Posts Tagged ‘Andrew Siegel MD’

The Prostate Is Getting No Respect Lately

May 27, 2023

Andrew Siegel MD  5/27/23 Memorial Day Weekend

Like Rodney Dangerfield (“I don’t get no respect”), the prostate gets little respect, at least not from ivory tower academia nor the powers that be who determine screening guidelines.  However, if it’s your prostate that decides to “break bad,” I assure you that you will develop deep respect for that small, walnut-shaped gland that some consider to be man’s “center of gravity.”

I promise that this will be my third and final rant against those who marginalize prostate cancer screening (“the third one is the charm,” right?). As a urologist, I am thoroughly aware of the importance of prostate cancer screening, and as a son, I am thoroughly grateful for the PSA test that enabled my father’s prostate cancer to be diagnosed and cured on a timely basis such that he is now almost 92-years-old and thriving.

On May 17th, in an online paper published in the British Medical Journal by an international team of “experts,” a new strategy was proposed to limit prostate cancer screening to men 50-70 years of age who are high risk or symptomatic.  The intention of this restriction is to reduce the potential harms from “overdiagnosis and overtreatment” of prostate cancer.  The article stated: “Most men with biopsy-detected cancers have either surgery or radiotherapy (with or without androgen deprivation therapy) even if they have low-risk tumors that are unlikely to cause cancer related morbidity or mortality.” (PLEASE NOTE WELL THAT THIS LAST LINE IS FALLACIOUS, BOGUS, AND CLEARLY FAKE NEWS—SEE INDISPUTABLE FACT #10 THAT FOLLOWS)

Photo of painting from Douro Art Museum in Portugal (one of our best trips ever!). I use it to illustrate the control that government, insurance companies, and task forces that issue screening guidelines desire to have over physicians ordering and patients receiving screening tests.

12 Indisputable Facts About the Prostate (and Why it Should be Respected)

  1. The prostate is vital for fertility, producing an essential fluid that is a nutrient vehicle for sperm. 
  2. Although man can live without his prostate, it is arguably quite valuable in terms of male sexuality. Ejaculation without a prostate gland provides the same sensation but is dry.
  3. Prostate cancer is the most common cancer in men (27% of all new male cancers), aside from skin cancer.
  4. Prostate cancer causes NO symptoms early on its course and screening is essential since prostate cancer is “silent.”
  5. As “benign” a cancer that many think prostate cancer is, the truth of the matter is that the biological behavior of any given prostate cancer can be highly variable depending on individual pathology.
  6. Advanced prostate cancer is an unpleasant and painful disease, marked by diffuse bone pain and often spinal cord compression and urinary tract obstruction.
  7. Prostate cancer is the second leading cause of cancer death in the United States, responsible for almost 35,000 deaths annually (11% of all male cancer deaths). Is that a “benign” cancer?
  8. Urologists do not screen for prostate cancer in men unlikely to live ten years.
  9. The intent of screening is to identify men with aggressive, or potentially aggressive, localized prostate cancer that can be successfully treated to prevent the morbidity and mortality associated with advanced or metastatic prostate cancer.
  10. Men with low-grade prostate cancer are managed with active surveillance, sparing them the potential side effects of treatment (the aforementioned article neglects to mention this fact).
  11. Many men under age 50 are diagnosed with prostate cancer.
  12. There are many healthy men above the age of 70 who may have twenty or more years remaining of quality life who are excellent candidates for screening.

The following are the first few pages of comments regarding this article, excerpted from Medscape. They are presented in the order in which they appeared with the names of the commentators withheld.  The comments say it all.

This is the usual kind of thing that comes from armchair experts likely University types who have never experienced any practice realities during their careers. It is unfortunate that the literature gets clogged up with garbage like this. Anyway, not a chance of this flying in North America where people at least have some fundamental freedoms and rights. I certainly am not libertarian but using health equity to justify denying access to potentially life life-saving technology is going too far for me personally.

This is another money-saving ploy. The dollars saved by not testing is greater than the values of lives lost. This is similar to limiting periodic cervical cancer tests for women – the only time some women would go to the doctor’s office annually.

The last time we followed this advice, advanced prostate cancer and deaths spiked. Where does this kind of thinking come from? Yes, a diagnosis presents options which can be difficult to navigate but when did that become a reason not to test, especially given that anyone can order a PSA test for less than $50. A few of my patients show up, test in hand.

And just which symptoms are we talking about? Prostate cancer seldom has symptoms until advanced. The media and apparently this author, confuse lower urinary tract symptoms with prostate cancer.

If my doctor followed this protocol, I would be dead. I had no symptoms. There are confirmatory tests to limit over treatment, but a patient would never get these more expensive tests without the inexpensive PSA test.

This is a load of you know what. At 62 years old I was totally asymptomatic, and my PSA tests saved my life. A rapid rise to a PSA of 10 prompted a biopsy which revealed a fast-growing tumor exiting the prostate.

I was totally asymptomatic at age 58 when I had my first PSA test. My PSA was 10.5, increased to 15 two months later and tripled to 30 three months after that. Stage 3 with positive lymph nodes in post-op pathology.

If my PCP and I had followed the advice of this panel, I probably would be dead by now.

Limit PSA screening but do not eliminate it for any male. Get a baseline test at an age appropriate to a man’s risk factors. PSA velocity is useful. Also, improve the guidelines for non-invasive next steps like the 4K Score and genetic testing for the latest correlations with specific genetic mutations.

To Medscape. It’s sad that no thumb down is available as an option. I wonder how there are so many thumbs up on an awful article, just read the reviews. I feel Medscape needs to address this issue. I know the Federal Trade Commission in the past has looked to these issues. I may plan to write to the FTC if this flaw is not corrected.

I totally agree with you! Medscape should add a “thumbs-down” option for all articles; a huge omission.

As for this article and its recommendations, it exudes bias relative to equity and population disparities as the driving issue for outcome recommendations for change in PSA testing. I support PSA testing and believe it should occur in conjunction with him and his provider. No ifs, ands or buts!

Probably the craziest proposal ever. Have these people ever worked in practice? If you knew you can test whether your car has a fatal error, but your garage forbids you to do this test because this fatal error “probably” won’t kill you before the vehicle is shut down: Would you ever enter this garage again?

Clearly, the authors don’t understand the word “screening,” if their advice is “wait for symptoms before testing.”

Why is ultrasound not included in these screening programs? MRI is undoubtedly better, but it is prohibitively expensive. Ultrasound can pick up hypoechoic centers and changes in the parenchyma of the organ that suggest cancer. In men with symptoms of prostate dysfunction, the combination of rectal exam, PSA, and ultrasound seems to be wise.

The cost of actually running the test is so low, you would have to start running them at birth and the person would have to live to well over 100, before the cost of the test would exceed the cost of surgical treatment of stage 1 prostate cancer. This is, in fact, a totally unethical, ignorant and insane suggestion.

Maybe it’s just an extremely sophisticated plan to increase PSA testing. Nothing increases demand like, “You can’t have one!”

Simply the most IGNORANT suggestion I’ve ever heard. By the time a man is symptomatic, treatment is palliative at best. I know multiple men whose cancer was discovered at stage 1 thanks to a routine PSA. My dad lived decades after his prostatectomy and was cancer free.

Simply, if these guidelines were in force, I’d be dead now.

You and thousands of other men.

This smacks of one rule for everyone else & another rule for themselves.

If indeed this has its origins in the USA health insurance, then it seems that the health insurance et-al needs ratifying & making fully accountable

It’s a very inexpensive test. And it’s illogical for an insurance company to refuse to pay for it (it costs less than $50 to actually run it). Why is it illogical?? Because the cost of treating even stage 1 prostate cancer far exceeds the cost of 100 annual PSA tests.

I think the current guidelines for yearly or so PSA testing seem generally to be beneficial. I know that many of my patients, if this new proposed criteria were applied, would be either dead or have very seriously advanced prostate cancer.

I agree that this would be a highly unethical policy. But why is it pursued?  This article does not lay down the specific criteria for vigilant PSA testing – it just speaks in general terms. Again, why and why not!

I bumped into a middle-aged patient of mine recently (I hadn’t seen for a while as I’ve changed jobs) and he said, “I wanted to thank you for saving my life.” I asked why. He said that I’d added a routine PSA checked for him at his last review.  PSA came back at 13. Investigations were done and he had grade 3 prostate cancer. He tells me he had NO SYMPTOMS OF PROSTATE ISSUES AT ALL. Similarly, I spoke to a lady whose 55-year-old husband had recently died of prostate cancer. Again, he had, she said, reported NO SYMPTOMS of prostate symptoms whatsoever.  So, don’t anyone dare tell me that we shouldn’t be doing routine PSA checks on middle aged men.

I agree, an article like this really could be construed as unethical.

It’s an unethical article, but Medscape likes to gaslight to get traffic. The last article like this provided them lots traffic and as usual us medical professionals find it hard to resist. Anyway, you can bet the authors are getting their PSA tests or their male family members are getting them and they probably are getting them monthly, and they are probably also getting MRIs for screening yearly. Don’t be fooled on this one. The ones in power and in government are getting every screening test and more in their “executive annual exams.” Let’s research if the researchers are actually following their “helpful expert” recommendations. Wow that would be an eye opener. To publish the percentage of authors who follow their guidelines on these type of screening articles. I bet it’s close to zero. But the real sadness in screening articles is these researchers go one step further by trying to take the screening test away from people by telling insurance or the government not to provide the cancer screening test if you don’t meet their criteria.

I couldn’t agree more. The number of people I know with prostate cancer who reported NO symptoms is alarmingly high. Many were only found through routine PSA testing. This article is unethical in my opinion too.

What next. Cutting down on breast etc. screenings?

Every male patient regardless of age should be tested if the symptoms presented indicate it is a possibility. This is especially so given the ever-increasing numbers pf prostate & other cancers which could be caused by environmental exposures to historic contaminants.

Rubbish! There is no room for this type of population-based criteria to justify forced rationing of early detection of cancer. In the US advanced prostate cancer cases rose over the last years since the USPSTF downgraded PSA testing. Wholesale screening is NOT done in the US. Informed choice is made by patients who know their diagnosis and are educated on all options. The authors here are simply not happy that more men are not choosing what THEY feel they should choose. Active surveillance is a recognized, widely studied, and legitimate option for treatment that many men have and are choosing after careful education. Additionally, new and more refined tests are coming online or in study to further identify those most truly at risk. The choice is more research and better science, not limiting access to diagnostic testing. This is bad medicine and bad social policy parading under the banner of the BJM.

Bottom Line: Prostate cancer is common (1 in 9 men in the USA) and causes NO symptoms early on in its course, so screening is essential to detect it on a timely basis. Treatment nowadays is highly nuanced, with surveillance used for low-risk patients, early intervention for most intermediate-risk patients, and multimodal treatments for high-risk patients.  The age at which to start screening, the interval between screening, and the age at which to stop screening are controversial and must be individualized.  The concept of “limiting PSA screening to symptomatic men” is thoughtless, imprudent, and irresponsible and the authors of this article as well as the editors of BMJ should be downright embarrassed for propagating untruths. If this concept were ever embraced, it would result in needless morbidity, suffering, and mortality.

Wishing you the best of health and a wonderful holiday weekend!

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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro AreaInside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, one of the largest urology practices in the United States.  He is the co-founder of PelvicRx and Private Gym.  His latest book is Prostate Cancer 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families. 

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Video trailer for Prostate Cancer 20/20

Preview of Prostate Cancer 20/20

Andrew Siegel MD Amazon author page

PROSTATE CANCER 20/20 is now available at Audible, iTunes and Amazon as an audiobook read by the author (just over 6 hours). 

Dr. Siegel’s other books:

THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health


MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health