Bad “Evidence” Used Against Men: Stupid PSA Conclusions From Smart People

Cruelty, misunderstanding, stupidity, or intentional bias resulted in statements  by a government task force warning men not to get prostate PSA measurements. I have been a cancer specialist since 1984, and one of the few who can recount the horrors of prostate cancer before PSA.

Risk of prostate cancer in two age groups base...

Prostate Specific Antigen (PSA) blood test is the best cancer detection test in existence. It is cheap compared to the dozens of other tests and, with expert interpretation, more accurate. Thus raising questions on how can a task force come up with conclusions in opposition to observable facts.

Prior to the use of PSA testing, 70% of prostate cancers were not discovered until symptoms from extensive disease developed. Severe, unremitting pain in the spine and pelvis, or from bladder or  kidney obstruction leading to emergency surgery, and bone marrow replacement leading to blood transfusions were routine.  The misery cannot be understood without seeing it and living with responsibility for it.

Osseous mets from prostate cancer; bone scan

Osseous mets (spread to bone) from prostate cancer; bone scan (Photo credit: Wikipedia)

The advice from a “high public official” of “just use morphine” translates to euthanasia.Morphine cannot stop the misery of advanced bone pain without causing sedation or death. If this is the policy, then why do we spend any money on any cancer? The failure to recognize the long term suffering (and cost) of failing to find and treat prostate cancer suggests a narrow focus. Failure to include clinicians or to look at other data suggests a lack of wisdom, lack of knowledge, or intentional bias in the committee.

The”Experts” making this proclamation shown in the paper written by “Virginia A. Moyer, MD, MPH, on behalf of the U.S. Preventive Services Task Force” have MPH and PhD degrees.  I am confident they have ability and can agree that these are not stupid people. You can read their report at http://www.annals.org/content/early/2012/05/21/0003-4819-157-2-201207170-00459.full.pdf+html However, assuming the conclusions of this research paper are valid, universally applicable, and without bias is not a very wise approach.

That  means that their primary cause of the error is either a simple misunderstanding or intentional.  The failure to include advice from experienced physicians across the spectrum of care might explain the “misunderstanding”. The picking and choosing of selected observations from selected studies support concerns of  “intentional” bias.

Further more, using old toxicity data from radiation and surgery, again indicates a

Table 1. Side-effects and effects on recovery ...

selective picking and choosing of information. Since they do not understand the data in context of the disease, their conclusions, while “pure” academically, are irrelevant clinically. However, that pureness can be questioned when the entire paper is justified by a handful of unrelated, selected papers for meta-analysis.  You don’t have to be a statistician to question how just 4 papers were selected from the 1.78 million listed on Google Scholar.

The following is an example of what is common from bad advice or bad research: this is a true story of a 75-year-old man from New York. He presented to his urologist a rising PSA. He was not sent to a urologist when it was only “elevated” since there were “official” recommendations to primary care providers that prostate cancer did not really need attention in the “elderly”. While obese and diabetic, this man was active and vigorous. His mother was still alive in her 90’s even with poorly managed diabetes and he went to work at his own store each day.

English: Micrograph showing prostatic acinar a...

English: Micrograph showing prostatic acinar adenocarcinoma (the most common form of prostate cancer) Gleason pattern 4 (left of image) and Gleason pattern 5 (right of image). H&E stain. Prostate currettings. See also Image:Prostate cancer with Gleason pattern 4 low mag.jpg (Photo credit: Wikipedia)

The patient underwent a procedure obtaining biopsies from 12 areas of the prostate. All came back as aggressive type (Gleason score 9 out of 10). His urologist told him that its spreading to the bones was inevitable, surgery was not indicated, and radiation “would cause too much harm”. Later, a radiation oncologist in his family advised him to get treatment to the prostate since there was no current sign of disease spread and to prevent the complications of cancer growing in the pelvis.  He listened to his urologist instead and experienced a clinical course which was common before PSA measurements were routine.

Photo of linear accelerator

Photo of linear accelerator for delivering radiation treatments (Photo credit: Wikipedia)

This gentleman lived another 8 years and would be listed as a “success” in the “no treatment” literature.  However, he went on hormone treatment which only helped for 18 months. He needed radiation anyway due to pelvic pain. Due to the size of the cancer by this time, the treatment could only have temporary benefit.  Later, cancer blocked his rectum and he needed an airlift to a hospital for emergency surgery diverting his colon to a colostomy exiting his abdominal wall.  Later, he again required an airlift for emergency surgery. This time due to kidney obstruction. The resultant kidney diversion to a small bowel pouch emptied on the other side of his abdominal wall.

English: Line drawing showing a permanent colo...

English: Line drawing showing a permanent colostomy for rectal cancer. (Photo credit: Wikipedia)

After 8 years of misery from hormones, multiple operations, and intense pain there was still no evidence of spread to other parts of the body.  His death certificate states that he died from an infection.  It does not recognize that the prostate cancer directly invading the bladder creating an opening between the remaining rectum and bladder was the cause of the infection.

Decreased number of prostate cancers even though there is an increase in the number of men at risk in the “baby boomer” generation

So, “Success!” as reported from researching medicare data. “He lived to 83 years old! What else should he want?”, are comments previously received on discussing this man. Live with a man going through this and then tell me my uncle made the right choice of initial treatment. Then tell me, preventing pelvic cancer growth is not “worth it”. Then tell me it is not cruel to stop all progress made by utilizing PSA measurements.

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