The great prostate cancer ‘hoax’: A call to arms

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For a response to this blog post by "The Great Prostate Hoax" co-author Richard J. Ablin, PhD, DSc (Hon), click here.

I recently read a very disturbing book that I wanted to share with everyone, as it presented a point of view that I, as a urologist, do not commonly encounter. “The Great Prostate Hoax: How Big Medicine Hijacked the PSA Test and Caused a Public Health Disaster,” by Richard Ablin and Ronald Piana (Palgrave Macmillan) was only recently published, but a quick Google search shows just how much publicity it is receiving.

Note that this blog is not a review of the book. For that I recommend reading either the review by The Economist (“Prostate cancer: Help or harm,” March 8, 2014) or the one by The New York Post (“Why the prostate cancer test is useless,” March 1, 2014). The first is a balanced review while the second is less balanced but informative in its own right.

The book was brought to my attention by a patient sent to me for evaluation of an elevated PSA. He seemed an ideal patient to have his PSA checked: He had a family history of prostate cancer, was in his mid-60s, and was very healthy. His primary care doctor had been checking PSAs yearly and when the value jumped from about 3.5 to over 5.0 ng/mL (even after recheck a month later), he was sent to me. During our conversation regarding what to do next (I highly recommend Dr. Hollingsworth’s excellent Urology Times article on talking about PSA to patients), he asked me about this book. While not buying into the book’s conspiracy theories, he was very alarmed at the limitations of the test that the book highlights.

“The Great Prostate Hoax” begins with a historical perspective on the discovery of PSA and its acceptance by the FDA and the urology community, first in 1986 to monitor those with prostate cancer and later in 1994 to screen for the disease. Unfortunately, the book quickly leaves historical reality and begins to make unfounded, usually illogical comparisons between PSA screening and, among others, the tobacco industry. This passage summarizes the remainder of the book: “But in a large sense, the situation dramatized by John [a patient described earlier as having been harmed by PSA screening] illustrates the grim reality of the health care system itself: encouraged by perverse incentives, many of the tests and procedures that doctors do are unnecessary, and quite a few are downright harmful.”

The authors paint a picture of doctors, motivated by greed and malevolence, diagnosing patients with prostate cancer simply so they can be treated. Clearly, Ablin and Piana have never seen a man expire from metastatic prostate cancer.

Next: "There appears to be a great deal of misunderstanding regarding PSA."

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This book, and the conversation between my patient and myself, highlighted another trend that my practice is seeing that I believe is common throughout the country. Prostate biopsies, as well as referrals for elevated PSAs, are down dramatically in the past few years. Talking with various primary care physicians in my community, there appears to be a great deal of misunderstanding regarding PSA, likely as a result of the plethora of conflicting recommendations from the various governing bodies, including the AUA, the U.S. Preventive Services Task Force, and the American Cancer Society, to name but a few.

Therein is my call to arms. Prostate cancer will not go away if we simply stop looking for it. Sure, I would theorize that if we were to universally stop checking PSA today, we would see a dramatic decrease in the incidence of the disease that would be nothing more than a reverse of the spike in incidence seen soon after the test’s widespread implementation.

But then what? Ten years from now, the number of men presenting with late-stage disease diagnosed by obstructive voiding symptoms or bone pain would increase and, barring a medical breakthrough, there would be nothing we as urologists could do to cure these patients. An entire generation would be lost to prostate cancer before the politicians and bean counters of the world awoke to the gravity of their mistake. As a man who lives in a state where politicians have decided that smoking marijuana should be legal, how dare anyone decide that a man doesn’t have the right to know whether or not he is at increased risk of having a disease that kills over 3% of all Americans?

I don’t know what other urologists are doing to address this growing problem, but in my practice we are reaching out to the primary care doctors in our community to educate them on the proper use of PSA. The use of the test has changed over the last 10 years, and it’s time that we use the relationships we have built with our primary care colleagues to update them on the proper ordering of this test.

Not everyone needs to be screened, not everyone found to have an elevated PSA needs to be biopsied, and Lord knows that not everyone with prostate cancer needs aggressive treatment. If a primary care doctor doesn’t want to spend the time to explain the advantages and disadvantages of the algorithm above, then I for one am willing to do that. Prostate cancer is not a hoax; the hoax is the assumption that if you don’t look for a disease, it won’t kill you.

If you are using a different approach in your community that has yielded good results, I would love to hear about it so that we can disseminate the best practices to everyone else. I welcome your comments.

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