The People's Perspective on Medicine

Show 837: Prostate Cancer Puzzle

Prostate cancer screening with a PSA can be confusing. What do you need to know about detecting and treating this cancer?
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Prostate Cancer Puzzle

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One American man in every six is diagnosed with prostate cancer at some point, so it is not surprising that proposed changes to prostate cancer screening have created controversy. When the U.S. Preventive Services Task Force recommended dropping the PSA (prostate specific antigen) test as a routine measure, many urologists and their patients protested.

The Trouble with PSA Screening:

The task force had found that the test flags too many men who don’t have dangerous forms of prostate cancer. As a result of a high level of PSA, too many men have been subjected to further procedures that are not always innocuous. A confirmation of prostate cancer leads to further confusion: which cancers must be treated and how? Dr. Aaron Katz clarifies the prostate cancer conundrum.

This Week’s Guest:

Aaron E. Katz, MD, is the Director for the Center of Holistic Urology and an Associate Professor of Clinical Urology at Columbia University, where he has been a faculty member since 1993. He is the author of The Definitive Guide to Prostate Cancer: Everything You Need to Know about Conventional and Integrative Therapies.

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About the Author
Terry Graedon, PhD, is a medical anthropologist and co-host of The People’s Pharmacy radio show, co-author of The People’s Pharmacy syndicated newspaper columns and numerous books, and co-founder of The People’s Pharmacy website. Terry taught in the Duke University School of Nursing and was an adjunct assistant professor in the Department of Anthropology. She is a Fellow of the Society of Applied Anthropology. Terry is one of the country's leading authorities on the science behind folk remedies. .
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This was a terrific show! My brother just got diagnosed with prostate cancer and there is so much confusion out there!

I found Dr. Katz’s comments about Prostate Cancer & testing very interesting. After examinations by my then Internist & my Urologist, it was determined that I had a very enlarged prostate. This was in 2004. My Urologist tested my PSA. It was 56. I was 74 years old. Even with the 56 PSA, my Urologist thought I might have Prostatitis, & he had me take a strong antibiotic. After 2 weeks of taking the antibiotic, tested my PSA. It fell 10 points to 46. He then had me stop taking the antibiotic.
After about 2 weeks he again tested my PSA. It jumped back to 56. The prostate was still very enlarged. He then told me that he thought it best that he do a Biopsy, It was done (under anesthesia) in the Surgery of the large hospital next to his office. He took 30 samples. This was done on Wednesday, 3 days later on Saturday morning, my Urologist phoned me & told me the Pathologist’s report showed that it is positive: it is Prostate Cancer & that it was advanced & aggressive.
He scheduled an appointment for my wife & I to discuss choices of treatment. At the appointment he said as a surgeon he would make more money by surgically removing the prostate. But he said the operation was very bloody, took 4 to 5 hours & was very traumatic. Since I was 74 years old instead of surgery he recommended Radiation & hormonal treatment which I agreed to.
I preferred to be treated at the hospital that was closer to our home. He started me with an an anti-testosterone: Casodex. Hr gave me an Rx to have a scan done to determine if the cancer had escaped the prostate capsule which I had done at the hospital near our home a couple of days later (on Friday.) After the scan was completed I phoned hospital’s division to see if my wife & I could speak to the Radiation Oncologist that would be taking care of me. Luckily he had some spare time & we went over to talk to him. He was very pleasant.
He said that since the scan was just done, & I’d have to wait over the weekend for the results, he would walk over & take a look at the films. When he came back he told us that the cancer had not escaped the capsule. He was going on vacation for about a week. I scheduled an appointment with him. At that time he set up my radiation treatment: High Beam External Radiation with IMRT, 40 doses, over 8 weeks. During this treatment my Urologist gave me the first injection of Zoladex.
After the completion of the 40 radiation, my Urologist tested my PSA. It fell dramatically to 0.5. He continued with the Zoladex injections every 3 months. About 6 months after the completion of the radiation treatment I had severe chest pains. My Internist checked me out & made an emergency appointment with a Cardiologist in the neighborhood. He checked me out & scheduled me for a Cardiac Catheterization. This showed that my arteries were clear except for a 40% percent blockage in the main artery in my heart & a problem with a valve. He scheduled me for various tests every 3 months & prescribed a few medications & supplements & healthy diet.
A colonoscopy showed that I had been severely burned in 3 places by the radiation. I had been bleeding severely. A Gastroenterologist at Cleveland Clinic In Weston, FL gave me 2 treatments. One was pouring Formalin into my rectum. That reduced the bleeding for about a month. He then used APC: Argon Laser Plasma Coagulation. This pretty much did the trick for about 98% of the time to stop the bleeding.
My Urologist at my appointment with him for PSA, DRE & Zoladex injection told me that my Radiation Oncologist had recommended that he continue giving the Zoladex injections for another year, but he saw that I had such severe side effects that since my PSA was low, with my permission he’d would stop the Zoladex injections & carefully do check-ups every 3 months, PSA, DRE & Urinalysis. So far this is working.
He does check-ups every 6 months, including PSA (last PSA was 0.56). I did have to have a Pacemaker put in about a year ago, since my pulse was 30. Considering all, I’m doing OK. It would be smart for men to go to support group meetings such as UsToo as I do. There is a meeting this Wednesday, 1/11/2012 at 4:45pm at the Jupiter Medical Center Cancer Research Building in Jupiter,FL.

Refreshingly intelligent and informative. No proselytizing. Unfortunately the podcast didn’t start at the beginning. I got about 14 minutes form “extra questions”. Is there any way to recover that?

Dear Sir: If only my husband had had the wisdom to pursue a similar path. As an engineer working into his seventies, he was not as patient and persistent as you were, and took some bad advice to “just zap” his very slow-growing and contained tumor with a very low Gleason score. Unfortunately for him, at one of the radiation sessions, the machine malfunctioned and he bled to death several months later from what was diagnosed as radiation proctitis, in other words, he bled to death from a hole in his rectum caused by over-radiation.
This was under the auspices of Cleveland Clinic! It behooves me to note that nowhere in the literature on treatment risks is the risk of death from over-radiation even mentioned, and he never even became a failure statistic.

I believe that this statement from Roswell Park Cancer Institute summarizes the studies that support the use of PSA screening very nicely:
“If PSA is used intelligently for early detection of prostate cancer and intelligent decisions are made regarding treatment of prostate cancer, deaths from prostate cancer in America should continue to decrease. Population-based studies performed in Goteborg, Sweden and Tyrol, Austria demonstrated declines in prostate cancer mortality of 40% and 54%, respectively.”
As for your comments, regarding the financial incentives that doctors may have to continue to do these tests and procedures, I would say that such conflicts exist for all doctors, in all specialties. Were one or two of these doctors to argue, without the support of their peers, for the continued use of a test, I would agree that greed was a likely factor.
However, when the preponderance of urologists, and cancer specialists, argue in favor of PSA screening, I have to surmise that this recommendation is based upon their experience, and what they deem to be in the best interests of their patients. To do otherwise would be to conclude that all of these doctors are motivated, above all else, by greed, and this I cannot accept.

Twenty years ago when I was about 45 (well before the ACS or U.S. Preventive Services Task Force recommendations), my family physician advised me that the PSA was not effective because it had not been shown to have any significant effect on mortality. It was known to produce great anxiety and almost demands lifetime follow up and recurrent anxiety.
Subsequent testing (i.e., prostate biopsy) is also not definitive (false positives & false negatives) and the procedure itself can produce severe side effects (infection, urinary complications). My personal view is that when the biopsy coring needle passes through the prostate it will violently puncture any cancerous growth it encounters and thus spread previously confined cancerous cells beyond the initial capsule. This is in addition to the possibility of bacterial infection from the biopsy. Treatment of prostate cancer (surgery, radiation, hormone therapy, many others) does not guarantee a cure and can lead to impotence, urinary problems, infection, bleeding, etc). I decided not to have the PSA test.
People’s Pharmacy hosts tried their best to have Dr. Katz address the fundamental methods and conclusions of the U.S. Preventive Services Task Force recommendation against routine PSA testing but he seemed to always return to his own personal experience that the PSA test “saves lives”. Personal experience is a wonderful thing but it’s impossible for Dr. Katz or any other physician to make such claims for the simple reason that he cannot know the outcome in the absence of the PSA test (which, by his own philosophy, he almost always recommends). In fact, very few men die of prostate cancer, PSA test or not. More often than not they die with the disease itself in a more or less benign state.
I believe that the U.S. Preventive Services Task Force recommendation is based on a large number of epidemiological studies which examined the mortality and cause of death of thousands of men. Some groups never had the PSA test. Others had the testing but did not act on the results and other groups had the testing and took action (biopsy & treatment). The results showed no significant differences in death from prostate cancer which could be attributed to the PSA test. Someone noted that prostate cancer deaths have dropped during the historical period after the advent of PSA testing. However, this could be just a correlation and not a cause and effect relationship.
Patients must keep in mind that the urological community, Dr. Katz included, and many other parts of the health care system (hospitals, medical testing companies, etc) have an enormous financial incentive to continue the PSA test along with every medical procedure and test which follows. I believe, for example, that most urologists perform the prostate biopsy, a bread and butter procedure, in their own offices. They also have the negative incentive from law suits which some patients may file if the doctor does not perform the test and cancer develops. I am personally very skeptical of the recommendations of any called “expert” when they have a financial stake in the outcome.
I think that the People’s Pharmacy should revisit this important topic by interviewing one of the lead researchers involved with the U.S. Preventive Services Task Force recommendations so that listeners will have a balanced look at this critical subject. Cancer “screening” such as the PSA and mammograms are assumed by most Americans to be nearly infallible and thus always desirable. Careful analysis of real data is revealing that these assumptions are far from proven and that the testing and subsequent treatment may indeed cause more harm than good. Counter-intuitive to be sure but this kind of thing has happened before.

This was a terrific show! My brother just got diagnosed with prostate cancer and there is so much confusion out there! Dr. Katz is a breath of fresh air and is a wealth of knowledge, congratulations on a terrific interview and I will be sure to pass this on to my brother, can’t thank you guys enough!!!

Does Zyflamend also help chronic inflammation with lymphoma? My brother-in-law keeps a low-grade fever and has a disturbing swelling around his eye–both above and below, connected with his lymphoma. He is currently receiving low doses of chemo in an attempt to deal with this swelling.

Hopefully, there will soon be a biomarker with much higher specificity than the PSA test. Although the PCA3 urine test has not yet been approved by the FDA, it is available for use (as indicated by Dr. Katz) in the United States, and it is another useful biomarker for making decisions regarding a possible prostate biopsy. The PCA3 test can be repeated every three to six months; and in the absence of prostate cancer, the PCA3 score will remain virtually unchanged, unlike the PSA test, which may be affected by a number of non-cancerous conditions.
The USPSTF states that “[u]nfortunately, the evidence now shows that the [PSA} test does not save men’s lives, nor can this test tell the difference between cancers that will and will not affect a man during his natural lifetime.” We need to find one that does, and research by Dr. Arul Chinnaiyan of the University of Michigan and Drs. Alan Partin, William Isaacs, Marion Bussemakers, and Jack Schalken of the Brady Urological Institute at Johns Hopkins may be pointing in the right direction .

Zyflamend is an amalgam comprised of 10 different herbal extracts (rosemary, turmeric, ginger, holy basil, green tea, hu zhang, Chinese goldthread, barberry, oregano, and Scutellaria baicalensis) and was originally chosen based upon their purported anti-inflammatory effects. Recent observations from a variety of both basic and clinical researchers suggest that inflammation and cancer may be intimately related.
Our studies have demonstrated that this preparation does, indeed, inhibit major enzymes involved in initiating an inflammatory response (COX-1 and COX-2). We have also shown that Zyflamend inhibits prostate tumor cell growth and induces cell death by a process known as apoptosis.
To understand the mechanisms through which Zyflamend is acting to suppress prostate cancer cells, we have continued our studies and have identified several key molecules in which Zyflamend appears to be acting upon.


The only direct cost of the PSA is the $30 fee for the blood test, which is comparable to a flu shot. A good investment, in my book.
As for the “hazardous treatment of 15 or 40 men”, that is the result of the therapies chosen, and not the PSA. If this argues for anything, it is that doctors and patients need to better understand the risks of the various treatments for this disease, versus the likelihood that a patient will die from it.
It does not argue against the use of the PSA. It is this misdirected recommendation that has led to so much controversy, and so much unnecessary confusion.
A better recommendation would have been for greater availability of “active surveillance” programs, and to encourage doctors to advise these for patients, when indicated.

I very much appreciate the People’s Pharmacy devoting a full show to this topic. There has been a lot of confusion since the recommendation of the Task Force, with regard to regular PSA screening, was released.
Most of this confusion has been the fault of that same Task Force. This group studied the way that men, and their doctors, respond to a diagnosis of prostate cancer, and they found that the treatment is sometimes more aggressive than the particular cancer indicates. Their solution was to recommend against routine PSA screening.
Dr. Katz correctly points out that this is the major failing of that Task Force. They should have addressed the issue at hand, which is the over treatment of the disease. Instead, they decided to recommend that men not be tested for the disease. In effect, they would rob men of the knowledge that they have cancer, since many of these men would make the “wrong” decision, concerning treatment.
If there is fault in the overly aggressive nature of the treatment of prostate cancer, this lies with doctors, and not with the PSA test. It is on this that the Task Force should have focused.
Please note that I do NOT fault the men for choosing aggressive therapies. If a man understands the benefits, and risks, of the treatment options, who are we, or the Task Force, to tell him that he is wrong?
At age 55, my mother was diagnosed with cancer in her left breast. The doctors, as well as her friends and family, advised that the lump be removed, and that she undergo chemo-therapy. Instead, she chose to have her entire breast removed, and to take Tamoxifen.
Was she “wrong” to do so? Is this an argument to ban mammography? Hardly. It was her body, and it was her choice. She had a right to know that she had cancer, and the right to choose her treatment.
These same rights apply to men.

Dr Katz talked about a product that helped with inflammation . Can you tell what that was called again?

Is this evidence based medicine or catering to the public clamor for solutions?
I don’t recall Dr. Katz ever referring to any study to support his assertions. It was just “I think, I think” all the way through thew interview.
People understandably want to believe there is a solution to every threat to our health and longevity. Having been told that the medical profession has answers to the threat of prostate cancer, we are now outraged to be told that we were misinformed.
And the professionals, who have been profiting handsomely from providing these non-evidence based solutions, are happy to feed our addiction to wishful thinking.
Often the Graedons divide the program between guests, when they present a program about which there is controversy, so I kept expecting to hear the evidence based side of this issue, but it never came. I suspect they have felt, and knuckled under to the public clamor to ignore the evidence and reach for feel good answers.
As Norton Hadler points out in his book “Worried Sick,” as long as we persist in dumping billions of dollars into expensive non-evidence based solutions, we will continue to have a very expensive health care system that leaves many out.

I hit the wrong stars for the show with Dr Katz….I meant to hit
5 stars. Very informative now to get my husband to listen.
Than you.

Above it states that prostate cancer deaths have not declined, which frankly if absolutely false. It has fallen by more than 30% in the PSA-era and is easily documentable but multiple sources.

My prostate surgery is scheduled for Dec 8th. Gleason 9. Have been reading and hearing about radiation therapy after the surgery as a precautionary measure. Dr. Patrick Walsh, in A Guide to Surviving Prostate Cancer, argues that the data show that radiation after prostate removal is both unwise and unnecessary — even when there are indicators that traces of cancer have escaped the prostate. Do Dr. Katz and others agree?

Fabulous show. We give it the highest rating. What was the name of the medication for reducing inflammation — It began with an “f”. Thanks
People’s Pharmacy response: It is Zyflamend, from New Chapter.

Dr. Katz gives a specialist’s view of prostate cancer. The good doctor reflects his training and comfort level with the subject. A policy decision for all men however should not be based on Dr. Katz’s concerns with 3% of men. The small number may benefit through somewhat longer life but death from the cancer in most cases is only delayed.
The cost, in Dr. Katz’s words, is unneeded and hazardous treatment of “15 or 40 men” but that number in reality could be even in the hundreds. Since the death rate from prostate cancer has not declined, we really do need a better test as Dr. Katz stated. In my view, we need to stop using our present ineffective and costly screening and treatment paradigm. We tried and failed to help mankind with the PSA test.
Genetics seems to play the biggest part in prostate cancer outcome. Research by scientists with “hearts of stone,” per Darwin, is needed to determine differences in this disease which has so far only one name.
Prevention strategy needs research free of corporate, moneyed influence for a change, but with only 3% of men dying from this disease, the studies are not easy.

I am a strong advocate for continuing the PSA test, and this post is for men diagnosed with low risk prostate cancer (PCA).
I began annual PSA tesing at age 50, and by age 55 my PSA level had increased from about 1 to just under 4. I was urged by my Primary Care physician to have a biopsy, which revealed evidence of PCA in 5% of 1 of 12 cores.
I chose to visit two specialists: a highly regarded urologist who was experienced with DaVinci prostatectomy and, on the same day, another who was a prostate specialist.
I was convinced by the specialist, who recommended Active Surveillance. He advised me to adopt a Mediterranean based diet and recommended high Vit D (up to 10,000 units/day), and several anti inflammatory supplements including resveratrol, biocurcumin, lycopene, soy isoflavones, pomegranate, and fish oil. He also strongly recommended I avoid processed and ‘fast’ foods in general and that I continue physical exercise.
He also recommended annual color Doppler ultrasound to image the tumor and for the first year, a monthly PSA tests.
Within 3 months my PSA dropped and in a year (at my next visit) my tumor had decreased 20% in volume. I now check my PSA at three month intervals and have a very thorough physical exam and ultrasound each year.
Curiously, I have shared my experience with several other men whose situation parallels my own but all have chosen more aggressive therapy including prostatectomy and radiotherapy. Each has said that they weren’t willing to ‘just wait and see’ or that they couldn’t live with the knowledge that they have cancer if there was something they could do about it.
I agree that so-called ‘watchful waiting,’ the strategy that simply monitors for signs of advance, makes no sense. But, for men with ‘low risk’ PCA, pursuing Active Surveillance has at least three major advantages over more aggressive treatment.
1. Active surveillance means the patient assumes control over his treatment by monitoring the cancer and by changing lifestyle. These changes – healthy diet, control of inflammatory influences, and exercise, have the added benefit of increasing the overall level of fitness and combating nearly all other diseases and conditions associated with aging. My specialist strongly recommends that all of his patients-including those with advanced or recurrent disease, also adopt the above changes.
2. You get to keep your body parts with their functions intact. All aggressive treatments carry significant risk of unpleasant side effects, especially incontinence and impotence.
3. If, despite your best efforts the cancer advances, you can always opt for the aggressive treatment.
So, if you are diagnosed with PCA, don’t panic. Get a second opinion, both for treatment and diagnosis. The pathology on my report was initially rated a Gleason 7 (3+4) but the second lab ‘downgraded’ it to a 6 (3+3). The recommended treatment also differed radically; one specialist ready to remove my prostate without consideration of alternatives and the other suggested Active Surveillance.
And finally, be prepared to battle your insurance company. My insurance would have covered the entire procedure and followup were I to undergo the ~$40K radical prostatectomy but only covered a fraction of the Specialist and ongoing Active Surveillance because the specialist is “out of network” and the supplements non-prescription.

Hi, My father died of prostate cancer with psa’s moving from mid 700’s to mid 800’s. There exists a curve, a plot of prostate problems verses age. That plot goes horizontal till males reach the age of 65 years old; then it changes to an almost vertical slope. This says that something is no longer being produced by the body to protect the prostate from problems. No medical professional to date has ever been able to tell me what happens and what’s no longer being produced that affects the prostate so severely. Do any of your experts know? If they don’t, get some post doc’s working to try to figure this out. Thank you. Paul C. G.

I’m a 55 year old male. My father had prostate cancer at age 69, which was treated with a radical prostatectomy. He survived 14 years, and his death was not cancer-related. I have been considering having a vasectomy, but I heard that it increases the probability of prostate cancer. Is there any truth to this?

What risks are associated with prostate biopsies?
People’s Pharmacy response: Infection, primarily

i always enjoy your show. It is my wake up call on saturday.
What is the defintion of Prostate, Prostate Cancer, and the signs of the problems ? I am 55 years

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