Prostate Cancer Summary
> The radical (robotic) prostatectomy is a scientific fraud that commonly fails to extend life and, is often debilitating.
> The Gleason 3+3=6 prostate “cancer” LACKS the hallmarks of a cancer.
> PSA-based screening of healthy males leads to the detection of mainly benign prostate conditions and non-lethal prostate cancers and, causes great harm.
> Only the 15% or so of high-risk prostate cancers with significant amounts of pattern 4 disease or above are potentially lethal but, because these cells can make little or no PSA and, have often spread before detection, both screening and radical treatment philosophies are flawed.
The Bogus Radical (Robotic) Prostatectomy
The radical (robotic) prostatectomy is an ill founded, debilitating and scientifically unproven procedure that urologists market aggressively as a “life-saving cancer treatment”. Shamefully, this deception serves as the cornerstone for many other exaggerations, misrepresentations and falsehoods concerning most prostate cancers and their “treatments”.
The Big Scare. The Business of Prostate Cancer, A. Horan MD
How to Avoid the Overdiagnosis and Overtreatment of Prostate Cancer, A. Horan MD
The Radical Prostatectomy Hoax
The treatment philosophy for the radical surgical removal of prostate cancer is founded upon ancient and often deadly perineal approaches for removing bladder stones. Over hundreds of years and because of the proximity of the prostate, the procedure gradually evolved towards removing some or all of this gland for both benign and malignant conditions. By 1883, Leisrink had described a perineal approach for excising a cancerous prostate. In the U.S., the obsession with radical surgery for removing prostate cancers arose directly because of W. S. Halstead’s exalted but very questionable status achieved championing his experimental treatment philosophy – the Halstead radical mastectomy. Also at Johns Hopkins in Baltimore, H.H. Young was prompted by his mentor Halstead to become the standard-bearer for the male counterpart of this breast cancer experiment and advance a radical surgical approach to “cure” prostate cancer.
In 1905, Young described his technique for a radical perineal prostatectomy in the Bulletin Johns Hopkins University, “The Early Diagnosis and Radical Cure of Carcinoma of the Prostate”. Young wrote that the object of his 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”. However, of these four men, the first two died (one postoperatively, and the other after undergoing surgery to treat a complication common to the radical prostatectomy) and, the other two were left with life-long, significant urinary problems after prolonged hospitalizations. Embarrassingly, not only was the title of Young’s paper deceitful in that there was no evidence for early diagnosis of prostate cancer but also, there was zero evidence for cure. Furthermore, Young’s contention that, “The four cases in which the radical operation was done demonstrated its simplicity, effectiveness and, the remarkably satisfactory functional results furnished”, was also, a barefaced lie.
The Radical Prostatectomy Charade
In reality, Young’s opinion about his radical procedure and supposed benefits was an appalling hoax and, the terrible results from his perineal prostatectomy experimentation were actually an indictment against this ill-conceived operation. Moreover, any hint of concern Young had for quality-of-life of his patients after the procedure was grossly overshadowed by his grandstanding and preoccupation with the technical particulars of his radical “curative” technique. Shockingly, urologists have remained mesmerized by the illusion of radical curative surgery and locked on a quest to “perfect” this crippling operation for the past 100 years or so instead of determining scientifically whether it was safe or even effective. Although there were periods of waning enthusiasm for this debilitating surgery after some urologists questioned its benefits, so-called advances like the retropubic approach, technical modifications to control potentially life-threatening bleeding and eventually, laparoscopic and robotic assisted approaches reignited the delusion of “radical surgical cure”, and the “remarkably satisfactory functional results furnished”.
By the 1980s, Johns Hopkins had reaffirmed its position as the bully pulpit for all things prostate cancer and, many urologists were now keen to showboat surgical prowess for “radical cure” just as their general surgical colleagues who also defied scientific evidence so they could continue performing the crippling radical mastectomy, with little regard for their patients. Underscoring this insensitivity, urologists went on to “prove” their preconceived notions about the “advantages” of the radical prostatectomy through self-serving clinical trials, herd mentality and, propaganda. In fact, by resorting to the pseudo-scientific practice of consensus medicine and implying that their radical prostatectomy had attained a scientifically proven benchmark for safety and benefits, urologists transformed a baseless, traditional, surgical ideology into something deemed “standard practice”.
Even more concerning than the hoax about radical treatments being “standard practice” is the knowledge that most, if not all cancers are shedding cells into the circulation to reside in the bone marrow and lymph nodes long before the main tumor or these cells, are detectable by conventional means. Although the shed cancer cells can remain dormant for several years and, only some will activate to become metastases, this realization spotlights the falseness of most screening programs; staging categories; the concept of “localized” cancer and, “curative” radical prostatectomy.
The Radical Prostatectomy and it’s Many Complications
Because the radical prostatectomy has never been scientifically validated with evidence-based studies, it is hardly surprising that its risks and complications are probably greater than that for any other operation. Indeed, aside from rare postoperative deaths and suicidal depression, for most men the false hope and drawbacks resulting from this so-called treatment are often much worse than living with the disease itself.
Despite the charade of “remarkably satisfactory functional results furnished”, urologists clearly recognize the dangers associated with the radical (robotic) prostatectomy. Consequently, several techniques were developed to combat the potential complications associated with this surgery such as intractable bleeding, rectal injury, ureteral injury and nerve injury. Moreover, in order to get you somewhat mentally prepared for the raft of possible postoperative complications, many surgeons will direct you to preoperative counseling programs for “outcome expectations”. However, despite these preoperative therapy sessions for managing expectations and, the development of surgical techniques attempting to minimize complications, many men will still need additional surgeries after their radical prostatectomy to deal with its after-effects.
Not surprisingly, the revenue streams generated by these extra surgeries have also proven to be a cash-cow for the prostate cancer industry and, a highly lucrative prosthetic industry was spawned to supply the implantable devices used to treat the legions of men left limp and leaking after their radical “curative prostate cancer treatment”. Even more reparative surgery could be counted upon to correct the many complications associated with the failure of these implants. Failures and problems of a magnitude that most men were left with lifelong regret for having “chosen” surgery.
Because urinary leakage is common after radical prostatectomy, some surgeons will try to stem its development by adding a sling procedure at the time the prostate is removed. Postoperatively, many patients will be pushed into performing months of valueless Kegels exercises or, directed to biofeedback or, other revenue producing incontinence “rehabilitation” programs. Unfortunately, many men will still be left leaking and have to wear pads or diapers. Others will be steered towards outpatient endoscopic bulking injections to the damaged urinary sphincter, needle suspension procedures or, nerve stimulator implants to try and restore urinary control. Some men will remain totally incontinent of urine and need to apply a penile clamp or, have a prosthetic sphincter implanted in order to stay dry.
Even more depressing and, despite the hollow assurances of a “nerve sparing technique” (or rarely, incorporating nerve grafts) you will likely still be robbed of your manhood and, unlike any other surgery, the radical prostatectomy will also compromise the conjugal rights of your wife/partner. Also, similar to the various programs for urinary rehabilitation, you will be steered toward money-making strategies for “penile rehabilitation” and “sexual healing”. However, most will find that they can only stuff the penis into the vagina because surgery has weakened their natural erections. Generally also, and a bit of a mood-killer, most men will need the help of pills, urethral suppositories, vacuum devices, vibration devices and penile injections or, a combination of these treatments for some penile rigidity. For others, impotence will be total and they may elect to have a penile “stiffener” or, penile prosthesis implanted.
Additionally, not only will all men be rendered infertile after the radical prostatectomy but, if the ability for orgasm was somehow preserved, there will be altered perception of orgasm and or, even pain at climax. Besides, there will be no ejaculate as before and, some men will now ejaculate urine. Adding to this sexual distress is the issue of being left with a shortened penis, the possibility of diminished erectile girth, penile deformity and, penile curvature. It is little wonder that many men have lost their libido after the radical prostatectomy.
There are other disturbing concerns associated with this myth of “curative” radical prostate surgery. First, the USPSTF (United States Preventive Services Task Force) has already concluded that treatment harms outweigh treatment benefits and, also fails to save significant numbers of lives. Second, some 20-40% of patients will be left with positive margins after their prostatectomy or, in other words, be left with residual cancer and negating any “benefits” for “cutting it out”. Third, the radical prostatectomy typically occurs some years into the natural history of high-grade prostate cancers (from mutation to being detected and then treated) and, after already spontaneously showering cells into the circulation for several years before treatment. Fourth, the radical (robotic) prostatectomy has been shown to shower even more cancer cells into the bloodstream during surgical manipulation. Studies using PSA reverse transcriptase-polymerase chain reaction assays and other sophisticated staining techniques have documented clearly the increased dispersal of cancer cells throughout the body during handling of the prostate at surgery. Surprisingly, not only can the spread of these cells be delayed but, once dispersed they can be in circulation for several years undetectable by conventional imaging means such as MRIs or PET scans. As well, these scattered cancer cells can exist dormant in the bone marrow for several years before some of them are activated to produce a metastases.
The Gleason 6 Prostate “Cancer” LACKS the Hallmarks of a Cancer
The Gleason 3+3=6 prostate “cancer” not only fails to behave as a cancer but, by applying the cancer label, urologists have painted all prostate cancers as equal and potentially deadly and shamelessly, used the shock value of a cancer label to direct men towards unnecessary treatment.
The Gleason 6 “cancer” designation represents an interpretation and judgment based upon a low-power microscopic appearance only. However, men do not die from the Gleason 6 “cancer”; it lacks a number of molecular biology mechanisms typically found in real cancer cells; unlike the division time of typical cancer cells, the Gleason 6 has a very long cell doubling-time at 475 +/- 56 days so that from mutation to a growth of about one cm (smaller than half an inch) in diameter takes some 40 years and, it appears to be a process of aging as the prevalence of this disease gradually increases to approach that of a man’s age from about 50 years on.
Therefore, because the Gleason 6 lacks the hallmarks of a cancer, it is not a cancer health-risk, does not progress to become a cancer health-risk, needs no detection, needs no treatment and, should not even be labeled a cancer. Furthermore, those unfortunate souls who were subjected to radical treatments such as the toxic radical prostatectomy, various radiation methods, proton beam or, focal therapy using HIFU, cryo or laser for their Gleason 6 disease are simply, survivors of the treatment and not, survivors of this bogus cancer. And, by including the Gleason 6 pseudo-cancer in both prostate cancer and family history statistics, the incidence of prostate cancer has been greatly overstated.
The Prostate Cancer Detection Scam
The early detection-to-treatment agenda promoted by urologists using PSA-based screening of healthy males is a scam because it fails to detect early enough the all-important potentially lethal high-risk prostate cancers. Although these high-grade prostate cancers are more common in older men, their medical comorbidities and life expectancy can make evaluation and treatment a questionable exercise.
PSA-based screening lacks credibility for several reasons. First and foremost, the PSA (prostatic specific antigen) marker fails to meet the criteria necessary to function as an effective screening tool as it fails to detect at least 80% of the all important, potentially lethal high-grade cancers early enough for possible curative therapy as these cancers often make little or no PSA. Instead, PSA-based screening leads to the detection of mainly benign prostate and non-lethal cancers like the Gleason 6 disease. Second, the PSA limits of 0-4 ng/l for what is considered normal are highly unreliable and, lack scientific validation. As well, the PSA is non-cancer specific and, the digital rectal examination (DRE) component of this screening lineup is about as reliable as a coin-toss for detecting cancer.
Just as unreliable as everything else in this prostate cancer detection scam is the transrectal ultrasound guided needle biopsy of the prostate. Not only is the so-called standard 12-core biopsy of the prostate uncomfortable and risky but, it is blind and purely random, sampling only some 0.1-0.3% of the prostate.
Since prostate cancers commonly grow in some 5 or so different areas of the prostate that cannot be seen on the ultrasound, it is quite clear that the prostate needle biopsy is a hit or miss affair. Furthermore, it is obvious that there can be no comparison between one inaccurate, random needle biopsy and another or, attempting to compare the findings of a needle biopsy with the findings of a whole gland examination after misguided surgery. Therefore, any claims about prostate cancer progression (increased amounts of disease) or, prostate cancer upgrading (to a higher grade or, biological progression) based upon needle biopsies are speculative at best.
Aside from needle biopsy sampling errors of the prostate, there also exists the possibility of interpretive errors by pathologists for assessing Gleason grades 1-5 and, for estimating Gleason scores 6-10. Although the reliability and reproducibility of these assessments is probably less of an issue for the non-lethal Gleason 6 disease or, the potentially lethal Gleason scores 8-10, accurately identifying intermediate-risk Gleason 7 disease may be problematic.
The Gleason 7 category is confusing as it can be either a 4+3 or, a 3+4. The 4+3 portends a much greater risk than the 3+4 and, may be potentially lethal. However, the 3+4 tends to behave like the Gleason 6 but its risk can increase depending upon the amount of pattern 4 disease detected. Further help in evaluating whether the 3+4 poses increased risk can be undertaken by using the PTEN/erg biomarker stain. If there is no PTEN deletion and only small amounts of pattern 4, many with 3+4 disease can hold up on treatment and be followed with active surveillance. However, sometimes a 3+3 is misread by the pathologist as a 3+4 and this misread or grade inflation can be intentional or, unintentional and underscores the need for validation of any pathology by a recognized authority.
Since the public has become more aware that the endless claims for PSA-based screening, early Gleason 6 “cancer” detection and, radical (robotic) prostatectomy “treatment” are bogus, there has been a quantum shift towards less screening, less treatment and, much more active surveillance. However, to redirect uninformed and vulnerable men back toward unnecessary treatment, urologists have been busy using the shock value of a mostly bogus prostate cancer label and stoking angst about the possible downsides of active surveillance. By promoting overly restrictive surveillance protocols along with misrepresentations about cancer progression to imply a sense of danger and urgency, urologists have steered men towards endless unnecessary office visits, prostate exams and PSAs. In addition, they are now employing newer and often costly, biomarkers, MRIs and fusion technology simply to support the ballooning and very lucrative focal therapy industry employing cryoablation, HIFU or laser. Currently, focal therapy is unnecessary for Gleason 6 disease but may be reasonable for apparently localized, validated intermediate-risk and high-grade prostate cancer. However, as for the radical prostatectomy, there is no scientific evidence proving focal therapy of any sort to be safe or effective.
Since most, if not all of the emerging biomarkers are also not fool-proof (and commonly promoted by urologists who have a stake in the company), men can reasonably undertake their own surveillance by monitoring PSAs, PSA derivatives and PSA density. The PSA density is especially important since big prostates produce “big” PSAs and make nonsense of the so-called “normal” levels of 0-4 ng/ml for PSAs. Should these levels continue to be abnormal on repeat study over a few months or, should they trend upwards, a 3T mp-MRI of the prostate by a recognized expert in the field could be the next recommendation. Unlike the risky, random needle biopsy, the mp-MRI examines the whole of the prostate and tends to identify only the important potentially lethal high-risk prostate cancers which can then be verified with a targeted biopsy.
The mp-MRI is also recommended for active surveillance especially if PSAs begin trending abnormally to ensure that an area of high-grade disease has not been missed in the anterior or, distal apical prostate with the undependable needle biopsy. Missed high-grade disease seems to be the most common reason behind so-called 3+3 disease progression. Also, serial MRIs may be able to show whether there is evidence for significant disease progression especially for those with “light” Gleason 3+4=7 intermediate risk cancer. However, like the interpretive concerns for pathologists in assessing Gleason grades and scores, radiologists are also open to interpretive and reproducibility errors for estimating the PI-RADS 1-5 categories, disease progression and, even disease detection on MRIs so that seeking a second opinion on image interpretation is not unreasonable.
Ablin RJ and Piana R. The Great Prostate Hoax. How Big Medicine Hijacked the PSA Test and Caused a Public Health Disaster.
Influence Peddling and Murky Medical Ethics
Underscoring the character concerns of urologists for the labeling of a cancer which actually lacks the hallmarks of a cancer, has been their willingness to influence and manipulate Government oversight agencies simply to protect their highly lucrative but unreliable and risky early prostate cancer detection-to-treatment racket. After a misguided FDA (Food and Drug Administration) approval of the robotic device for gallbladder removal on the basis of some low-level clinical studies in Mexico, and despite the absence of significant benefits for the device, urologists were eventually able to step up and, through the corrupt 510(k) process, have the robotic device FDA “approved” for use in the radical prostatectomy. This underhanded achievement successfully bypassed all standard and accepted safety and benefits testing on even a single case of prostate cancer. Not surprisingly, the robot has simply added a slew of new complications to the already extensive list of concerns associated with the very troubled radical prostatectomy.
In addition to urologists achieving this bogus FDA “approved” status for the robotic device and implying it had been rigorously tested for safety and effectiveness as a treatment for prostate cancer, urologists are comfortable feigning impartiality when acting as consultant panelists for the FDA. Protected by sham disclosures, unprincipled urologists shamelessly flaunt biases and conflicts of interest simply to protect their radical prostatectomy franchise and scuttle any competing FDA applications such as happened to HIFU so urologic surgeons could pretend a denial was based upon scientific deliberation.
Using their experience gained from influencing FDA decision-making and, to protect their prostate cancer detection and surgical treatment scheme, urologists have now targeted the medical illiteracy of certain Senate Staff for a political pushback on the USPSTF and its “D” or fail, grading for PSA-based prostate cancer screening of healthy males through the self-serving USPSTF Transparency and Accountability Act. This unscrupulous maneuver serves only to coerce an agency reversal and a return to financially rewarding “approved” PSA-based screening. As if this reprehensible capitalizing on the medical ignorance of Senate Staff and using them to undermine the independence of the USPSTF was not egregious enough, urologists had the gall to demand the inclusion of one of their own (an obvious conflict) to the panel of reviewing physicians in order to make the USPSTF more “transparent”. Climaxing this embarrassment however, was for a urology representative 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 confused and vulnerable men to seek PSA-based screening and unnecessary treatment but, the brazen demand that “guidance is evidence-based” underscores once more the misrepresentations and falsehoods urologists will use to protect their radical surgery treatment philosophy when there is zero evidence-based scientific data proving the radical prostatectomy to be safe or effective.
Warnings about Prostate Cancer Screening from Regulatory Agencies
In contrast to urologists unending self-serving promotion of prostate cancer “awareness” programs simply for financial gain, numerous sources including Government agencies, have warned the public about the many dangers associated with PSA-based screening and the treatment of screen-detected prostate cancers in healthy men. In fact, the FDA’s own product safety site MAUDE (Manufacturer and User Facility Device Experience) has pages of self-reported harms, representing only about 8% of actual adverse events associated with the robotic device for radical prostatectomy because, this site seems intentionally onerous for posting data and, it appears the site may also be open to the editing of data by both the FDA and manufacturer. Also, a simple Google search for robotic prostatectomy complications will reveal scores of product-liability lawsuits against the robotic manufacturer and its surgeons.
Furthermore, urological surgeon Anthony Horan has warned the public about falling for this shameful radical prostatectomy hoax by providing a valuable insiders perspective on the many dangers associated with this “treatment” through his damning expose entitled, “The Big Scare” and subsequently a revised edition, “How to Avoid the Overdiagnosis and Overtreatment of Prostate Cancer”. In these profoundly important books, Dr. Horan makes it abundantly clear that the radical prostatectomy, borne of egos and dishonesty, is a baseless and misguided procedure. Additionally, clearly recognizing the many dangers associated with the use of their robot, the device-makers themselves have been adding to their website disclaimer page with each revision.
Complementing these many negative concerns about the radical prostatectomy has been the “D” or “fail” grading given for PSA-based prostate cancer screening of healthy males because the USPSTF identified critical evidence gaps to the supposed preventive benefits of PSA-based screening and found that its perceived advantages were clearly outweighed by its many harms and as well, the process failed to save significant numbers of lives.
Even more telling for the failings of PSA-based screening and, underscoring the trickery surrounding the standard urologist lie about “the remarkably satisfactory functional results furnished”, the women partners of these radical prostatectomy victims are painfully aware of the debilitating complications that their suffering men have had to live with, but are too embarrassed to admit.
The Radical (robotic) Prostatectomy and it’s Shameful Legacy
The public has an unqualified right to expect honesty and protection from physicians. However, for elective treatments especially, there has been a shameless opportunistic almost predatory move by some in the healthcare arena for using pseudoscience to promote self-serving agendas and economic interests.
No greater medical injustice has been served on the public than the false prostate cancer narrative concocted by urologists. A monumental travesty that promotes, a risky and highly unreliable PSA-based prostate cancer screening program that fails to detect consistently the important 15% or so of potentially lethal high-risk cancers; detects mainly non-lethal prostate diseases; labels the Gleason 6 as a cancer when the Gleason 6 lacks the hallmarks of a cancer and, market the invasive radical (robotic) prostatectomy as a treatment and life-saver when it not only lacks scientific, evidence-based validation for safety and benefits, but is in fact debilitating and fails to extend the lives of significant numbers of patients. Unfortunately, because of a profit-over-patient addiction, the same appalling concerns exist for all of the radiation, proton beam and focal therapy options being marketed as treatments by the prostate cancer industry.
Like many other scientifically unvetted but “standard” medical treatments in practice currently, financial incentives along with a gross lack of physician accountability for outcome have clearly breached the ethical standards of medicine and, betrayed the trust of patients. A trust which can only be restored by honesty, truth and, independent review of healthcare treatment outcomes for factual data. However, as all too common today, this challenge for truth is commonly answered with even more misrepresentations and exaggerations and, the early prostate cancer detection-to-treatment prescription unloaded on the public represents simply a gigantic dose of medical abuse which has caused an appalling public health disaster that leaves only, a shameful legacy.
“And I will use regimens for the benefit of the ill in accordance with my ability and my judgment, but from (what is) to their harm or injustice I will keep (them). Paragraph 4 The Hippocratic Oath
“Our medical history is filled with men (physicians) who refused, in the face of evidence, to change their course even when it was proven wrong. This type of ego-driven conviction has led medicine into its darkest corners”. Piana
Ron Piana underscored how PSA-based prostate cancer screening was a gigantic hoax in, Ablin RJ and Piana R. The Great Prostate Hoax. How Big Medicine Hijacked the PSA Test and Caused a Public Health Disaster.
Anthony Horan M.D. documented how the radical prostatectomy was an enormous scientific fraud in, The Big Scare. The Business of Prostate Cancer.
Larry Klotz M.D. along with the help of others provided irrefutable evidence that the Gleason 6 “cancer” lacked the hallmarks of a cancer and, was in fact a pseudo-cancer.
Ablin RJ, Piana R. The Great Prostate Hoax: how big medicine hijacked the PSA test and caused a public health disaster
Abramson J. Overdo$ed America
Barrett S. and Jarvis W. The Health Robbers
Blum R, Scholz M. Invasion of the Prostate Snatchers
Brawley O. How We Do Harm
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Hadler N. Worried Sick
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Klotz L. Adequate Patient Selection: active surveillance in prostate cancer. SIU Newsletter Vol 9, May 2013
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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 bladder reflex arcs, he earned the honor of a Masters of Surgery Diploma for his thesis entitled “Urinary Bladder Reinnervation” 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 to understand fully the implications of their particular prostate cancer as well as the minimally invasive treatment options available to certain men with localized, high-risk prostate cancer. Dr Vorstman owns healthcare stock. He is the grandson of acclaimed Dutch author, Amy Vorstman/Amy Groskamp-ten Have who wrote the best-seller on etiquette, “Hoe Hoort Het Eigenlijk”.