When To Test For Prostate Cancer?

IRA FLATOW, host:

Prostate cancer is very common in men as they age, and the most widely used treatment for prostate cancer is surgical removal of the prostate.

But one of my next guests, Dr. Mark Scholz, says that for many, if not for most men, those surgeries are not necessary. And while 27,000 men in the U.S. will die of prostate cancer each year, a great majority of the 170,000 or so men diagnosed with prostate cancer annually in this country do not have life-threatening forms of the cancer and will live a normal lifespan, he writes in his new book, "Invasion of the Prostate Snatchers."

Is intensive screening and aggressive treatment, often involving surgery, the best option? What about watchful waiting or using drug or radiation therapies as alternatives to surgery?

As someone who may be facing that decision, what do you think? What alternative would you like to choose or have you chosen? That's what we'll be talking about in the moments ahead. Give us a call. Our number is 1-800-989-8255, 1-800-989-TALK. Also you can tweet us, write the @ sign followed by scifri, that's S-C-I-F-R-I.

Let me please introduce my guests. Otis Brawley is the medical director of the American Cancer Society. He joins me from their offices in Atlanta. Welcome, Dr. Brawley.

Dr. OTIS BRAWLEY (Chief Medical Officer, American Cancer Society): Hello.

FLATOW: Nice to have you.

Dr. BRAWLEY: Thank you for having me, sir.

FLATOW: You're very welcome. Also joining me now is Mark Scholz. He is an M.D., a doctor. He's author, co-author with Ralph H. Blum of "Invasion of the Prostate Snatchers: No More Unnecessary Biopsies, Radical Treatment or Loss of Sexual Potency." Welcome to SCIENCE FRIDAY.

Dr. MARK SCHOLZ (Medical Director, Prostate Oncology Specialists Inc.): Thank you. Thanks so much for having me.

FLATOW: You're welcome. This being, Otis Brawley, this being National Prostate Cancer Awareness Month, what do you want men to be aware of?

Dr. BRAWLEY: Well, I think the most important thing - Prostate Cancer Awareness Month frequently tries to encourage screening. Rather than encouraging screening, I'd like men to know the pros and cons of screening and ultimately make a decision for themselves as to whether or not they want to be screened.

You know, it's actually true that no American organization outright says men should be screened. Several say men need to know the known harms, the possible benefits and make a choice for themselves, and I think that's what we need to be stressing.

FLATOW: And when you say they should be screened, what is involved in that process?

Dr. BRAWLEY: Well, screening first off is doing the test in an asymptomatic man of a certain age. If a man has any kinds of symptoms having to do with difficulty urinating or other things, pain or bloody discharge, it is not a screening test, and it's - that man needs to be evaluated with many of these same tests.

In an asymptomatic man, we're talking about a blood test called a prostate-specific antigen and a digital rectal examination, where a finger is placed up the rectum to feel the prostate.

FLATOW: And how often should that happen and what age should it happen?

Dr. BRAWLEY: Well, I'm not sure it should happen. What should happen is a man needs to be informed and needs to make a decision as to whether he wants to get it because keep in mind, all the major organizations, be it the American Cancer Society or the American Urologic Association or others, say that there are some known harms associated with prostate cancer screening. There can be overtreatment, as well as alarming men necessarily.

So there are some harms associated with this, and the benefits have not been truly proven scientifically, although the benefits may exist.

FLATOW: Mark Scholz, the subtitle of your book is "No More Unnecessary Biopsies, Radical Treatment or Loss of Sexual Potency." Your book is very much against the established methods of screening, mass screening for cancer and biopsies and standard treatment, which is the total removal of the prostate.

What is wrong with how we screen and treat prostate cancer these days?

Dr. SCHOLZ: Well, the main problem is that prostate cancer, thankfully, relative to other cancers is less dangerous, and that's good. The bad thing is that the commonly implemented treatments so often lead to a drastic hit on your quality of life, specifically loss of sexual function and also sometimes loss of urinary control - major, major problems that can really detract from quality of life.

FLATOW: And your book says that there are alternatives to all of this, and in fact, the co-author of your book, Ralph Blum, has been living with prostate cancer for 20 years now, correct?

Dr. SCHOLZ: Yes, that's absolutely correct. And of course, it's well-known that most men get prostate cancer as they get older and probably to their good fortune don't know that they have it because it'll never hurt them.

There has to be selectivity for - my thing for Prostate Cancer Awareness Month would be that prostate cancer is different from other cancers and that we need education prior to screening, and then of course if people are screened, or if they're diagnosed with prostate cancer, they need a lot of education before they select treatment.

The options for men with newly diagnosed disease can range from simple observation up to and including surgery. But in my opinion, oftentimes the other options, if skillfully implemented, treatments like seed implantation, modern forms of radiation, are substantially less toxic than surgery and equally or even more effective, possibly, at controlling cancer.

FLATOW: All right. We're going to talk about a lot of different options. If you'd like to talk about it with us, our number is 1-800-989-8255. Now we cannot diagnose and tell you exactly what to do if you have prostate cancer or suspect that you do. So please, it's just unethical for us to have the doctor to do that.

So we'll talk about it in generalities. Stay with us. You can tweet us @scifri, @-S-C-I-F-R-I. So we'll talk more about it when we come back. Stay with us. We'll be right back after this break.

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FLATOW: You're listening to SCIENCE FRIDAY from NPR. I'm Ira Flatow. We're talking about prostate cancer this hour with Mark Scholz. Dr. Scholz is co-author of "Invasion of the Prostate Snatchers: No More Unnecessary Biopsies, Radical Treatment or Loss of Sexual Potency." We're also talking with Otis Brawley. Otis Brawley is medical director of the American Cancer Society. Our number, 1-800-989-8255.

One of the things you talk about, Mark, in the book is that people think there's only one kind of prostate cancer, but there are a lot of different kinds of prostate cancer.

Dr. SCHOLZ: Absolutely, and this reflects most importantly the type of treatment you pick. How sad to undergo a radical operation that makes you impotent when you basically had a non-life-threatening condition.

And of course, how sad to undergo surgery if you have a more serious type of cancer that's already spread, and there's really no hope that the surgery could cure you.

So there needs to be a lot of expertise and selectivity implemented in the selection of treatment for men with the different types of prostate cancer.

FLATOW: Otis Brawley, what factors do you suggest a man consider when considering different treatment options?

Dr. BRAWLEY: Well, I agree - first off, I agree with almost everything that's been said here. I think first, men need to know that we don't know yet for sure. There's one test that suggests yes, but we don't know for sure that early testing and early diagnosis actually saves any lives whatsoever. It might. It might not.

It does cause a great deal of apprehension, and then men end up on a slippery slope where they know that they have cancer, they're labeled a cancer patient. And we don't have a test - and we desperately need a test, by the way - to tell cancers that need to be treated versus cancers that need to be watched.

And so we're going to make a guess as to whether we're going to watch this or not, or we're going to treat it. I frequently tell these men: Look at all the various different treatment options, talk to a number of different doctors and then make a gut feeling as to what you as a patient feel is best for you.

And by the way, most of the patients end up not as much worried about impotence as an outcome of treatment. They worry about urinary incontinence and having to wear diapers.

FLATOW: Do you agree with this, Mark, that...

Dr. SCHOLZ: Absolutely, the...

FLATOW: But don't we have the PSA? You know, people go, they get a PSA test, they look for the number, they see if it's high. And doctors will say, well, now you've got to go get a biopsy?

Dr. BRAWLEY: That's exactly what is going on, and that may be the wrong thing. First off, our studies have shown that PSA screening misses as much prostate cancer as it finds. And our studies have shown - we have one study that suggests that we can diagnose 28 percent of men in their 60s with prostate cancer, but only three percent of men in their 60s will ever die from prostate cancer.

I don't have a test to tell me the 25 out of 28 who don't need to be treated. So in the United States, we frequently treat everybody and tell everyone they need to be treated. And some of the treatments have terrible, awful side effects.

I've had patients actually die as a result of treatment for a cancer that probably was never going to kill them.

Dr. SCHOLZ: I heartily agree with Dr. Brawley's position.

FLATOW: Is that heartily or hardly?

(Soundbite of laughter)

Dr. SCHOLZ: Heartily, with all my heart, with passion and conviction. There is a tremendous amount of overtreatment going on, and it - much, not all of it, much of it is rooted in screening tests that lead to knee-jerk reactions, immediate referral to surgeons who are - they're sitting there with knives sharp and ready to go. And it's not because they're bad people. It's because that's what they've been trained to do. Our system is mindlessly grinding out treatment in many men that don't need it.

Now, I don't think PSA testing is going to go away, and we're going to have to deal with this not simply by, in my opinion, stopping - yes, education as to who is going to get PSA tests. But these things are done so routinely now.

So I believe that our fallback position is to start educating men about the different grades of the disease and to try and exercise some selectivity about who can be watched and who maybe more reasonably should be treated.

It's true that there's no 100-percent accurate test for deciding who needs treatment and who doesn't, but there are some rough and ready rules of thumb about how high PSA is, how high grade is and things like that can be quite helpful.

Dr. BRAWLEY: If I could, I'd go one step further. We need to recognize that we need to do the scientific studies to develop the tests to be better than PSA, to develop the test that will tell us the cancers that kill versus the cancers that don't kill. Right now, many people in American medicine have not accepted these as legitimate questions. So that has hindered enrollment of men onto the clinical trials to actually find the answers that will benefit men.

FLATOW: You know, in reading this, in reading your book - excellent book, Dr. Scholz - I thought, you know, we're with prostate cancer where we were with breast cancer 30 years ago, you know: Cut out the whole thing, and, you know, now we have lumpectomies and other kinds of treatment that spare.

Dr. SCHOLZ: The amount of research dollars spent on breast cancer dwarfs what is spent on prostate cancer. And prostate cancer's been like the poor cousin in the research area. It's really sad. And as a result, research definitely lags behind breast cancer.

Dr. BRAWLEY: Can I speak to that, though?

FLATOW: Sure.

Dr. BRAWLEY: You know, three times over the last 40 years, we have actually tried to do the clinical trial to figure out is radiation, external-beam radiation, better than surgery. Three times, we have closed those trials because urologists and men will not participate in the clinical trials.

Now, I can do a clinical trial where I can get women to allow a computer to decide whether their breast gets cut off in a mastectomy or whether they get radiation after a lumpectomy, but I can't get men to go into a trial to figure out if radiation is better than surgery.

Part of the reason there's been a under-amount of money spent on prostate cancer is if we did those trials, it's probably $40,000 to $50,000 per enrollee.

So sometimes I hear we're not spending money on prostate cancer, but the reason we're not spending money on prostate cancer research is men and their physicians won't participate in the research, not that the research is not there.

FLATOW: Well, and Mark Scholz points that out clearly in his book when, and he talks about Ralph Blum, his co-author, that when the doctor told him he had prostate cancer, and he said, you know, I don't want to have the operation. I want to get a second opinion. I want to wait. The doctor said okay, that's up to you. You've got two years to live. See you later. Right? More or less that's the attitude, and if you scare the hell out of the patient like that...

Dr. SCHOLZ: Yes, there's - fear is - and Dr. Brawley already mentioned that there's a tremendous overlay of fear with that word cancer because most cancers, pancreas cancer, lung cancer, even colon cancer, are so very deadly. And there's enough of that going on in the general population.

People know that, and they assume that prostate cancer, being called cancer, is equally dangerous. And it's basically just not true. There are fatal forms, but even the bad ones usually take more than 10 years to cause mortality, and those thankfully are in the minority.

FLATOW: Are we getting to a point where we could find a gene like we have for the BRCA breast cancer genes?

Dr. SCHOLZ: Yes, absolutely, there's definite new breakthroughs. Maybe Dr. Brawley can address that more and better than I can, but there's really hope in that area.

Dr. BRAWLEY: Yeah, actually, the area is probably genomics, which is actually looking at not one gene but a number of genes and looking at genes that are actually producing protein at a high rate or genes that are producing protein at - are at a repressed rate and then looking at a number, perhaps 18 to 30 genes, and then coming up with this is a cancer that is known to be a cancer that spreads and can cause tremendous harm, or this is a cancer that is destined to stay within this man's prostate for the next 40 or 50 years. And of course, the man only has a life expectancy of 20 or 30.

FLATOW: 1-800-989-8255. Alan(ph) in Fairfield, Iowa. Hi, Alan.

ALAN (Caller): Hi.

FLATOW: Hi there.

ALAN: Yeah, I'd like to point out that there are a lot of alternatives to surgery, chemo and radiation when it comes to prostate cancer or any cancer. I'd like to address it from the point of view of what cancer is actually doing, what it's doing for us as opposed to why we should be afraid of it.

What it's doing for us is it is encapsulating toxins that otherwise would damage our organs. That's why we have anchor genes, which turn cancer on. The reason we have anchor genes is because the body needs to create cancer if we have so much toxicity in a certain area that in order to protect the brain or the other organs in the body, the body needs to encapsulate those toxins in a cancerous tumor. I think they way to deal...

FLATOW: Okay - do you have a question?

ALAN: I'm not going to finish until I've made the point.

FLATOW: 1-800-989-8255 is our number. He forgets I have the button.

(Soundbite of laughter)

FLATOW: What - did he have any validity to what he was saying there?

Dr. SCHOLZ: My opinion, not much, no.

Dr. BRAWLEY: Yeah, I would definitely agree with you. I don't understand where he was going.

FLATOW: Let's talk about one of the options. And we've heard a lot - a bit about this is watchful waiting. What is watchful waiting, and why are we hearing more about this at this time, Mark?

Dr. SCHOLZ: Yeah, I'll jump in on that. We're hearing more about it because the technology with biopsies and PSAs is finding these little tiny cancers that people strongly suspect are not life-threatening. And therefore, rather than launching into these radical surgeries, which are so disfiguring and devastating to quality of life, the thought is that maybe we can just keep an eye on these and spare the men the immediate destruction of their sexual lives and their urinary function.

FLATOW: Mm-hmm. And what goes on in watchful waiting? What does that mean? What does that process involve?

Dr. SCHOLZ: Well, it's a new thing. The consensus conference that gave some credibility to this approach was only in 2007. They came up with some rough and ready guidelines of checking PSA levels three or four times a year, doing another prostate biopsy every one to three years, depending on who you talk to. And some scanning techniques are starting to come online with MRI and ultrasound, but that's probably too early to say it's got any consensus.

FLATOW: Otis, want to add a little bit to that?

Dr. BRAWLEY: Yeah, you know, the principle is because literally we had a study that was published in 2003. It really drove the point home. We actually have the technology to diagnose 28 percent, better than one in four men in their 60s, with prostate cancer, but we know only three percent of men who are 60 will ever die from prostate cancer.

That means that the majority of the men who we diagnose with an early prostate cancer need to be watched, as opposed to need to be aggressively treated. And this is a way of watching men, and if their tumor seems to be growing, maybe they're someone who needs to be treated. If their tumor seems to be quiescent and not changing over time, that's someone who can avoid all the problems associated with treatment.

FLATOW: And if the tumor seems to be growing or if the PSA levels are going up, Dr. Scholz, you describe in your book how your coauthor, Ralph Blum, was put on something I haven't heard very much about, and that is a treatment that removes testosterone from your body. And it seems to just shrink up the whole tumor.

Dr. SCHOLZ: Prostate cancer is uniquely sensitive to hormonal - or the removal of the male hormone testosterone. There is some hormone sensitivity in breast cancer, but it's probably only about 20 percent as effective as the hormone treatments for prostate cancer.

There are several reasons we don't hear about it too much. I mean, this is a condition that is basically managed by surgeons, and so surgery is sort of the default treatment.

The other thing is, that it is quite toxic to fiddle with a man's hormones. I mean, it causes loss of sex drive, weight gain. There's been questions about, even, heart problems, which I don't think are true, but it's out there. So it's not something that many doctors think about doing, and there's certainly skills attached to doing it.

However, the effectiveness is undeniable. It is - hormonal treatment is considered standard treatment for the people with the really bad cancers. So it does shrink up cancers in a big way, and it can buy time. It's been used, to some degree, in men that are felt to be too old for surgery and radiation who need treatment. But we contend that it may have a place in people that are unwilling to do standard things like surgery or radiation.

FLATOW: Talking about prostate cancer this hour on SCIENCE FRIDAY from NPR. I'm Ira Flatow. Here with Mark Scholz, author of "Invasion of the Prostate Snatchers," and with Otis Brawley, American Cancer Society. Our number: 1-800-989-8255. Manuel(ph) in North Carolina - oh, what? No, it's Lyle Emmanuel(ph) in North Carolina. Hi, Lyle.

LYLE EMMANUEL (Caller): Hello, how are you doing?

FLATOW: Hi there.

Mr. EMMANUEL: Thank you so much for addressing this problem, this condition. The rate for men is one in six, versus one in eight for breast cancer, but we don't talk about it because we don't like to admit the side effects of impotence and incontinence - it's somewhat embarrassing for men. So it needs to be talked about, and money needs to be spent on it. I myself am prostate cancer survivor. I was diagnosed two years ago, and I spent six months researching it. And I can talk about it with some degree of authority. I have a Ph.D. - not in medicine - and I chose to have a radical prostectomy.

I'm neither impotent, nor incontinent. I'm driving down the road right now, perfectly fine, by the way, and let me - and I was a candidate for active surveillance. My initial Gleason score was six. I had less than 20 percent involvement. Although I did note I had a high PSA velocity, and my pre-PSA was less than five percent so...

FLATOW: But did you think you had to have surgery? You thought that your best bet is go ahead with the surgery and get it done with? Are you willing to take the risk?

Mr. EMMANUEL: In my opinion, yes. From the research I did - and again, I'm not an expert and I'm not a medical scientist, but I looked at my velocity, two to four to 5.8, pre-PSA, less than five percent. There is no good test to differentiate between, you know, aggressive prostate cancer and indolent prostate cancer. It doesn't exist.

But in my opinion - and then while - here's the bottom line, I had a Gleason of six at biopsy, and I had two biopsies; because of course prostate cancer are like little mushrooms, they're throughout the prostate. And you're handling them with 12 needles, your probability of hitting them is not 100 percent. So the first biopsy came back negative, although I was pretty sure I had prostate cancer.

The second one came back positive with two pores. And when I looked at all my options and after surveillance was, of course, one of them. Now, I went ahead with the surgery. And at surgery, the Gleason was upgraded to seven, and I had a positive margin, so...

FLATOW: So you're glad you had it because they were wrong about the diagnosis, you feel, and it was worse than they diagnosed?

Mr. EMMANUEL: Yeah, that's true. And just let me say something about surgeons. I did a lot of research on surgeons, because my first surgeon, like - that story you told was classic. My first urologist I went to, he just - all right, we're going to take it out right now, and I was like whoa, whoa, wait. Wait a second. You just hit me with cancer, the C-word. I'm frightened here. And he said: No, no. We have to take it out. And...

FLATOW: All right.

Mr. EMMANUEL: I walked out the door. And I did research, and I found that 80 percent of the surgeons do less than 10 procedures a year. And in order to become proficient, you need to do a total of at least 250 procedures, which means they will never be proficient.

FLATOW: All right, Lyle, I got to go, but thanks for sharing your story.

Dr. SCHOLZ: Excellent point about the variability in surgical skill. And if all the men out there were as thorough and did as much research as Lyle, we'd have a lot fewer problems.

Dr. BRAWLEY: Yeah, I would agree. Now first, I would say that men need to first make a decision whether they want to be screened or not. Because many men, the answer is: I don't want to be screened.

If they choose to be screened, they need to do as Lyle did and they need to do research, they need to ask questions.

FLATOW: All right.

Dr. BRAWLEY: ...they need to find a doctor who's good.

FLATOW: All right. We've run out of time. I want to thank both my guests today. Otis Brawley, medical director of American Cancer Society; Mark Scholz, author of "Invasion of the Prostate Snatchers," an excellent book if you're thinking about it, anything about prostate cancer. I think you should read this book before you make any decision. Thank you both for taking time to be with us today.

Dr. SCHOLZ: Thank you.

Dr. BRAWLEY: Thank you, sir.

FLATOW: I'm Ira Flatow. This is SCIENCE FRIDAY, from NPR.

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