In view of the recent hooraw over whether or not testing for and treating prostate cancer saves lives, I feel I should re-visit this subject, which I first discussed in my blog of May 15, 2009. I want to begin by emphasizing once again, speaking as a trained scientist, that in any given field what counts is what we can show to be true by experiment, and not what we can deduce or think should be true (with Einstein's Theory of General Relativity being a notable exception, but even that theory was based upon an experimental result, namely the equivalence of inertial and gravitational mess, as first shown by Galileo). It also doesn't matter what we would like to be true, because Mother Nature's rules are independent of our beliefs.
Some of the examples of medical facts and treatments that we thought should be true or benefit patients but were shown to be false or harmful or not proven when subjected to clinical testing are:
1) If a patient has calcium oxalate kidney stones then the proper treatment is toDEcrease the amount of calcium in the diet.
2) Beta-blockers should never be used in a patient who is in heart failure.
3) Everyone needs 8 glasses of water or fluid a day for good health.
4) Everyone needs at least one bowel movement a day.
5) If a patient is ill, bleeding with leeches will generally make him/her better.
6) An hour of sleep before midnight is worth two hours after.
7) If you go swimming right after eating you will develop an abdominal cramp and drown.
8) Vitamin E, because of its anti-oxidant properties, prevents heart attacks.
9) Beta-carotene, because of its anti-oxidant properties, protects smokers from lung cancer.
10) Mammograms taken between the ages of 40 and 50 saves lives.
11) The optimum time interval between complete physical exams is one year.
12) The optimum time interval between colonoscopies is 10 years.
13) The optimum time interval between mammograms is one year.
14) A drink of alcohol a day cannot possibly be good for you.
15) Daily doses of saw palmetto help treat an enlarged prostsate.
16) Daily doses of gingko balboa help prevent Alzheimer's Disease.
I could easily add another 10 to 20 pseudofacts to the above list. Now let us look at the question of PSA testing as well as the treatment of prostate cancer. Before asking whether or not measuring the PSA saves lives, we first have to determine if treating prostate cancer saves lives. As of today, there is absolutely no evidence that it does. It may seem counterintuitive that this is so, but the fact is that the majority of men die WITH prostate cancer, and not OF prostate cancer. Roughly speaking, the percentage of men who have prostate cancer at autopsy is equal to their age at death: 70% of men at age 70 have microfoci of prostate cancer, etc. Much as we would like to believe that detecting prostate cancer early and treating it will save lives, there is absolutely no evidence that this is so.
There have been many review articles coming to this conclusion, and you can check PubMed, the abstract archive of the National Institutes of Health for references. So why do people do the PSA, or take treatment if a prostate biopsy shows prostate cancer? The answers are many and varied, and all are ultimately the result of individual decisions by individual patients. Some of the reasons are:
1) Some people cannot tolerate the thought of having cancer within their bodies.
2) Some wives cannot tolerate the thought that their husband is walking around with cancer.
3) Some men believe that treatment of prostate cancer will save their lives.
Very few men are told that most prostate cancers detected on biopsy will not spread and kill them. Very few men are told of the possible lingering (6 months to 2 years) or permanent symptoms of radiation proctitis that can result (chronic bloody or non-bloody diarrhea). Many men don't fully understand the implications of the fact that 30% of treated men will develop urinary incontinence (and need to wear a diaper) or be unable to mount or maintain and erection (even with the help of Viagra), or both.
Since a physician's first duty to his/her patient is to "do no harm", I lay out all the above info to my patients, and if asked, I tell them that I never have taken a PSA test and would never treat prostate cancer in myself. However, if a patient decides on treatment, I urge him to consult with both a urologic surgeon and a radiation oncologist to listen to the pros and cons of each procedure, and then to consult with a medical oncologist for an overall view. I also suggest that he not discuss his decision with any friends who have been treated in order to avoid impassioned but not dispassionate arguments and lectures. And then I remind him that it is his body, that he is the patient and must make the final decision, and not to do any treatment or non-treatment that he does not fully agree with.
Showing posts with label prostate cancer. Show all posts
Showing posts with label prostate cancer. Show all posts
Tuesday, October 11, 2011
Saturday, December 18, 2010
Robotic Surgery
There has been a flood of people requesting robotic surgery, especially men with prostate cancer, and I fear that they are not aware of all the pertinent facts. These men seem to think that robotic surgery is superior (i.e. more curative), and therefore have greater disappointment when the cancer returns. I have certain biases against robotic surgery, both medical and economic, and I would like to explain these to you, with reference to both general (open) and laparoscopic ("mini") surgery.
First some background, and an explanation of what robotic surgery really entails. The first surgery, of course, was "regular" surgery, which left a long scar because the surgeon needs adequate exposure to visualize the surgical field and its surroundings, and thereby minimize the chance of transecting the common bile duct during gall bladder surgery, etc. The need for adequate field of view was drilled into the heads of all surgical residents. The result for cholecystectomies was usually a long (8 to 12 inch) scar under and parallel to the lowest right rib, and a 10 day recovery period in the hospital. The surgery was almost always done after a severe gallbladder attack, with the idea of preventing a second severe attack and possible ascending cholangitis.
Laparoscopic surgery typically involves only four small incisions in the abdomen, each no longer than an inch. Lights and a TV camera are inserted, and the surgeon then directly manipulates his/her instruments to remove the gall bladder. They have gotten so skilled at this that last year a surgeon removed a gall bladder through the superior vaginal wall (!), leaving no abdominal scar whatsoever. In addition, because of minimal incisional tissue damage, the time in the hospital after a laparoscopic cholecystectomy was reduced from ten to three days, and now it may be as little as two. Therefore there is less trauma and faster healing than under the old method, and it was thought that with fewer days in the hospital, the nationwide annual cost of cholecystectomies would decrease. Unfortunately, as shown by an article in NEJM 10-15 years ago, this was not the case. The surgery was so "easy" that satisfied patients informed their friends, and more and more patients with asymptomatic gall stones elected to have the laparoscopic cholecystectomy. The overall result was that the annual total cost of gall bladder surgery increased in the United States.
Now we come to robotic surgery. It is essential to remember that the FDA does NOT have to clear or approve of any new surgical technique, unless a medical device (artificial hip, heart valve) is implanted. If I wanted to drill a hole in your head to let the "evil humors" escape,, and you were agreeable, then it is a go.
If I wanted to remove your gall bladder through an endoscope, it is also a go. In robotic surgery, several things are true that are not true for laparoscopic surgery:
(1) There is an extra $3,000 added to the cost of the surgery,---$1500 for the instruments that have to be disposed, and $1500 to amortize the cost of the equipment. Whether or not Medicare or your HMNO will pay the extra expense is a separate question.
(2) There is no direct tactile feel by the surgeon on your organs. Even with laparoscopic surgery, the instruments are directly moved by his hands, and he can feel resistance, texture, etc. But in robotic surgery, he types in commands to a computer console, and the computer then moves the instruments. It is true that the computer has finer motions than human hands, but it has no "feel", and the patient also has to hope that the program was properly entered, not like the CT scans of the brain or the gamma-ray vs. electron beam treatment of tumors where the wrong button was pushed or the wrong program entered, and the patient's tissues were fried. So the robotic surgeon is deprived of tactile feedback.
(3) Most important of all: There is a sharp learning curve in robotic surgery, precisely because of the lack of tactile feedback. It has been estimated that it takes between 50 to 100 robotic operations on the prostate for the surgeon to become proficient enough so that the results and the time of robotic surgery equals that of non-robotic surgery. Skin-to-skin prostate surgery takes 2 to 2.5 hours, and the first time a surgeon uses the robot it can take 4.5 to 5.0 hours, and the depressive effect of anesthesia on your heart and lungs increases after 2.5 hours. Therefore, the first question you should ask any surgeon who wants to to robotic prostate or heart valve or any other critical surgery on you is : HOW MANY OF THESE ROBOTIC OPERATIONS HAVE YOU DONE? If the answer is fewer than 50, I, for one, would not let him/her touch me. It makes you wonder: Who "volunteered" to be the surgeon's first robotic surgery patient, and did the patient know that he/she was the first? Did the surgeon tell the patient?
First some background, and an explanation of what robotic surgery really entails. The first surgery, of course, was "regular" surgery, which left a long scar because the surgeon needs adequate exposure to visualize the surgical field and its surroundings, and thereby minimize the chance of transecting the common bile duct during gall bladder surgery, etc. The need for adequate field of view was drilled into the heads of all surgical residents. The result for cholecystectomies was usually a long (8 to 12 inch) scar under and parallel to the lowest right rib, and a 10 day recovery period in the hospital. The surgery was almost always done after a severe gallbladder attack, with the idea of preventing a second severe attack and possible ascending cholangitis.
Laparoscopic surgery typically involves only four small incisions in the abdomen, each no longer than an inch. Lights and a TV camera are inserted, and the surgeon then directly manipulates his/her instruments to remove the gall bladder. They have gotten so skilled at this that last year a surgeon removed a gall bladder through the superior vaginal wall (!), leaving no abdominal scar whatsoever. In addition, because of minimal incisional tissue damage, the time in the hospital after a laparoscopic cholecystectomy was reduced from ten to three days, and now it may be as little as two. Therefore there is less trauma and faster healing than under the old method, and it was thought that with fewer days in the hospital, the nationwide annual cost of cholecystectomies would decrease. Unfortunately, as shown by an article in NEJM 10-15 years ago, this was not the case. The surgery was so "easy" that satisfied patients informed their friends, and more and more patients with asymptomatic gall stones elected to have the laparoscopic cholecystectomy. The overall result was that the annual total cost of gall bladder surgery increased in the United States.
Now we come to robotic surgery. It is essential to remember that the FDA does NOT have to clear or approve of any new surgical technique, unless a medical device (artificial hip, heart valve) is implanted. If I wanted to drill a hole in your head to let the "evil humors" escape,, and you were agreeable, then it is a go.
If I wanted to remove your gall bladder through an endoscope, it is also a go. In robotic surgery, several things are true that are not true for laparoscopic surgery:
(1) There is an extra $3,000 added to the cost of the surgery,---$1500 for the instruments that have to be disposed, and $1500 to amortize the cost of the equipment. Whether or not Medicare or your HMNO will pay the extra expense is a separate question.
(2) There is no direct tactile feel by the surgeon on your organs. Even with laparoscopic surgery, the instruments are directly moved by his hands, and he can feel resistance, texture, etc. But in robotic surgery, he types in commands to a computer console, and the computer then moves the instruments. It is true that the computer has finer motions than human hands, but it has no "feel", and the patient also has to hope that the program was properly entered, not like the CT scans of the brain or the gamma-ray vs. electron beam treatment of tumors where the wrong button was pushed or the wrong program entered, and the patient's tissues were fried. So the robotic surgeon is deprived of tactile feedback.
(3) Most important of all: There is a sharp learning curve in robotic surgery, precisely because of the lack of tactile feedback. It has been estimated that it takes between 50 to 100 robotic operations on the prostate for the surgeon to become proficient enough so that the results and the time of robotic surgery equals that of non-robotic surgery. Skin-to-skin prostate surgery takes 2 to 2.5 hours, and the first time a surgeon uses the robot it can take 4.5 to 5.0 hours, and the depressive effect of anesthesia on your heart and lungs increases after 2.5 hours. Therefore, the first question you should ask any surgeon who wants to to robotic prostate or heart valve or any other critical surgery on you is : HOW MANY OF THESE ROBOTIC OPERATIONS HAVE YOU DONE? If the answer is fewer than 50, I, for one, would not let him/her touch me. It makes you wonder: Who "volunteered" to be the surgeon's first robotic surgery patient, and did the patient know that he/she was the first? Did the surgeon tell the patient?
Monday, March 8, 2010
Prostate, Prostate CA, BPH, and economics
There has been much written in the news lately about the prostate: prostate cancer, new guidelines for Dx. and Rx., robotic prostate surgery, and a recent article in Archives of Internal Medicine (vol 170, #5, 3/8/10, pp 451-452)by Dr. M. Barry.
Just as an aside, "regular" prostate surgery is generally done in less than 2 hours, and robotic surgery generally takes longer than 3 hours. If you undergo more than 2.5 hours Operating room time,the risk of complications rises sharply.
What it all boils down to is that THERE IS NO INCONTROVERTIBLE EVIDENCE THAT TREATING PROSTATE CANCER SAVES LIVES.This does not mean that every male with prostate cancer will die from the cancer, but only that no treatment has been shown to cure it. The only study that has not been done is to do quadrant biopsies on all males annually, beginning at age 40, and treating all cancers with a Gleason score of 3 or less. Once prostate cancer is diagnosed (prompted by a rectal exam or an elevated PSA) surveys have shown that your family doctor will often recommend watchful waiting, your urologist will most likely recommend surgery, and a radiation oncologist will most likely recommend radiation. Since there is no evidence that treatment saves lives, it is difficult to justify an annual PSA test, unless the patient agrees to treatment. And, based upon my office experience, his wife will never agree to watchful waiting, so send the lab results to his office.
Once the CA is treated, many men have a few months of urinary incontinence, and/or erectile dysfunction. This may last for 2 years, or be permanent. If the ED seems to be permanent, the most satisfying treatment seems to be to transplant the 12th rib to the center of the penis, so that the "erection" is permanent.
Since the prostate grows without limit, all men will eventually have symptoms of BPH, evidenced by having to get up at night to urinate, or reduction in urinary stream force,etc. The prescribed treatment is with selective alpha-blockers, and/or reductase inhibitors (Proscar, etc.)The newest selective alpha-blocker, which has the least effect on the ciliary artery and therefore is the safest vis-a-vis future cataract surgery, is Rapaflo, (silodosin) 4mg or 8mg at bedtime. Only the combination of a reductase inhibitor plus an alpha-blocker has been shown to reduce the future need for a TURP to open up the prostatic urethra. However, since the old TURP involved inserting a rotatable knife thru the penis and up to the prostate, much like a Roto-rooter operation, and the procedure is now relatively bloodless and pain-free when done with the "green light" laser, not all men opt for the two drugs, especially since Proscar and its relatives diminish the amount of seminal fluid that is ejaculated. One should also remember that alpha blockers can increase the amount of retrograde ejaculation, i.e. backwards into the bladder, rather than forward and out of the urethra.
As for economics, why do you think surgeons recommend surgery and radiators recommend radiation? This leads into the larger question of economics. It is somewhat paradoxical that in today's times, microeconomics would suggest that you save your money, while macroeconomics wants you to help America spend its way out of the recession.
As a former mathematical and experimental physicist, I have looked into the mathematics, models and predictions of all branches of economics, and they all have the same fallacy: They assume that humans are always rational, and never panic sell or binge buy. This is clearly not the case (cf. "The Madness of Crowds"), but since arbitrary,"irrational" behavior cannot be mathematically modeled, calculated or predicted, it is excluded from ALL economic mathematics and their models. When the Black-Scholes "Theorem" was used to model the portfolio of Long Term Capital Funding, it was implicit in their model that no major country would fail to support its own currency. No allowance was made for this occurrence because (a) its happening was abrupt and unpredictable, and (b) the results depended on which country forfeited its currency. Therefore, when Russia defaulted on the ruble, LTCF would have gone bankrupt to the tune of $4B, but the U.S. Gov't bailed them out.
I won't even go into the required nonlinearity of any market model,that is caused by feedback. What we are dealing with here is the drunkard looking under the lamppost for his lost auto keys because the light is better there, rather than in the dark up the block where he actually dropped them. (And no, I lost no money in the market plunge.) People feel more comfortable with a "prediction" created by mathematics, even though GIGO is operating on a huge scale. Now in physics, if the result of an experiment differs from that predicted by our model of the world, we change our model. But economists cannot change their models, because catastrophe theory is too difficult to be mathematically tractable enough to use for predictions (see Rene Thom's work on this problem).
There are and seemingly will always be market crashes, because it is impossible to predict their occurrence or their nature (?something similar to earthquake prediction). No matter what the model, it basically assumes that the past can be used to model the future. How a tulip bulb crash can model Penn Central or the crash of 1873 is not clear to me. It is the question of predicting individual economic behavior vs. mass economic behavior. We have the same problem in medicine. I have no problem recommending that 1,000,000 women have annual mammograms beginning at age ??, but I have 25 female patients over the age of 85 who have never had mammograms or breast cancer, and so far they are right, too.
Just as an aside, "regular" prostate surgery is generally done in less than 2 hours, and robotic surgery generally takes longer than 3 hours. If you undergo more than 2.5 hours Operating room time,the risk of complications rises sharply.
What it all boils down to is that THERE IS NO INCONTROVERTIBLE EVIDENCE THAT TREATING PROSTATE CANCER SAVES LIVES.This does not mean that every male with prostate cancer will die from the cancer, but only that no treatment has been shown to cure it. The only study that has not been done is to do quadrant biopsies on all males annually, beginning at age 40, and treating all cancers with a Gleason score of 3 or less. Once prostate cancer is diagnosed (prompted by a rectal exam or an elevated PSA) surveys have shown that your family doctor will often recommend watchful waiting, your urologist will most likely recommend surgery, and a radiation oncologist will most likely recommend radiation. Since there is no evidence that treatment saves lives, it is difficult to justify an annual PSA test, unless the patient agrees to treatment. And, based upon my office experience, his wife will never agree to watchful waiting, so send the lab results to his office.
Once the CA is treated, many men have a few months of urinary incontinence, and/or erectile dysfunction. This may last for 2 years, or be permanent. If the ED seems to be permanent, the most satisfying treatment seems to be to transplant the 12th rib to the center of the penis, so that the "erection" is permanent.
Since the prostate grows without limit, all men will eventually have symptoms of BPH, evidenced by having to get up at night to urinate, or reduction in urinary stream force,etc. The prescribed treatment is with selective alpha-blockers, and/or reductase inhibitors (Proscar, etc.)The newest selective alpha-blocker, which has the least effect on the ciliary artery and therefore is the safest vis-a-vis future cataract surgery, is Rapaflo, (silodosin) 4mg or 8mg at bedtime. Only the combination of a reductase inhibitor plus an alpha-blocker has been shown to reduce the future need for a TURP to open up the prostatic urethra. However, since the old TURP involved inserting a rotatable knife thru the penis and up to the prostate, much like a Roto-rooter operation, and the procedure is now relatively bloodless and pain-free when done with the "green light" laser, not all men opt for the two drugs, especially since Proscar and its relatives diminish the amount of seminal fluid that is ejaculated. One should also remember that alpha blockers can increase the amount of retrograde ejaculation, i.e. backwards into the bladder, rather than forward and out of the urethra.
As for economics, why do you think surgeons recommend surgery and radiators recommend radiation? This leads into the larger question of economics. It is somewhat paradoxical that in today's times, microeconomics would suggest that you save your money, while macroeconomics wants you to help America spend its way out of the recession.
As a former mathematical and experimental physicist, I have looked into the mathematics, models and predictions of all branches of economics, and they all have the same fallacy: They assume that humans are always rational, and never panic sell or binge buy. This is clearly not the case (cf. "The Madness of Crowds"), but since arbitrary,"irrational" behavior cannot be mathematically modeled, calculated or predicted, it is excluded from ALL economic mathematics and their models. When the Black-Scholes "Theorem" was used to model the portfolio of Long Term Capital Funding, it was implicit in their model that no major country would fail to support its own currency. No allowance was made for this occurrence because (a) its happening was abrupt and unpredictable, and (b) the results depended on which country forfeited its currency. Therefore, when Russia defaulted on the ruble, LTCF would have gone bankrupt to the tune of $4B, but the U.S. Gov't bailed them out.
I won't even go into the required nonlinearity of any market model,that is caused by feedback. What we are dealing with here is the drunkard looking under the lamppost for his lost auto keys because the light is better there, rather than in the dark up the block where he actually dropped them. (And no, I lost no money in the market plunge.) People feel more comfortable with a "prediction" created by mathematics, even though GIGO is operating on a huge scale. Now in physics, if the result of an experiment differs from that predicted by our model of the world, we change our model. But economists cannot change their models, because catastrophe theory is too difficult to be mathematically tractable enough to use for predictions (see Rene Thom's work on this problem).
There are and seemingly will always be market crashes, because it is impossible to predict their occurrence or their nature (?something similar to earthquake prediction). No matter what the model, it basically assumes that the past can be used to model the future. How a tulip bulb crash can model Penn Central or the crash of 1873 is not clear to me. It is the question of predicting individual economic behavior vs. mass economic behavior. We have the same problem in medicine. I have no problem recommending that 1,000,000 women have annual mammograms beginning at age ??, but I have 25 female patients over the age of 85 who have never had mammograms or breast cancer, and so far they are right, too.
Friday, May 15, 2009
Prostate Cancer: Knowns and Unknowns
Prostate cancer is one of the (too many) fields of medicine where there is more heat than light, and more data than verified theories, and very few reproducible facts. I shall begin by listing what are , in my opinion, mutually agreed-upon facts. And please remember, that if there is argument in the refereed journals about the interpretation of facts, then there is no agreed-upon interpretation. Also, this blog is for both doctors and patients, so please bear with me if some of the data is well-known to you.
1) Only men get prostate cancer.
2)Eunuchs never get prostate cancer.
3) One treatment that slows down the progression of metastatic prostate cancer is androgen reduction and/or blocking its actions.
4) Yet, giving a man with low testosterone androgen supplements does not increase his risk of getting prostate cancer.
5)Sexual activity, whether heterosexual intercourse, homosexual intercourse, or masturbation does not seem to affect the incidence of prostate cancer (although some husbands tell their wives that it is a sure preventative).
6) If your father had prostate cancer, this increases your risk of getting prostate cancer.
7) There is no known dietary preventative, but the data does get twisted. For instance, one popular theory was that lycopenes in vegetables reduces the incidence of prostate cancer. A large dietary study seemed to indicate that both tomato and strawberry ingestion reduced the risk of prostate cancer. Yet, because tomatoes have lycopenes and strawberries do not, the authors of the studies immediately stated in their conclusion that strawberries had to be a statistical error, because it contained no lycopenes. This happens all too often in medical "science", where an inconvenient piece of data is "assumed away" because it does not fit the theory. In physics, we try to explain anomalous data, or re-investigate it (the advance of the perihelion of Mercury, atomic spectral lines, the black body catastrophe, etc.). In medicine it is ignored, so we never have "a beautiful theory ruined by an ugly fact".
8) There is no convincing evidence that surgery is superior to radiation therapy, and little evidence that either is superior to "watchful waiting". Yet in the newspaper reports of Mayor Giuliani's prostate cancer, watchful waiting was never mentioned as a possibility by any of the news articles, thereby planting a false impression of the "proper" treatment in non-medical readers. It has been my experience that only single men choose watchful waiting; a wife seems to be psychologically incapable of letting an untreated cancer stay in her husband.
9)THERE IS NO INCONTROVERTIBLE EVIDENCE THAT EARLY DETECTION AND TREATMENT EXTEND LIFE EXPECTANCY. If you look at the recommendations of the USPHS, vs Canadian HS, vs. AMA, vs. ACP, vs. Am. Urological Assn., you of course get differing opinions, much as urologists overwhelmingly recomment surgery, and radiation oncologists overwhelmingly recommend radiation. We internists are supposed to lay out all the data for the patient, and let him decide.
10) Proscar, aka finasteride, which blocks adrogen action on the prostate, reduces the incidence of prostate cancer, but then the cancer that does occur is more aggressive.
11) Under "first, do no harm", my inclination is against drawing PSA levels, but if there is a familoy history and the man's father died from prostate cancer, he generally wants to know.
12) Let me throw out a question to the doctors in the audience: We know that having had cancer is a risk factor for DVT. If a patient who has been treated for prostate cancer develops a DVT, should one assume that the cancer has recurred, and search aggressively for its spread?
1) Only men get prostate cancer.
2)Eunuchs never get prostate cancer.
3) One treatment that slows down the progression of metastatic prostate cancer is androgen reduction and/or blocking its actions.
4) Yet, giving a man with low testosterone androgen supplements does not increase his risk of getting prostate cancer.
5)Sexual activity, whether heterosexual intercourse, homosexual intercourse, or masturbation does not seem to affect the incidence of prostate cancer (although some husbands tell their wives that it is a sure preventative).
6) If your father had prostate cancer, this increases your risk of getting prostate cancer.
7) There is no known dietary preventative, but the data does get twisted. For instance, one popular theory was that lycopenes in vegetables reduces the incidence of prostate cancer. A large dietary study seemed to indicate that both tomato and strawberry ingestion reduced the risk of prostate cancer. Yet, because tomatoes have lycopenes and strawberries do not, the authors of the studies immediately stated in their conclusion that strawberries had to be a statistical error, because it contained no lycopenes. This happens all too often in medical "science", where an inconvenient piece of data is "assumed away" because it does not fit the theory. In physics, we try to explain anomalous data, or re-investigate it (the advance of the perihelion of Mercury, atomic spectral lines, the black body catastrophe, etc.). In medicine it is ignored, so we never have "a beautiful theory ruined by an ugly fact".
8) There is no convincing evidence that surgery is superior to radiation therapy, and little evidence that either is superior to "watchful waiting". Yet in the newspaper reports of Mayor Giuliani's prostate cancer, watchful waiting was never mentioned as a possibility by any of the news articles, thereby planting a false impression of the "proper" treatment in non-medical readers. It has been my experience that only single men choose watchful waiting; a wife seems to be psychologically incapable of letting an untreated cancer stay in her husband.
9)THERE IS NO INCONTROVERTIBLE EVIDENCE THAT EARLY DETECTION AND TREATMENT EXTEND LIFE EXPECTANCY. If you look at the recommendations of the USPHS, vs Canadian HS, vs. AMA, vs. ACP, vs. Am. Urological Assn., you of course get differing opinions, much as urologists overwhelmingly recomment surgery, and radiation oncologists overwhelmingly recommend radiation. We internists are supposed to lay out all the data for the patient, and let him decide.
10) Proscar, aka finasteride, which blocks adrogen action on the prostate, reduces the incidence of prostate cancer, but then the cancer that does occur is more aggressive.
11) Under "first, do no harm", my inclination is against drawing PSA levels, but if there is a familoy history and the man's father died from prostate cancer, he generally wants to know.
12) Let me throw out a question to the doctors in the audience: We know that having had cancer is a risk factor for DVT. If a patient who has been treated for prostate cancer develops a DVT, should one assume that the cancer has recurred, and search aggressively for its spread?
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