewer inappropriate P.S.A. tests and less aggressive treatment in their wake.  Some urologists and oncologists have called for a different kind of shift — in nomenclature. “Why are we even calling it ‘cancer’ in the first place?” asked one oncologist - Dr. Sartor, who has argued against using the word for small, low-risk tumors in the prostate.  

Well this gets back to Devra Davis' arguments that given the current highly refined level of scans -observations  (like with PET scans or PSMA scans) something - "anyplasms"- are now likely to be detected, necessitating treatments. And we know the first mandate of the Medical industrial complex is to treat first, ask questions later.  

What about the renaming option?  A less frightening label — indolent lesions of epithelial origin, or I.D.L.E., was one suggestion — could leave patients less inclined to see test results as lethal portents and more willing to carefully track a common condition that might never lead to an operating room or a radiation center.  But then one can just hear the screaming of the urological community that patients are risking their lives.  But what good is living to 80 or 85 if your cognition is cratered, your body has turned into a blob of 'man-boobs' and your risk of myocardial infarction now exceeds that for death by cancer?  Good questions more men need to ask before they commence a prostate cancer treatment journey.

See Also:

• Yes, Truth Is A Casualty In The "War On Cancer"

And:

• Never Go On A Prostate Cancer Forum And Suggest PSA Screening Is Out of Control...

And:

https://www.youtube.com/watch?v=GFHUCnwox7o

And:

Understanding the Progression of Bone Metastases to Identify Novel Therapeutic Targets - PMC (nih.gov)

And:

https://www.pcf.org/c/adt-what-you-really-need-to-know/

And:

PSMA PET Scan for Prostate Cancer | UCSF Radiology

And:

https://www.youtube.com/watch?v=kQ4im2WQ75E