the BOGUS Gleason 6 prostate cancer

DSC00588the BOGUS Gleason 6 prostate cancer

(and, most everything else about prostate cancer)

Bert Vorstman MD, MS, FAAP, FRACS, FACS

Summary
> the Gleason 3+3=6 prostate “cancer” is a pseudo-­cancer mislabeled as a cancer. It needs neither detection nor treatment.
> the radical (robotic) prostatectomy is a scientific fraud which not only fails to extend life but, is associated with an unenviable list of complications.
> PSA-­based screening of healthy males is a hoax since it commonly misses the 15% or so of potentially lethal high­-grade cancers as they often make little or no PSA.
> prostate cancer evaluation follows a treacherous path which leads mostly to the detection of non-­lethal prostate “cancers” and unnecessary and debilitating treatments.
> because of biases, conflicts­ of ­interest and money, a lot of medical information, like much of that from most media outlets, represents simply the dark art of disinformation.

The Gleason 6 “cancer” deception

The all-­inclusive prostate cancer label is deceitful by implying that all prostate cancers are equal and have the power to kill rapidly whereas it has been well established that the very common Gleason 6 type of prostate “cancer” (an interpretation based upon a microscopic appearance only) fails to behave as a cancer and, should not be called a cancer.

In fact, Larry Klotz M.D. and others, have shown irrefutably that the Gleason 6 prostate “cancer” is a not a real cancer for two fundamental reasons: no man has died from this disease and, this so-­called cancer lacks a number of molecular biological mechanisms normally found in cancerous behaving cells. Furthermore, unlike a typical cancer cell, this cell has a very long doubling­time at 475 +/­ 56 days so that from mutation to a growth of about 1 cm (smaller than half an inch) in diameter takes some 40 years.

Therefore, because the Gleason 6 lacks the hallmarks of a cancer, it is not a health risk, it does not progress to become a health risk, needs no detection and, needs no treatment. The Gleason 6 is a pseudo-­cancer mislabeled as a cancer; this false cancer tag is a monstrous medical error and public health disaster, inviting legal retribution. Only the 15% or so of the high­-grade forms of prostate cancers have the potential to kill and, only they demand detection and treatment.

http://www.ncbi.nlm.nih.gov/pubmed/26816834

Prostate Cancer: Opinions Vary on Gleason Scores and Surgery

The radical (robotic) prostatectomy travesty and its shameful legacy

The radical (robotic) prostatectomy is a debilitating and scientifically unproven procedure that urologists market aggressively as a “life-­saving cancer treatment”. This treatment philosophy had its origins in ancient times as a crude and often deadly approach for removing bladder stones; by the late 1800s it had evolved into an approach for prostate surgery.

In the USA, the obsession with the radical prostatectomy arose directly from Halstead’s misguided, unbridled medical experimentation with the mutilating radical mastectomy. Also at Johns Hopkins, H.H. Young M.D. became the standard-bearer for the male counterpart to this radical surgical experiment. He was subsequently given, the misplaced and dubious honor of being the “originator” of the radical perineal prostatectomy after his publication “The Early Diagnosis And Radical Cure Of Carcinoma Of The Prostate” in the Johns Hopkins Hospital Bulletin, 1905.

The object of Young’s paper was, “to give in detail, a radical operation proposed as a routine for cases of cancer of the prostate with histories of four operated cases”. Although the first two patients died (one after undergoing surgery to treat a complication common after the radical prostatectomy, the other post­operatively) and, the other two were left with significant urinary issues after prolonged hospitalizations, Young concluded his paper with the shocking line, “The four cases in which the radical operation was done demonstrated its simplicity, effectiveness and the remarkable satisfactory functional results furnished.” Not only was the title of his paper deceitful in that there was zero evidence for early diagnosis of prostate cancer ­there was no evidence for cure. Moreover, his contention that the radical perineal prostatectomy furnished “remarkably satisfactory functional results” was a bare­-faced lie. In reality, any concern for patient outcome in Young’s publication was grossly overshadowed by his grandstanding and preoccupation with the technical nuances of radical prostate surgery. Shamefully, nothing has really changed since Young’s 1905 paper.

To this day, urologists are still intoxicated by the illusion of radical cure along with perpetuating the deception that the radical prostatectomy affords “remarkably satisfactory functional results”. In fact, urologists were so smitten by the idea of radical surgical cure and showboating surgical prowess (like their colleagues who also defied scientific evidence so they could continue performing the crippling radical mastectomy with little regard for their patients) that they never once sought to prove the safety or benefits of radical prostatectomy through scientific, evidence-­based studies. Instead, and with the endorsement of this culture for radical cure by their urology hierarchy, urologists “proved” their preconceived notions and treatment philosophy with self-­serving studies, dogma, propaganda and cronyism to transform an ideology into something deemed “standard practice”.

Yet, urologists were always aware of the many dangers associated with the radical prostatectomy as demonstrated by the numerous academics that undertook experiments with not only different approaches to the prostate, but also developing various techniques to lessen hemorrhaging, nerve injuries and other serious complications. The surgical side effects from this crippling radical prostatectomy also proved to be a cash cow for the urology community. A highly lucrative prosthetic industry sprang up to supply the implantable devices used to treat the men left “limp and leaking” after their surgery. Unbelievably however, steadfastly indifferent and insensitive to real patient outcome as well as the affirmation of “first do no harm”, urologists continued their focus on the concept of radical surgical cure by eventually incorporating robotics into their procedure.

Thanks to a corrupt FDA 510(k) approval process, use of the robotic device in radical prostatectomy also bypassed standard safety or effectiveness testing on even a single case of prostate cancer. Not surprisingly, the robotic prostatectomy added a raft of new complications to the many dangers already associated with the radical prostatectomy. Contrary to the prostate cancer industry’s media hype about the merits of the robotic prostatectomy, the many men harmed by this ill­-founded operation can only counter the tsunami of deception with product liability lawsuits against the manufacturer and its physicians and, listing their post­-surgical complications on the FDA’s own product liability website, MAUDE (Manufacturer and User Facility Device Experience). Here, voluminous pages documenting serious adverse events have been listed by injured patients (representing only about 8% of actual adverse events as the site is voluntary and not patient­-friendly).

Underscoring further, the trickery surrounding the standard urologist line about “remarkably satisfactory functional results”, the women partners of these post­-prostatectomy victims are all too aware of the cruel reality of the many adverse effects that their suffering men are too embarrassed to acknowledge. Problems such as, having to wear a pad to soak up leaking urine as well as being left with a horrible loss of manhood because intimacy, if even possible, may only occur with a shortened, soft and barely stuffable penis and, should climax occur, results only in an ejaculate of urine.

Trying to empower men before they fall for this appalling prostate cancer surgery hoax, urologist A. Horan MD has given a valuable insider perspective to the lies of urologists through his damning expose entitled, “The Big Scare” and subsequently, a revised edition, “How to Avoid the Over-diagnosis and Over-treatment of Prostate Cancer”. In these profoundly important books, Dr. Horan highlights how the radical prostatectomy has lifelong debilitating consequences and, fails to extend life. Dr. Horan and other enlightened experts make it abundantly clear that the radical prostatectomy, borne of egos and dishonesty, is a misguided procedure that has created monstrous morbidity among millions of unwitting men who were purposely scared onto the operating table for financial gain.

http://urologyweb.com/robotic-prostatectomy-spreads-prostate-cancer-cells/

http://urologyweb.com/the-many-robotic-prostatectomy-complications/

A. Horan M.D. “How to Avoid the Over-diagnosis and Over-treatment of Prostate Cancer”

http://www.fda.gov/ohrms/dockets/ac/99/transcpt/3523t1.pdf

http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfm?ID=K011002

The great PSA hoax

The PSA (prostatic specific antigen) blood test is unable to predict the presence of a significant prostate cancer and its unethical use by profiteering urologists chasing flawed abnormal levels has resulted in untold millions of men being robbed of their health after trumped-­up cancers were “treated” unnecessarily with destructive surgery, radiation, seeds or proton beam.

All PSAs fluctuate normally and, because laboratory errors and other causes may lead to false positives, no action should ever be undertaken on a single so-­called abnormal level. The PSA test is highly unreliable when used for prostate cancer detection in healthy males as there is no specific level that detects a prostate cancer and, this test is unable to discriminate between normal prostate, inflamed prostate, the fake Gleason 6 “cancer” or, the 15% or so of potentially lethal high­-grade prostate cancers. In fact, because the high-­grade cancers commonly lose the ability to make PSA, the PSA test often misses these important cancers.

Despite a misguided approval by the FDA in 1994 for prostate “cancer” detection, PSA elevations above the so-­called normal range of 0-­4 ng/ml, an arbitrary cut­off point, leads to risky prostate needle biopsies that detect mostly benign prostate or, the Gleason 6 pseudo-­cancer. Although labeled a cancer, the Gleason 3+3=6 (after pathologist Donald F. Gleason M.D. who devised an arbitrary scoring system of 1­-5 given to each of the two predominating patterns of growth seen in the specimen under the microscope) is a pseudo­-cancer which will then be “treated” unnecessarily at great patient expense.

Although the PSA test is very lucrative and marketed as potentially “life­saving”, it’s a coin toss that comes nowhere near the 80% true detection rate necessary to qualify as a useful prostate cancer screening marker, even when the PSA test is combined with the equally unreliable DRE (digital rectal examination) and or, the PCA3 test. In fact, despite attempts to improve the sensitivity of prostate cancer detection by determining PSA velocity and PSA doubling time; calculating the PSA density (big prostates, “big” PSAs); determining the Pro PSA; determining the PSA derivative, percent free PSA; undertaking the finasteride PSA deflation test (Horan) to see if the PSA will drop by half after a three month course of finasteride; using the phi (prostate health index) test or, using the 4K SCORE test, no test comes close to detecting 80% of the all­-important high-­grade prostate cancers.

Therefore, because the risk-­to­-reward ratio for the PSA test weighs heavily against its use as a detection tool that leads simply to an overwhelming amount of unnecessary and harmful evaluations and treatments, the USPSTF (the United States Preventive Services Task Force) has recommended against the PSA test and given it a “D” or fail grade.

Nonetheless, not to be thwarted by the USPSTF’s determination that the potential harms associated with PSA testing far outweigh any benefits, urology leaders used their experience gained from manipulating and influencing the FDA to target the medical illiteracy and gullibility of certain Senate Staff. By using Senate clout, urologists hope to facilitate a political pushback on the USPSTF and reverse its “D” grading of PSA -based prostate cancer screening through the self-serving USPSTF Transparency and Accountability Act (H.R. 1151, S. 1151) and protect their meritless but profitable PSA-­based prostate cancer screening and robotic surgical treatment charter.

As if this reprehensible capitalizing on the medical ignorance of Senate Staff were not enough, urologists also had the gall to demand the inclusion of one of their own (an obvious conflict of interest) to the panel of reviewing physicians in order to make the USPSTF more “transparent”. More disturbing however, a urology representative went on to assert that “urologists should be involved in the development of prostate cancer screening recommendations to ensure that the guidance is evidence­-based and also targets the preferences of individual patients”. Not only is the concern for “preferences of individual patients” totally insincere as it was argued simply to continue the flow of vulnerable and confused men to seek treatment for their Gleason 3+3=6 when none is required but, the brazen demand that “guidance is evidence­-based” underscores the deceptive messaging urologists will use to promote lucrative PSA screening despite the egregious harms associated with this ineffective test and, the lack of any scientific supporting evidence­-based documentation.

Finally, the coup de grace, which should now put an end to misguided and harmful PSA-­based prostate cancer screening in healthy males has been delivered by Ablin and Piana in their treatise, “The Great Prostate Hoax” wherein the full display of pseudo-­science, biases, conflicts of interest, misrepresentations and falsehoods perpetrated by unprincipled urologists to deceive the public for personal gain has been undeniably documented. Clearly, the USPSTF “fail” position regarding the PSA is correct and the AUA (American Urological Association) stance endorsing it is wrong.
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/prostate­cancer­screening

http://urologyweb.com/prostate­cancer­biomarkers/

Ablin,R. and Piana,R. “The Great Prostate Hoax”

The treacherous prostate “cancer” detection path

When the PSA comes back “high” (above the arbitrarily determined 4 level) in a healthy man, it is virtually guaranteed that he will be directed down the treacherous path for prostate cancer detection. A path that commonly leads to unnecessary biopsies and unnecessary treatments that ultimately has dire health consequences.

Not only is this journey loaded with inaccuracy and potential harm but also, the screening PSA test cannot be trusted as it is not cancer specific; the hysteria about the need for early stage prostate cancer detection is a hoax since it detects mostly insignificant disease and often misses the 15% or so of important high-­grade cancers since they tend to produce little or no PSA and, its radical robotic prostatectomy “treatment” is a scientific fraud that has been exploited through savvy and deceptive advertising campaigns centered on pseudoscience and fear-mongering.

In fact, fundamental to this prostate cancer detection scam is keeping the Gleason 6 disease under the cancer umbrella so that urologists can continue the deception that the Gleason 6 is a cancer and health-risk or, could possibly become cancerous and a health-risk when neither are true. By including the Gleason 6 pseudo-­cancer in prostate cancer statistics it becomes apparent that the incidence of prostate cancer is greatly overstated creating a dangerous illusion that prostate cancer is the second most common cancer in men. Likewise, implications of family history or ethnicity relating to prostate cancer incidence is also likely to be overreaching.

Additionally, since the prostatic specific antigen (PSA) and digital rectal examination (DRE) are both highly unreliable tests, the urologist’s call for prostate screening based on these tests stands on very shaky grounds. Not only shaky but, any “abnormalities” detected with this PSA-based screening format will lead to a risky transrectal needle biopsy of the prostate attempting to establish whether or not any “cancer” is present. However, the trans­rectal ultrasound (TRUS) is unable to detect a cancer and its use is limited to estimating the size of the prostate and for directing the biopsy needle into very general locations. Although the customary 12­-core needle biopsy only takes samples from about 0.1% of the prostate, it can be quite uncomfortable as well as carry the risk of a life­ threatening septicemia. Mostly, the prostate biopsy for an elevated PSA will show just benign disease (the PSA has a 70% plus false positivity rate) or, the Gleason 6 pseudo­-cancer.

However, to capitalize on this Gleason 6 “cancer” farce, many men will go on to be exposed to radiation from unnecessary CAT scans and bone scans on the pretext of “cancer” staging. Not surprising, many of their physicians have a financial stake in these imaging centers. Even worse, many men will be talked into undergoing more of these risky 12­-core biopsies or saturated and template biopsies by doctors chasing elevated PSAs while other patients will be steered towards expensive and still imperfect mp­-MRIs to continue the hunt for smaller and smaller (probably insignificant at this level) high­-grade disease for a possible target biopsy.

Following this assault on your prostate, the needle biopsy specimens will be assessed by pathologists (be especially wary of potential conflicts with pathologists employed by urologists) whose interpretations are affected by subjectivity (observer error) and differences of opinion. These troubling issues emphasize why getting a second opinion from a recognized pathologist is important. Aside from the less common finding of a high­-grade prostate cancer, the significance of everything else like the so­-called pre­cancerous findings of high-­grade PIN and ASAP and, phenomena like perineural invasion will be misrepresented and exaggerated to justify more prostate biopsies whether or not an active surveillance program and its overly restrictive Epstein criteria is adopted for a Gleason 6 “cancer”. Disgracefully, many men will be spooked intentionally into undergoing an unnecessary treatment for their Gleason 6 pseudo­-cancer.

Even more biopsies and treatments are generated by urologists using the scare-­tactic ploy of “possible prostate cancer upgrading” or, “progression” to imply that the Gleason 6 pseudo­-cancer can become a significant cancer. If the pathologist believes a cancer grade “progression” may have occurred, almost always it will be to a Gleason 3+4=7 prostate cancer, which behaves like the noncancerous Gleason 3+3=6 disease. This so­-called upgrading is invariably not because of any real cancer progression but because of better biopsy sampling and or, a difference of opinion from the pathologist.

Adding to this confusion about the Gleason score interpretation are the various attempts by urologists at categorizing prostate cancer “risk” level. From low­-risk to high­-risk; to “intermediate” risk Gleason 7 which deceptively, consists of two distinct risk categories, the Gleason 3+4=7 which acts like the Gleason 3+3=6 pseudo­-cancer (especially when low amounts of pattern 4 are noted) and, the Gleason 4+3=7, which is very different and behaves like the high-­risk Gleason 4+4=8; to most favorable and least favorable and now, prognostic grade groupings 1 to 5. Shockingly, although it has been established that the Gleason 6 is a pseudo­-cancer, this disease is still listed in the favorable cancer risk or, group 1 category.

Nonetheless, also capitalizing on these various fear­-mongering risk classifications, the “pre-­cancer” labels and the overstated concerns for possible grade progression of the Gleason 6 pseudo-cancer, has been the prostate cancer biomarker industry. Despite all of their fantastic claims for predicting the “biological potential” of various forms of prostatic cancer most, if not all prostate cancer biomarkers remain imperfect predictors of biological behavior and foster mainly the urology propaganda that all prostate cancers are a health-­risk or, could become a health-­risk.

However, the great hoax and tragedy is that, PSA-­based screening of healthy men is a sham as it fails to detect enough of the 15% or so of potentially life-­threatening high­-grade prostate cancers early enough for curative treatment. Instead, you are much more likely to be robbed of your health in this misguided and treacherous prostate cancer detection quest as it discovers mostly normal prostate and the Gleason 6 prostate pseudo-­cancer. Shamefully, most men diagnosed with this Gleason 6 “cancer” will be fooled into being “treated” with the scientifically unproven and toxic robotic prostatectomy (or some other treatment “option”) and then, fooled again into believing they are “cancer” survivors when they never had a real cancer.

http://urologyweb.com/wp­content/uploads/BEWARE­BEWARE­FDA­_APPROVE D_­ROBOTIC­PROSTATECTOMY­CARE­1.pdf

http://urologyweb.com/which-prostate-cancers-really-need-treatment/

http://urologyweb.com/stop-treating-the-fake-gleason-6-prostate-cancer/

Prostate cancer quackery and money

Much of the medical information and advice dispensed today cannot be trusted as it is heavily influenced by money and, just as Pavlov’s dog salivated every time he anticipated a reward, endless financial incentives for healthcare evaluations and treatments generate predictable physician responses.

So it is for prostate cancer management where urologists receive unlimited financial rewards for testing and treatments whether or not they have been scientifically validated or, even necessary. Shamefully, many urologists have lost all connection to the Hippocratic Oath as they are determined to protect the financial windfall from their sham PSA­-based screening of healthy males and their ill-­founded radical (robotic) prostatectomy treatment. Especially, when they know full well that the downstream effects from their prostate cancer screening and treatment philosophy fails to extend life and often leaves men with after­ effects worse than the disease itself.

Surprisingly, the history of medicine is replete with these misguided treatment philosophies that, through academic hubris, paternalism and obedience, gave rise to a herd mentality and consensus medicine. In fact, it is only through consensus medicine that radical surgery for prostate cancer became “standard practice” and, when perverse financial incentives came along, the focus of prostate cancer management became much less about the patient and much more about the money.

This epidemic of profit-­over-­patient mentality is draining our health system’s resources. It is estimated that at least one third of all healthcare services in the U.S. is unnecessary and disgracefully, predatory urologists are responsible for a good portion of this egregious waste of precious healthcare dollars through their gaming of a cancer label using the flawed PSA test. Appallingly, many self­-absorbed urologists have become quite slick at shocking men senseless with deceptive cancer messaging simply to engender fear and doubt and jar them onto the lucrative assembly line for prostate “cancer” detection and unnecessary treatments.

Helping urologists stoke the fires of this phony war on prostate cancer and profiteering handsomely from all of this wasteful evaluation and treatment of psychologically battered men are the other key players of this cozy symbiotic medical-­industrial relationship, Big Pharma, biotech and hospitals. Their addiction to revenue may surpass even that of some physicians since public company allegiance (as for the profit driven health insurance companies) is primarily to their stockholders. Not surprisingly, corporate America has become particularly adept at milking the healthcare system by “collaborating” with physicians and indebting them through endless “sponsorship” of their medical meetings, journals, marketing, social media, dinners and even, “research”. In fact, all of this medical sponsorship and corporate maneuvering in healthcare has successfully extracted more and more physician loyalty to corporate philosophy to the point where the business of healthcare is now influencing and dictating medical practice management and, not always for patient benefit.

This follow-the­-money trail influencing medical practice management is clearly evident in the business of prostate cancer where urologists are rewarded for unnecessary PSA­-based screening, unnecessary treatment of the Gleason 6 pseudo-­cancer and, rewarded by radiation centers for steering patients their way. Financial rewards can also induce physicians who favor a certain healthcare company and its corporate philosophy to act as a consultant and or, be invited to take part as a board member simply to lend legitimacy to that corporation’s interpretation of medical management. Shamefully, some of these physician consultants and board members have even had the gall to discount the baggage of their biases and conflicts of interest by functioning as consultants for the FDA.

Shockingly, physicians seem particularly impervious to these blatant financial conflicts of interest potentially clouding medical judgment and are under the illusion that these conflicts can be easily sanctified with disclaimers. However, despite these hollow disclaimers, this relationship between money and medicine in the prostate cancer industry has reached a level where a number of urologists are knee­-deep in prostituting themselves for the business of prostate cancer and, making an absolute mockery of the AUA PSA and prostate cancer treatment guidelines. Guidelines which can even be molded accordingly to accommodate the advent of new techniques and treatment philosophies such as MRI­ultrasound fusion imaging and, focal therapy technology using cryoablation, NanoKnife, laser or HIFU just so urologists can continue profiteering from unnecessary treatment of the Gleason 6 pseudo­-cancer.

This outrageous ongoing waste and harm associated with the screening of healthy men for prostate cancer and its unnecessary and debilitating treatments has already been spotlighted by the USPSTF when they found that at best, 1 in 1000 men given the PSA test may be saved as a result screening and, underscoring again the indolent nature of most prostate cancers is the fact that 80% of 80 year olds’ prostates have areas of prostate cancer. However, there is zero evidence that these prostate cancers are progressing or, have contributed to the deaths of these men.

Yet, when urologists are content with perpetuating the hoax about the “benefits of PSA­-based screening and early prostate cancer detection” and, implying that all “cancers” are equal but, well aware that only the 15% or so of high-­grade prostate cancers are potentially lethal but often missed on screening and, are wise to the facts that both the Gleason 6 cancer and the radical robotic prostatectomy are bogus, most everything about prostate cancer information and its management violates categorically, the ethical standards of medicine. A violation easily legitimized and justified by corrupt doctors and healthcare businesses (along with their duped foundations, so-­called advocacy networks, support groups and, Prostate Cancer Awareness programs) that have generated a false prostate cancer crisis involving disinformation and contrived dangers to exploit vulnerable, medically illiterate men simply for endless physician and corporate financial gain. In fact, this unethical and amoral profit at the expense-of-patient mentality is pervasive throughout the business of healthcare and, the doctor­-patient relationship previously based on trust and protection is now based mostly on quackery, money and conspiracy medicine.

http://urologyweb.com/robotic-prostate-cancer-surgery-a-public-health-nightmare/

http://urologyweb.com/which-prostate-cancers-really-need-treatment/

Prostate Cancer: Opinions Vary on Gleason Scores and Surgery
Prostate Cancer: Opinions Vary on Gleason Scores and Surgery , ASCO, June 10, 2016

KUDOS to:
Ron Piana, Science Writer, who helped me realize that PSA­-based screening of healthy men is a hoax.
Larry Klotz M.D., urologist, who helped me realize the the Gleason 6 is a fake cancer.
Anthony Horan M.D. urologist, who helped me realize that the radical (robotic) prostatectomy is a scientific fraud.

SELECTED BIBLIOGRAPHY:

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About Bert Vorstman MD, MS, FAAP, FRACS, FACS

Dr. Bert Vorstman is a Board Certified urologic surgeon. Born to Dutch parents in Indonesia, he grew up in New Zealand. After training at the Otago Medical School in Dunedin, New Zealand he completed a urology residency at Auckland Hospital, Auckland, New Zealand. He fellowship trained in adult and pediatric reconstructive Urology at the Eastern Virginia Medical School in Norfolk, Virginia and, after NIH sponsored pioneering research on “Urinary Bladder Reinnervation” he earned the honor of a Masters of Surgery Diploma from the University of Otago in 1988. Dr. Vorstman was a faculty member at the University of Miami, Jackson Memorial Hospital, Miami, Florida and then went on to found Florida Urological Associates, a busy urology practice in Coral Springs, Florida, USA.

Dr Vorstman’s passion and dedication is to help men and their spouses/partners understand fully the implications of their particular prostate cancer as well as the minimally invasive treatment options available to certain men with localized, high-­grade prostate cancer.

Dr Vorstman owns healthcare stock. He is the grandson of acclaimed Dutch author, Amy Vorstman/Amy Groskamp­ten Have who wrote the best­seller on etiquette, “Hoe Hoort Het Eigenlijk”.
https://nl.wikipedia.org/wiki/Amy_Groskamp-ten_Have