Dr. Holden’s rebuttal in conjunction with Dr. Vorstman’s extreme position has made for some of the most useful and informative reading on this topic I have seen to date.
Dr. Holden’s perspective is so rational and well documented, I think he would be an excellent speaker. In fact, a debate between them could be quite worthwhile.
While I agree with much of Dr, Holden's response, some is highly controversial although he presents it as fact. AnCan urges you to do your own research.
Gleason 3 evolution is just one example of several. Dr. Holden is a contrarian by his own admission, and some of his views are controversial. As advocates. we believe that controversial information should be flagged otherwise it can deceive readers like yourself.
(should really follow my comments immediately below)
I am disappointed with Howard Wolinsky. He remains a good friend and a trusted AnCan Advisory Board Moderator but is subject to criticism here. His attack on me personally was questionable but not worth the time to respond. Besides much of what he said is true but also relies on personal correspondence he did not ask permission to share. A journo no-no.
More to the point, is a criticism voiced privately by Dr. Jack Baruch, that I will repeat because it is very astute.
As a journalist Howard has every right to publish and expose all sides of any issue. We view that as good journalism.
As a patient advocate, especially one with laser focus on early Active Surveillance, HW has obligations to his readers to provide solid, reliable advice. Just saying a piece is controversial is not enough.
Howard published the first Vorstman piece on May 30, then just a few days later on June 4th, his headline states "Don’t miss your PSA screening—your life may depend upon it".
For 'gnarly', aged advocates like HW and myself, we can digest the information and sort the wheat from the chaff. Newby and less educated readers may have more difficulty in doing that, and even believe the dangerous rhetoric.
Howard - the rules of journalism you practice so well and have taught in eminent schools fall away when you wear your advocate cap. Admit you blew it this time, but please try to separate the two going forward. Maybe Prostate Cores can house this disinformation.
Take 2??? No - just a regurgitation of the rhetoric and propaganda of Take1. There is no response to the criticisms, simply a parroting of what was said originally.
How do we detect prostate cancer that needs treating in men beyond Grade Group 1???
My antenna went up immedately. with the reference to "treatments that often failed to cure them". A urologist of 40 years should know better. We can't cure prostate cancer with a Gleason 4 in your number. Best we can do is a continuing, durable or treatment free remission .
And if you are 3+3, do you really need surgery or radiation? We might be able to agee on that one.
Dr. Vorstman and Ron Piana still fail to address how we detect the 15% of men with high risk disease without a PSA test. And the consequences of letting men with treatable disease progress to denovo metastasis. And the consequences of that found in 35,000 PCSM deaths in 2025. Lotsa words from them again but no solutions or action items. At AnCan action s what carries the weight.
AnCan strongly advocates for all men of any age to test their PSA. That should be accompanied by SDM allowing the patient to make an informed choice.
This week we helped an 87 yr old denovo Mx man who had not had a PSA test in 12 years. Justify that to a patient who now faces treatment and a possible painful death. Sadly he's not alone - men as young as 45 are in the same boat because they failed to test. We invite anyone to listen to these guys in our Group sessions. We don't just talk the talk; we walk the walk.
PSA IS ABOUT INFORMATION NOT TREATMENT.
I also want to respond to HW, and will do that in a separate post.
I have a problem with "shared decision making, what should be shared is information, data, risk benefit analysis. The decision is wholly the patients. Are we trying to make the doctor feel better, by saying it's shared?
We appreciate Dr. Holden’s perspective. However, we prioritize evidence-based facts over subjective interpretations. The current fear-driven prostate cancer narrative, as detailed in our article "What's the Truth About Prostate Cancer?" highlights the troubling issues of over-diagnosis, over-treatment, and the significant harm inflicted on countless men under the guise of curative care.
The Gleason 3+3 = 6 Controversy
The Gleason 3+3 = 6 classification fundamentally lacks the defining characteristics of true cancer. While the urology community maintains that G6 represents low-risk cancer—citing evidence such as basal cell layer loss, perineural invasion, and molecular alterations—they fail to acknowledge a critical fact: these same changes occur in benign conditions. More importantly, no reproducible documentation exists of anyone dying from pure Gleason 6 disease.
The Complex Nature of Prostate Disease
Prostate cancer presents as a multifocal disease influenced by field effects, with each focus exhibiting distinct genetic characteristics. This genomic heterogeneity is significant, yet no replicated genomic study has demonstrated that individual grade 3 cell lines can progress to grade 4 cell lines.
Problems with Clinical Research
John Ioannidis's landmark conclusion that most published research contains fundamental flaws applies directly to prostate cancer studies. These flaws stem from methodological deficiencies, conflicts of interest, and irreproducible results. The PIVOT and ProtecT studies exemplify these issues.
The majority of prostate cancer treatment studies lack scientific rigor and should be viewed with skepticism. These studies consistently include:
Patients with the questionable Gleason 6 "cancer"
Mixed populations with varying Gleason grades, scores, and tumor volumes
Inadequate follow-up periods
Arbitrary selection of participants for testosterone suppression therapy
The Failure of Current Approaches
Despite these studies including patients with Gleason 6 and other low-risk conditions that artificially inflate treatment benefits, urologists' own research reveals damaging truths:
PSA testing fails to meet established criteria for effective screening tools
After 20 years, radical prostate cancer treatments fail to save meaningful numbers of lives
These findings underscore the urgent need for a fundamental reassessment of current prostate cancer diagnosis and treatment paradigms. Bert Vorstman MD, Ron PIana
That pretty much lays out both sides of the issues...Shared decision is the key, using incomplete and confusing data (including the economic incentives involved) to try and make sense of the whole process. Less time spent figuring out which side is right and just admitting that this is an evolving journey that every prostate cancer patient enters at a different point. We do know that Gleason 3+3 is a different animal (except when it isn't) in most men and careful AS can delay or prevent treatments that have serious side effects. That much we know. My hope is that micro ultrasound will help make AS less intrusive (costs less, done in office) so that AS follow up can be less costly and easier done (all in the office). Let's hope the biomarker field improves to even make the PSA a less objectionable test. Let's also not forget that knowledge about prostate cancer or cancer in general evolves and changes...this does not make it a right or wrong issue but an ever changing and evolving process. Quit the right and wrong attitude and remember we are all in this together.
Just incredibly useful. I am PI-RADS 2 on AS and this piece, the Vorstman view vs Holden was just incredibly illuminating. At the end of the day they are both subject to the stochasticity of medicine. It reduces every case to a unique milieu that cannot be addressed adequately by the group statistic. This is where the clinician comes in and how well they understand the science and the patient. This is more stochastic than medicine itself. The only way for a man to mitigate this issue is to become knowledgeable about his own disease. Good luck if he does not have the mental acumen to do that.
Hi Howard, Good for you including Keith Holden's rebuttal to your earlier essay. Dr. Holden is a wise doctor, and he has become a correspondence friend. My key contribution to this discussion is that during my own disease treatment '19-'25, there seems to have been more diagnostic improvements including the PSMA-PET scans and their variations plus improved MRI usage. We cannot forget, that medical insurers are always seeking to minimize their payments of diagnostic surveillance costs. You will never hear a Medicare Advantage underwriter encourage for more testing. Med Advantage insurers have a sweet deal set-up with the federal government. They have placed themselves between the government payor and the patient recipient. What the Med Advantage insurer does not approve for reimbursement becomes the Med Advantage insurers' net profits. They fight aggressively using everything including anti-testing propaganda to reduce expenses and increase profits. Some would argue that some medical insurers do nit give a rat's ass about their insureds. Welcome to American capitalistic medicine.
Dr. Holden’s rebuttal in conjunction with Dr. Vorstman’s extreme position has made for some of the most useful and informative reading on this topic I have seen to date.
Dr. Holden’s perspective is so rational and well documented, I think he would be an excellent speaker. In fact, a debate between them could be quite worthwhile.
Good stuff, Howard!
Hello Joe - hope this finds you well!
While I agree with much of Dr, Holden's response, some is highly controversial although he presents it as fact. AnCan urges you to do your own research.
For example, his view that Gleason 3 cells can evolve into Gleason 4. There is another well substatiated opinion endorsing Vorstman's view that Gleason 3's always remain 3s. Here's another view "Do Gleason patterns 3 and 4 prostate cancer represent separate disease states?". https://pubmed.ncbi.nlm.nih.gov/22998919/#:~:text=Correspondingly%2C%20increasing%20amounts%20of%20Gleason,of%20cancer%20within%20individual%20prostates.
Gleason 3 evolution is just one example of several. Dr. Holden is a contrarian by his own admission, and some of his views are controversial. As advocates. we believe that controversial information should be flagged otherwise it can deceive readers like yourself.
(should really follow my comments immediately below)
I am disappointed with Howard Wolinsky. He remains a good friend and a trusted AnCan Advisory Board Moderator but is subject to criticism here. His attack on me personally was questionable but not worth the time to respond. Besides much of what he said is true but also relies on personal correspondence he did not ask permission to share. A journo no-no.
More to the point, is a criticism voiced privately by Dr. Jack Baruch, that I will repeat because it is very astute.
As a journalist Howard has every right to publish and expose all sides of any issue. We view that as good journalism.
As a patient advocate, especially one with laser focus on early Active Surveillance, HW has obligations to his readers to provide solid, reliable advice. Just saying a piece is controversial is not enough.
Howard published the first Vorstman piece on May 30, then just a few days later on June 4th, his headline states "Don’t miss your PSA screening—your life may depend upon it".
For 'gnarly', aged advocates like HW and myself, we can digest the information and sort the wheat from the chaff. Newby and less educated readers may have more difficulty in doing that, and even believe the dangerous rhetoric.
Howard - the rules of journalism you practice so well and have taught in eminent schools fall away when you wear your advocate cap. Admit you blew it this time, but please try to separate the two going forward. Maybe Prostate Cores can house this disinformation.
Take 2??? No - just a regurgitation of the rhetoric and propaganda of Take1. There is no response to the criticisms, simply a parroting of what was said originally.
How do we detect prostate cancer that needs treating in men beyond Grade Group 1???
My antenna went up immedately. with the reference to "treatments that often failed to cure them". A urologist of 40 years should know better. We can't cure prostate cancer with a Gleason 4 in your number. Best we can do is a continuing, durable or treatment free remission .
And if you are 3+3, do you really need surgery or radiation? We might be able to agee on that one.
Dr. Vorstman and Ron Piana still fail to address how we detect the 15% of men with high risk disease without a PSA test. And the consequences of letting men with treatable disease progress to denovo metastasis. And the consequences of that found in 35,000 PCSM deaths in 2025. Lotsa words from them again but no solutions or action items. At AnCan action s what carries the weight.
AnCan strongly advocates for all men of any age to test their PSA. That should be accompanied by SDM allowing the patient to make an informed choice.
This week we helped an 87 yr old denovo Mx man who had not had a PSA test in 12 years. Justify that to a patient who now faces treatment and a possible painful death. Sadly he's not alone - men as young as 45 are in the same boat because they failed to test. We invite anyone to listen to these guys in our Group sessions. We don't just talk the talk; we walk the walk.
PSA IS ABOUT INFORMATION NOT TREATMENT.
I also want to respond to HW, and will do that in a separate post.
I have a problem with "shared decision making, what should be shared is information, data, risk benefit analysis. The decision is wholly the patients. Are we trying to make the doctor feel better, by saying it's shared?
Totally agree with you, @Guylaine, but you overlook that part of SDM is facilitating the patient to make an informed decision.
Response to Dr. Holden’s Opinions
We appreciate Dr. Holden’s perspective. However, we prioritize evidence-based facts over subjective interpretations. The current fear-driven prostate cancer narrative, as detailed in our article "What's the Truth About Prostate Cancer?" highlights the troubling issues of over-diagnosis, over-treatment, and the significant harm inflicted on countless men under the guise of curative care.
The Gleason 3+3 = 6 Controversy
The Gleason 3+3 = 6 classification fundamentally lacks the defining characteristics of true cancer. While the urology community maintains that G6 represents low-risk cancer—citing evidence such as basal cell layer loss, perineural invasion, and molecular alterations—they fail to acknowledge a critical fact: these same changes occur in benign conditions. More importantly, no reproducible documentation exists of anyone dying from pure Gleason 6 disease.
The Complex Nature of Prostate Disease
Prostate cancer presents as a multifocal disease influenced by field effects, with each focus exhibiting distinct genetic characteristics. This genomic heterogeneity is significant, yet no replicated genomic study has demonstrated that individual grade 3 cell lines can progress to grade 4 cell lines.
Problems with Clinical Research
John Ioannidis's landmark conclusion that most published research contains fundamental flaws applies directly to prostate cancer studies. These flaws stem from methodological deficiencies, conflicts of interest, and irreproducible results. The PIVOT and ProtecT studies exemplify these issues.
The majority of prostate cancer treatment studies lack scientific rigor and should be viewed with skepticism. These studies consistently include:
Patients with the questionable Gleason 6 "cancer"
Mixed populations with varying Gleason grades, scores, and tumor volumes
Inadequate follow-up periods
Arbitrary selection of participants for testosterone suppression therapy
The Failure of Current Approaches
Despite these studies including patients with Gleason 6 and other low-risk conditions that artificially inflate treatment benefits, urologists' own research reveals damaging truths:
PSA testing fails to meet established criteria for effective screening tools
After 20 years, radical prostate cancer treatments fail to save meaningful numbers of lives
These findings underscore the urgent need for a fundamental reassessment of current prostate cancer diagnosis and treatment paradigms. Bert Vorstman MD, Ron PIana
That pretty much lays out both sides of the issues...Shared decision is the key, using incomplete and confusing data (including the economic incentives involved) to try and make sense of the whole process. Less time spent figuring out which side is right and just admitting that this is an evolving journey that every prostate cancer patient enters at a different point. We do know that Gleason 3+3 is a different animal (except when it isn't) in most men and careful AS can delay or prevent treatments that have serious side effects. That much we know. My hope is that micro ultrasound will help make AS less intrusive (costs less, done in office) so that AS follow up can be less costly and easier done (all in the office). Let's hope the biomarker field improves to even make the PSA a less objectionable test. Let's also not forget that knowledge about prostate cancer or cancer in general evolves and changes...this does not make it a right or wrong issue but an ever changing and evolving process. Quit the right and wrong attitude and remember we are all in this together.
Just incredibly useful. I am PI-RADS 2 on AS and this piece, the Vorstman view vs Holden was just incredibly illuminating. At the end of the day they are both subject to the stochasticity of medicine. It reduces every case to a unique milieu that cannot be addressed adequately by the group statistic. This is where the clinician comes in and how well they understand the science and the patient. This is more stochastic than medicine itself. The only way for a man to mitigate this issue is to become knowledgeable about his own disease. Good luck if he does not have the mental acumen to do that.
Hi Howard, Good for you including Keith Holden's rebuttal to your earlier essay. Dr. Holden is a wise doctor, and he has become a correspondence friend. My key contribution to this discussion is that during my own disease treatment '19-'25, there seems to have been more diagnostic improvements including the PSMA-PET scans and their variations plus improved MRI usage. We cannot forget, that medical insurers are always seeking to minimize their payments of diagnostic surveillance costs. You will never hear a Medicare Advantage underwriter encourage for more testing. Med Advantage insurers have a sweet deal set-up with the federal government. They have placed themselves between the government payor and the patient recipient. What the Med Advantage insurer does not approve for reimbursement becomes the Med Advantage insurers' net profits. They fight aggressively using everything including anti-testing propaganda to reduce expenses and increase profits. Some would argue that some medical insurers do nit give a rat's ass about their insureds. Welcome to American capitalistic medicine.