This is such a bracing and important read! I really appreciate the insistence on unflinching truth at the exact moment when fear makes patients most vulnerable to “default-to-do-something” medicine. A few things that feel especially worth underscoring from a clinician’s lens:
1. Prostate cancer is a spectrum, not a single disease. The central harm isn’t PSA or treatment per se; it’s treating biology we don’t need to treat (or treating without a clear, shared plan for the downstream cascade).
2. The piece rightly spotlights the information asymmetry: patients often hear “cure” and don’t hear “tradeoffs”, “uncertainty”, or “what we’ll do if the PSA rises again”. The honest endpoint is usually risk management over time, not a single decisive act.
3. Where I’d love to see the field keep evolving is making “standard of care” mean standardized decision quality: mpMRI/reflex biomarkers when appropriate, clear absolute-risk framing, explicit values elicitation (what outcomes matter most), and long-term reporting of patient-centered outcomes (continence, sexual function, regret) using consistent definitions.
I’m firmly pro–active surveillance for truly low-risk disease and pro–decisive treatment for appropriately selected higher-risk disease; the win is getting better at matching the right intensity of care to the right biology and person, while being transparent about incentives and uncertainty.
Richard Davis, Bert Vorstman - I appreciate your responses and all the back and forth opinions. While it is all very confusing in many ways for just a regular person like me, I don’t know any other way to make decisions than to listen and ask questions and try to evaluate options.
It seems to me that like many things in life it is all about risk/reward and percentages of risk which unfortunately are either not known or not communicated clearly and precisely to us. Here are some examples of risks I would like to know:
1. At my age of 76 what is my risk of dying of prostate cancer (pca)?
2. If I get psa tests what is my risk of getting incorrect results that push me to have treatments?
3. What is my risk of getting procedures that cause bad side effects?
My sense so far is that while my overall risk of dying of pca is low, the risk of psa tests being incorrect is high, and the risk of being pushed into treatments because of those results is fairly high, and the risk of treatments causing side effects like incontinence and ED is very high.
Am I off on any of those? If anyone could put % risk numbers on any of those, it would help in making decisions.
I hope you will ask dr. Epstein if he disputes the many specific statistics in this informative article. Thanks for posting it. Always good to hear both sides although it is confusing to try to figure out who to believe.
This is a naive and uninformed question to my way of thinking!
No one would want to die from prostate cancer - it is a very painful, difficult and unpleasant way to go. That's even true with hospice and palliative care. Ask Scott Adams - he's gone on record in the past couple of months.
If you are fortunate enough to be diagnosed with Gleason 3+3 disease, it is NOT going to spread. That's the common wisdom. So if your cure is worse than your disease, you only have yourself to blame. You should have been on AS, as HW will tell you. I am not discounting the anxiety, but I doubt that's what Howard had in mind when when he spoke of the cure being worse.
Anything more than G3+3 - get treatment! You do NOT want to deal with the alternative!
I should add that certain 3+4 situations are appropriate for AS, although many of those men will need interventional treatment. And that AS is a form of treatment.
For Dr. Vorstman's benefit, that's based on cohorts run by Drs. Carroll, Klotz , Canary and others - not junk science.
I believe Richard Davis has a valid point. Richard Davis is probably one of the best sources on the planet to access the Prostate patient’s perspective given the sheer volume of prostate patients that he interacts with on a weekly basis.
Ralph - the reaon the byline is in appropriate and misleading is first because we cannot cure prostate cacner unless it is still at a Gleason 3+3 level. That's the level most men with undiagnosed PrCa live with; and frankly most do not need interventionary tretment.
I frankly question whether Vorstman adn Piana even appreciate that nuance.
I read the byline as intended to ask "Is the treatment worse than the disease?"
As a Gent unaffected by PrCa, you may find the title relevant but cannot understand its implications. For men with prostate cancer who need treatment, and many do, dying of the disease is not something to contemplate. Vorstman makes no attempt to address that.
thank you richard once more - however, sadly, opinions abound in the healthcare arena (from both lay folks and physicians) - most of these opinions are based upon junk science and beliefs - and not on irrefutable and reproducible data - cheers bert
It's not an opinion that 35,000 are forecast to die in 2025 from prostate cancer (ACS Cancer Facts & Figures). That number will likely rise to 40,000 before long. That's a lay opinion ,Dr. Vorstman.
It's hardly an opinion that we can't "cure" prostate cancer if it features a Gleason 4. The best we can do is a "continuing and durable" remission, to quote the late Dr. Snuffy Meyers. I feel sure HW can arrange a debate with Dr. Carroll or Klotz to debate that without referencing junk science.
And it's sure not an opinion that dying from prostate cancer is an exceptionally painful and unpleasant death.. No "junk science or belief' in that. I've witnessed it way too often over the past 17 years.
"Is the cure worse than the disease?"belittles all those men who live with greater than 3+3 dsease. That's an opinion uninfluenced by junk science. Challenging if they may be better off avoiding treatment lacks compassion and understanding that prostate cancer has a 30%+ recurrence rate and how this disease progresses. 30% is no junk science and widely quoted in the literature.
Acknowledging the inappropriate byline rather than making snide comments and/or casting dispersions with references to junk science and beliefs more befits your reputation, Dr. Vorstman. I am disappointed - that's an opinion!
hey rich - might help for you to to read and digest the 2 books that came before me - The Rise and Fall of the Prostate Cancer Scam by my colleague Anthony Horan MD and - The Great Prostate Hoax by my colleague and co-author Ron Piana - these books come with 100s of references - this will get you educated quickly and bring you up to speed Rich - cheers bert
This is such a bracing and important read! I really appreciate the insistence on unflinching truth at the exact moment when fear makes patients most vulnerable to “default-to-do-something” medicine. A few things that feel especially worth underscoring from a clinician’s lens:
1. Prostate cancer is a spectrum, not a single disease. The central harm isn’t PSA or treatment per se; it’s treating biology we don’t need to treat (or treating without a clear, shared plan for the downstream cascade).
2. The piece rightly spotlights the information asymmetry: patients often hear “cure” and don’t hear “tradeoffs”, “uncertainty”, or “what we’ll do if the PSA rises again”. The honest endpoint is usually risk management over time, not a single decisive act.
3. Where I’d love to see the field keep evolving is making “standard of care” mean standardized decision quality: mpMRI/reflex biomarkers when appropriate, clear absolute-risk framing, explicit values elicitation (what outcomes matter most), and long-term reporting of patient-centered outcomes (continence, sexual function, regret) using consistent definitions.
I’m firmly pro–active surveillance for truly low-risk disease and pro–decisive treatment for appropriately selected higher-risk disease; the win is getting better at matching the right intensity of care to the right biology and person, while being transparent about incentives and uncertainty.
Richard Davis, Bert Vorstman - I appreciate your responses and all the back and forth opinions. While it is all very confusing in many ways for just a regular person like me, I don’t know any other way to make decisions than to listen and ask questions and try to evaluate options.
It seems to me that like many things in life it is all about risk/reward and percentages of risk which unfortunately are either not known or not communicated clearly and precisely to us. Here are some examples of risks I would like to know:
1. At my age of 76 what is my risk of dying of prostate cancer (pca)?
2. If I get psa tests what is my risk of getting incorrect results that push me to have treatments?
3. What is my risk of getting procedures that cause bad side effects?
My sense so far is that while my overall risk of dying of pca is low, the risk of psa tests being incorrect is high, and the risk of being pushed into treatments because of those results is fairly high, and the risk of treatments causing side effects like incontinence and ED is very high.
Am I off on any of those? If anyone could put % risk numbers on any of those, it would help in making decisions.
Dr. Vorstman – are there any prostate cancer tests that you would recommend? How about the ExoDx test that says it is 91% accurate?
https://www.exosomedx.com/patients/exodx-prostate-test#:~:text=The%20EPI%20Test%20works%20by,or%20clinically%20significant%20prostate%20cancer.
I think it should be noted that one of the authors wrote a great book about this topic with the inventor of the PSA test.
I hope you will ask dr. Epstein if he disputes the many specific statistics in this informative article. Thanks for posting it. Always good to hear both sides although it is confusing to try to figure out who to believe.
Is the cure worse than the disease?
This is a naive and uninformed question to my way of thinking!
No one would want to die from prostate cancer - it is a very painful, difficult and unpleasant way to go. That's even true with hospice and palliative care. Ask Scott Adams - he's gone on record in the past couple of months.
If you are fortunate enough to be diagnosed with Gleason 3+3 disease, it is NOT going to spread. That's the common wisdom. So if your cure is worse than your disease, you only have yourself to blame. You should have been on AS, as HW will tell you. I am not discounting the anxiety, but I doubt that's what Howard had in mind when when he spoke of the cure being worse.
Anything more than G3+3 - get treatment! You do NOT want to deal with the alternative!
I should add that certain 3+4 situations are appropriate for AS, although many of those men will need interventional treatment. And that AS is a form of treatment.
For Dr. Vorstman's benefit, that's based on cohorts run by Drs. Carroll, Klotz , Canary and others - not junk science.
I believe Richard Davis has a valid point. Richard Davis is probably one of the best sources on the planet to access the Prostate patient’s perspective given the sheer volume of prostate patients that he interacts with on a weekly basis.
Those were the submitted titles for their article from Dr. V. and Mr. Piana. So I am presenting their commentary. HW
Please convey to them that it was a very poor choice.
I think it was a great choice for a title, makes you think.
Do you live with prostate cancer, and if so what level?
not that i know of, but at 76 some people say almost every man has some cancer cells that could be detected if you look hard enough.
Ralph - the reaon the byline is in appropriate and misleading is first because we cannot cure prostate cacner unless it is still at a Gleason 3+3 level. That's the level most men with undiagnosed PrCa live with; and frankly most do not need interventionary tretment.
I frankly question whether Vorstman adn Piana even appreciate that nuance.
I read the byline as intended to ask "Is the treatment worse than the disease?"
As a Gent unaffected by PrCa, you may find the title relevant but cannot understand its implications. For men with prostate cancer who need treatment, and many do, dying of the disease is not something to contemplate. Vorstman makes no attempt to address that.
thank you richard once more - however, sadly, opinions abound in the healthcare arena (from both lay folks and physicians) - most of these opinions are based upon junk science and beliefs - and not on irrefutable and reproducible data - cheers bert
It's not an opinion that 35,000 are forecast to die in 2025 from prostate cancer (ACS Cancer Facts & Figures). That number will likely rise to 40,000 before long. That's a lay opinion ,Dr. Vorstman.
It's hardly an opinion that we can't "cure" prostate cancer if it features a Gleason 4. The best we can do is a "continuing and durable" remission, to quote the late Dr. Snuffy Meyers. I feel sure HW can arrange a debate with Dr. Carroll or Klotz to debate that without referencing junk science.
And it's sure not an opinion that dying from prostate cancer is an exceptionally painful and unpleasant death.. No "junk science or belief' in that. I've witnessed it way too often over the past 17 years.
"Is the cure worse than the disease?"belittles all those men who live with greater than 3+3 dsease. That's an opinion uninfluenced by junk science. Challenging if they may be better off avoiding treatment lacks compassion and understanding that prostate cancer has a 30%+ recurrence rate and how this disease progresses. 30% is no junk science and widely quoted in the literature.
Acknowledging the inappropriate byline rather than making snide comments and/or casting dispersions with references to junk science and beliefs more befits your reputation, Dr. Vorstman. I am disappointed - that's an opinion!
hey rich - might help for you to to read and digest the 2 books that came before me - The Rise and Fall of the Prostate Cancer Scam by my colleague Anthony Horan MD and - The Great Prostate Hoax by my colleague and co-author Ron Piana - these books come with 100s of references - this will get you educated quickly and bring you up to speed Rich - cheers bert
I am reasonably educated in the prostate cancer world, its politics and history. HW will attest.
My comment was purely about your byline that was inappropriate -
Is the cure worse than the disease?
If it requires reading two books to understand that byline, you may want to avoid it in future.
onward & upwards.
PS On a side note for you, Dr. Horan, and Ron Piana, please take to heart something we hold dear throughout our AnCan prostate programming
PSA TESTING IS ABOUT INFORMATION NOT TREATMENT
PPS And it's rick... not rich.
Terrific article, new fact learned relevant to my husband, in this article, discontinuation of statin drugs can raise PSA.