Uro-Skeptic Vorstman Sounds Off: 'PSA Testing, Active Surveillance and More Damned Lies'
(Editor’s note: Bert Vorstman, MD, has always had an outsider’s perspective. He was born to Dutch parents in Sumatra in the former Dutch East Indies. Think of Mel Gibson and the movie, “The Year of Living Dangerously.”
At age four, his family left behind the unrest and moved to New Zealand. He only spoke Dutch and Malay when he started school in New Zealand.
He attended medical school in New Zealand. Radical prostatectomies weren't performed there. He says doctors there didn’t believe in prostatectomies because they were linked with impotence and incontinence - limp and leaking.
Vorstman learned the technique when he came to the University of Miami as chief resident in urology.
Until around 40 years ago, prostatectomies were rare in the United States as well. They were a response to the epidemic of overtreatment and overdiagnosis of prostate cancer that came with the spread of the PSA (prostate specific antigen) screening, and also the development of nerve-sparing prostatectomies.
By the 1990s, radical prostatectomies had become the bread-and-butter surgery for urologists.
Vorstman said he is amazed now that he had bought into Gleason 6 being a cancer. That debate still raging.
What changed his mind were the writings of Laurence Klotz, MD, who noted that Gleason 6 lacked all the hallmarks of a cancer since it virtually never spread. Vorstman began questioning what he viewed as the lack of science throughout urology. He received additional inspiration from Anthony Horan, MD (“The Big Scare”) and Richard J. Albin, PhD, Ron Piana (“The Great Prostate Hoax”).
He reminds me of an old friend of mine in Chicago, the late Dr. Bob Mendelsohn, the so-called “medical heretic,” who questioned standard practices in medicine and accepted “wisdom.” He wrote bestsellers such as“Confessions of a Medical Heretic.”
Vorstman is the urological heretic, the last angry doc.
In 2010, Vorstman began writing a blog sharing his concerns, including those about screening with PSA and the widespread adoption of unproven robotic surgery. You may not agree with Vorstman on everything. But he is worth reading and challenging yourself and your doctors.
I admire his motto: ‘It's high time someone with balls stepped up to the plate and demanded that we return to scientific principles and stop the bullshit.”
I know Vorstman is controversial and asked him to write this blog to share his thoughts in hopes of hearing yours.)
By Bert Vorstman, MD
PSA testing and prostate cancer management remain controversial. In recognition of the fact that many prostate cancer treatments are harmful and that many low-risk prostate cancers can be outlived without intervention, a less hurried active surveillance program was developed. Although heavily promoted, is this monitoring program (doctor visits for a PSA, prostate exam, and other possible practices, including mpMRIs, and biopsies) safe and beneficial or, is it merely a cutdown version of unsafe and scientifically unproven prostate cancer management drills?
(Dr. Bert Vorstman)
The prostate exam.
The prostate exam or digital rectal exam (DRE) is dependent on the interpretive skills of the doctor and is no more reliable than a coin toss. Additionally, the sensitivity for detecting prostate cancer is low, and even for those where a “nodule” was felt there’s no scientific evidence that the finding led to life extension. Little wonder, a strong argument exists for eliminating the DRE from physical examinations.
The PSA.
The PSA (prostate-specific antigen) test is highly unreliable with a false-positive rate of 78 percent. It is neither specific to the prostate nor specific to prostate cancer. Along with fake levels of normal, a raised PSA does not mean prostate cancer and lowering the PSA does not confer less risk. The PSA can’t distinguish between aggressive and non-aggressive cancers, and it can be artificially raised or lowered in numerous situations without a cancer being present or advancing. As well, since some aggressive cancers produce little or no PSA they may be missed. Not surprisingly, a 2009 study by urologists showed that PSA testing failed to save significant numbers of lives.
The 12-core prostate needle biopsy.
The 12-core ultrasound-guided prostate needle biopsy is a grossly unscientific test that potentially exposes patients to serious complications of sepsis and bleeding while sampling blindly and randomly about 0.1 percent of the prostate. With such a large sampling error, missing a cancer is embarrassingly common. And, although one study showed a false negative rate of 30 percent, the actual error rate is much greater as over half the “cancers” included were Gleason 5 and 6 pseudo-cancers.
Imaging for prostate cancer.
Imaging for the detection and staging of prostate cancer using ultrasounds, CT and bone scans are recognized as being relatively insensitive. For staging, they lack accuracy at detecting small volume spread. Underlining this concern is the fact that prostate cancer cells have been found in the bone marrow of patients with so-called localized disease. The best screening tool for prostate cancer detection appears to be the non-contrast MRI (by an expert) and then a real time MRI-guided targeted biopsy of areas judged as Pirads 4 or 5 for diagnosis. Staging using the whole body MRI to detect boney spread and the PMSA PET-CT scan to detect lymph node spread are now considered standard practice.
The Gleason 3+3=6 “cancer”.
The Grade 3 in the Gleason 3+3=6 “cancer” is a classification of cellular growth judged to be consistent with a low-grade prostate cancer under low-power microscopy. However, the Gleason Grade 3 lacks the hallmarks of a cancer on both clinical and molecular biology grounds, especially, since the genetic pathways enabling invasion and cancer spread are inactive. And, because biology mechanisms eclipse microscopic appearances, both the Gleason and cancer labels need to be dropped and the Grade 3 retagged as a benign disease.
The unreliable Gleason grading system.
Because of the complexity of the Gleason grading classification system, errors of interpretation and disagreements amongst pathologists are common. Underscoring a profound lack of reproducibility with this very subjective prostate cancer diagnostic system Swedish pathologists disagreed about Gleason grades a staggering 50 percent of the time. Since grade misclassifications are common, second opinions are strongly recommended.
The unproven radical prostatectomy “treatment”.
Radical prostatectomy has been a fraudulent cornerstone of prostate cancer management since Johns Hopkins surgeon H.H. Young’s claim of early diagnosis, cure and that “The four cases in which the radical operation was done demonstrated its simplicity, effectiveness and the remarkably satisfactory functional results furnished.” Unbelievably, there was no evidence for early diagnosis or cure, two patients died and the other two were left with lifelong urinary incontinence. Yet, this risky treatment philosophy became standard practice and continues so despite a study concluding that surgery failed to save significant numbers of lives. More disturbingly, when robotics arrived, the device received a Food and Drug Administration approval although it delivered no clear surgical benefits. Worse still, the FDA’s fallacious 510(K) process was manipulated to obtain approval for use of the tool in robotic prostatectomy without any evidence for safety or benefits.
The false urgency for prostate cancer treatment.
The mislabeling of Grade 3 as a cancer has pushed men towards unneeded treatment and falsely increased the incidence of prostate cancer.
Not all prostate cancers are equal - only some 10 to 15 percent of cases are aggressive and potentially lethal and responsible for the deaths of about 30,000 U.S. men annually.
Most men diagnosed with prostate cancer do not die from it. More than 3.1 million men in the United States who have been diagnosed with prostate cancer at some point are still alive today. Surprisingly, the $32.7 billion market for treatments doesn’t appear to drive increased survival.
Many prostate cancers have a cell doubling time of some 475 +/- 56 days so that it takes about 40 years for the cell to multiply and grow to a diameter of one centimeter.
The 15-year survival for all prostate cancers is estimated to be about 96 percent regardless of the type of treatment while no treatment has a similar 10-year survival to those who did have treatment.
Bogus cancers, false positives, and errors of interpretation.
The evidence delivered in this review underscores clearly that not only is the Gleason Grade 3, a bogus cancer but that there’s an intolerable degree of false positives with PSA testing, an intolerable degree of errors of interpretation in both pathology and imaging, and, that both PSA testing and surgery fail to save significant numbers of lives. According to lore, the definition of insanity is doing the same thing over and over again and expecting a different result. John Ioannidis MD identified a possible cause for this mischief in healthcare when he concluded that most published research findings are false. In light of the many falsehoods surrounding prostate cancer management and active surveillance programs, retooling studies to generate irrefutable and reproducible data instead of information supporting unfounded biases could restore trust in disease management.
Vorstman on active surveillance:
AS sounds like a good idea but it's a bit like putting lipstick on a pig - the testing is still a pig.
We are still monitoring men with highly unreliable and risky tests like the DRE, PSA, and biopsy AND although many men are not immediately railroaded into a harmful "treatment," many often get injured during the course of AS
AS tries to portray an element of care. AS seems to acknowledge the fact that most prostate cancers can be outlived and that our treatments are harmful BUT, many men get tired of being hurt during AS, tired of living with a cancer label, tired of scare-tactics, and often want something done to put it behind them
I stopped ordering routine PSA tests and doing DREs a few years ago,
Patients sent to me with elevated PSAs would have a series of PSA tests and a PSA density to try and confirm a possible issue and, if abnormalities persisted would undergo a non-contrast MRI +/- an MRI-guided biopsy of PI-RADS 4/5 areas
AS is often a delaying tactic before patients are massaged towards treatment - like sustainable cropping (biopsies) - harvest a little every six months or so and then take the whole crop.
More Vorstmanisms:
—” Prostatectomy and the insurance industry make my blood boil.”
—”Some of these urologists are like a fox in the henhouse. Neither PSA testing nor robotic prostatectomy saves significant numbers of lives. So why are we still mutilating men? Because exploiting men with false hope and false promises is a $6.8 billion dollar global industry.”
—“In terms of AS, here's where I believe urologists shot themselves in the foot and began tilting to AS
“First - sampling errors - the embarrassing and grossly unscientific 12-core biopsy sampled only 0.1% of the prostate - urologists were basing their prostate ‘cancer’ management without any knowledge of what was happening in 99.9% of the prostate."
“Second - prostatic tissue - especially in some men can exhibit field change effects (similar to bladder cancer) and a more significant Gleason grade may originate in another area of the prostate (rather than evolve from an existing lesion). Dr. Joe Busch has the impression that this may happen when someone has been diagnosed with several low-grade areas on a well conducted and interpreted MRI.”
—TheActiveSurveillor.com has been part of an effort to remove the cancer label from Gleason 6. Vorstman suggests: “We need to delete both the Gleason label and the cancer label - I'd call it age-related prostatic neoplasia or ARPN.”
—“In the prostate cancer arena, urologists have clearly strayed from science into junk science and delivered mainly a deep well of false hope and false promises. Until we can support every step of our so-called standard-of-care dogma with irrefutable and reproducible data, we need to rescind the FDA approvals for PSA for testing and for the robotic device for robotic prostatectomy - neither save significant numbers of lives.”
—“We need to stop teaching our residents this prostate cancer quackery and health robbery - we've been there before with the radical mastectomy treatment philosophy - also a product of Johns Hopkins - after 80 years or so of mutilating women and failing to save significant numbers of lives, doctors smartened up - no one does that ‘treatment’ anymore.”
Vorstman sounds off at https://urologyweb.com/uro-health-blog/
How about signing up for a free AnCan webinar on how lifestyle can affect prostate cancer?
AnCan is presenting a program on lifestyle choices and all grades of prostate cancer at 8-9:30 p.m. Eastern on May 31. Register at: https://bit.ly/3KkxcfC
The webinar, entitled “Optimizing Sleep, Exercise, and Nutrition in Prostate Cancer," features Dr. Stacy Loeb, professor of Urology and Population Health at the New York University School of Medicine and the Manhattan Veterans Affairs Medical Center, and Dr. Justin Gregg, assistant professor of Urology and Health Disparities Research at UT MD Anderson Cancer Center, of UT MD Anderson Cancer Center in Houston.
Did you miss the best program on AS to date: “Your Voice in the future of Active Surveillance,” on April 22.? Here’s the link: https://aspatients.org/meeting-videos/
A Who’s Who of experts joined the conversation along with patients and advocates, who were not too shabby either.
Dr. Kerry Courneya, a professor and Canada Research Chair in physical activity and cancer and director of the Behavioral Medicine Laboratory and Fitness Center at the University of Edmonton, has pioneered research on the importance of exercise for anxiety, fear of cancer progression, and quality of life in active surveillance patients.
He is presenting a program from 4:30-6:30 p.m. PDT/7:30-9:30 p.m. EST on May 14 at the Active Surveillance Nationwide Surveillance Support Group in Canada. Register here: https://bit.ly/AS1year
If RP is terrible (which I agree with), and AS is lame, then what options are we left with? (besides radiation treatments)
I agree to a healthy debate anytime, any place.
I would desperately like to see urologists - as did these authors (see Anthony Horan MD and his book "The Rise and Fall of the Prostate Cancer Scam" and Richard Ablin and Ron Piana with their book, "The Great Prostate Hoax") get away from treatment philosophies based on unfounded biases and return to treatments based on irrefutable and reproducible data - let's drill down and see where the scientific evidence is supporting the merits of PSA-based testing and prostate cancer surgery. Unfortunately, we have plenty of evidence that there is no merit to these treatment philosophies. John Ioannidis MD has already warned us - "that most published research findings are false". We have to do a lot better as physicians, get away from junk science and doublespeak.