FUNDAMENTALLY, THERE ARE 2 TYPES OF PROSTATE CANCER
* the LESS COMMON high-risk prostate cancer which DEMANDS TREATMENT and receives all of the prostate cancer PUBLICITY and concerns about SURVIVORSHIP
* the VERY COMMON Gleason 6 (3+3) prostate “cancer” which poses NO HEALTH RISK and which usually needs NO TREATMENT whether focal treatment or total whole gland treatment, is frequently OVERDIAGNOSED and OVERTREATED (especially surgically), leaving many men debilitated and with ZERO BENEFITS
* NOT ALL PROSTATE CANCERS ARE EQUAL, MANY NEED NO TREATMENT
> FUNDAMENTALLY, ANY CANCER TREATMENT SHOULD ACHIEVE 2 CRITICAL GOALS:
* SAVE SIGNIFICANT NUMBERS OF LIVES,
* COMPLETE TREATMENTS WITH ACCEPTABLE NUMBERS OF COMPLICATIONS
THE RADICAL SURGERY/ROBOTIC PROSTATECTOMY HAS NEVER ACHIEVED EITHER OF THESE MOST BASIC OF GOALS AND THIS APPALLING SITUATION HAS BEEN UNDERSCORED ONCE MORE BY THE VERY EMBARRASSING USPSTF REPORT ON THE LACK OF BENEFITS FROM PROSTATE CANCER SCREENING AND THE LACK OF BENEFITS FROM TREATMENT OF SCREEN DETECTED PROSTATE CANCER
FALLACY #1, “cutting out your prostate cancer offers the best potential cure”
This is the SUPREME FALLACY of all fallacies concerning prostate cancer management.
* Prostate cancer, like MANY other cancers, does NOT benefit from surgery
* Stage for stage, radical surgery/robotic prostatectomy offers NO ADVANTAGES over other
LESS INVASIVE treatment options and only INCREASED RISK and HARM
* Except for some self-serving “clinical” studies, the various surgical approaches of radical
retropubic prostatectomy, radical perineal prostatectomy, laparoscopic prostatectomy and
robotic prostatectomy have resulted in:
* NO significant survival rate or survivorship
* NO significant cure rate
* NO curative life extension
* NO decrease in prostate cancer specific mortality
Most men will have the life sucked out of them by the “cancer” label. All men want a speedy cure, few after-effects and a long life. Under the guise of medical counselling newly diagnosed men will be told about “potential cure” from surgery. This talk is particularly insincere and disingenuous but serves as a most powerful magnet for the surgeon to steer a man towards the
ill-conceived, toxic and scientifically unproven robotic prostatectomy.
Hopeful sounding speak like, “cut it out and its gone”, “best chance of cure”, “curative intent”,
“definitive treatment”, “excellent results”, “zero PSA progression”, “relapse-free survival”, “survival benefit”, “minimally invasive”, “outpatient”, and many other combinations of hopeful and upbeat speak will be offered. These words and phrases have ABSOLUTELY NO MERIT, are IMMATERIAL and IRRELEVANT as NO SIGNIFICANT NUMBERS OF LIVES ARE SAVED FROM RADICAL SURGERY/ROBOTIC PROSTATECTOMY and only great harm is incurred. Any talk of great “cure” rates and “survivorship” is especially insincere and preposterous when these misguided surgeons are discussing results pertaining to the Gleason 6 (3+3) “cancer” as this particular “cancer” is not even a health risk.This positive sounding rhetoric serves simply to manipulate and exploit a mans’ vulnerability and errant thoughts about taking an immediate but misguided surgical action.
You WILL AND CAN TAKE ACTION regarding your prostate cancer diagnosis BUT, it should NOT be immediate, take very careful thought, and should NEVER entail surgery.
Knowledge is king.
> FALLACY #2, “robotic prostatectomy is high tech and low risk”
this statement is on par with the first outrageous fallacy regarding prostate cancer surgery as offering the “best potential cure” when there are NO significant numbers of lives saved. In fact, the risks and complications associated with this “high-tech”, robotic prostatectomy are FAR GREATER than for any other treatment option for prostate cancer and probably more than for any other operation performed on man ever. Indeed, for most men, the complications stemming from the surgical treatment are much worse than the prostatic cancer disease itself. So bad, that many prostate cancer surgeons attempt to mitigate against these well known and well documented harms by counselling men before prostate cancer surgery on “outcome expectations”. Postoperatively, debilitated men will run the gauntlet of all sorts of “penile rehab”, “sexual healing” and incontinence “rehab” programs. Of course, many of these “rehab” programs fail to deliver so quite an industry has developed to correct all of these terrible post-prostatectomy complications with additional surgery using prosthetic devices.
The following are some of the many complications associated with the robotic prostatectomy. One can also gain a perspective on the many complications associated with the robotic prostatectomy by googling and perusing the material on class-action legal battles taking place:
a) IMMEDIATE COMPLICATIONS
blood loss, anesthetic complications, death, rectal fistula
b) DELAYED COMPLICATIONS
anesthetic, pulmonary, pneumonia
cardiovascular, arrhythmia, heart attack, deep vein thrombosis, pulmonary emboli, stroke,
blood loss, transfusions, transfusion complications
infections, wound and urinary
leakage of lymph or urine from wound and drain sites
mental, psychological, depression, suicide
pudendal nerve injury
quality of life issues (QoL), disappointment, loss of manhood, relationship issues
urological, shortened penis
lack of ejaculation at orgasm (IF orgasm retained)
ejaculation of urine (IF lucky enough to have erections preserved)
bladder neck contracture
positive margins (retained cancer or, cancer left behind in 20-40% of all cases)
impotence/loss of erections
or, “limp and leaking” with a smaller penis. This surgery affects man and wife and many of these sexual and urinary after-effects and complications are reflected upon more accurately by the wife/partner than the patient himself because of the great embarrassment resulting from this debilitating surgical “assault” on his manhood.
The incredible list of harms associated with this toxic radical prostate surgery/robotic prostatectomy is quite understandable and elementary when considering the anatomy of the prostate and its intricate juxtaposition between the bladder and urethra. Any surgery, whether robotic (in this case not truly robotic but through the aid of a mechanical arm) or not, cuts out and therefore divides the prostate and its intimately associated smooth muscles and nerves. This dividing and “cutting out” naturally, and very logically, leads to the very extensive list of unwanted complications and debilitation. Harm and debilitation from the radical surgery/robotic prostatectomy is virtually guaranteed and, with NO significant lifesaving benefits, it is very clear that urologists have betrayed the trust of patients by endorsing this surgery. Like cutting out a piece of spinal cord and sewing it back together, bad things happen. You can use all available hopeful sounding rhetoric and even sprinkle pixie dust on the surgical site but, no matter how you “slice” it, you will be worse off than without surgery.
NO AMOUNT OF “RECONSTRUCTION” WILL RETURN YOU TO YOUR FORMER SELF.
> FALLACY #3, “radical surgery/robotic prostatectomy is the “gold standard”
although the radical surgery approach was first performed in the early 1900s and was the first treatment option available for localized prostate cancer, this antiquated procedure was
ill-conceived and its use misguided. This “gold standard” moniker was self-anointed by egotistical surgeons without any scientific evidence based medicine support, absolutely baseless and devoid of scientifically conducted post-treatment accountability data. As noted above, this high-risk procedure has failed to save significant numbers of lives and has NOT dented the prostate cancer specific mortality rate in any way.
In addition, this toxic surgical procedure is at the forefront of OVERTREATMENT concerns in that 75% of all prostate cancers diagnosed are low or favorable-risk Gleason 6 (3+3 and/or a little bit of 4) and MOLECULAR and CLINICAL evidence has shown that the majority of these stage T1c Gleason 6 (3+3) cancers are NOT a health risk, are really pseudo cancers and these “cancers” deserve NO TREATMENT.
In reality, the robotic prostatectomy is the “gold standard” for OVERTREATMENT and HARM.
This sort of surgical OVERTREATMENT simply sets the stage for OVERTREATMENT malpractice. Flawed science and/or surgical tradition will never authenticate a treatment.
> FALLACY #4, “radical surgery/robotic prostatectomy is FDA approved”
the surgery is FDA “approved” BUT, the “FDA approved” label was simply “rubber stamped” and radical surgery/robotic prostatectomy was NEVER FDA SCRUTINIZED SCIENTIFICALLY FOR RISK OR REWARD. This absolute lack of scientific evidence based medicine support for this ill-conceived prostate surgery has not stopped surgeons from gloating and misusing this errant FDA labelling in order to exploit vulnerable men given the “cancer” label with this irreversible high-risk surgery. AN OPERATION WHICH FAILS TO SAVE SIGNIFICANT NUMBERS OF LIVES AND ONLY INCURS GREAT HARM.
> FALLACY #5, “radical surgery/robotic prostatectomy is indicated for younger men”
this contention is another profound fallacy, wishful thinking on the part of surgeons, absolutely baseless and for which there is NO scientific evidence based medicine support
> FALLACY #6, “radical surgery/robotic prostatectomy is indicated for aggressive or high-risk prostate cancers”
this again, is pure, unbridled self-serving surgical conjecture with NO scientific evidence based medicine support and potential only for great HARM
> FALLACY #7, “radical surgery/robotic prostatectomy is not possible after previous radiation”
NOT TRUE. BUT, PROSTATECTOMY AFTER ANY PROSTATE CANCER TREATMENT IS ASSOCIATED WITH EVEN MORE DEBILITATING COMPLICATIONS AND ZERO BENEFITS. YOU JUST DO NOT WANT TO GO THERE.
Prostatectomy after a previous treatment for a prostate cancer and where residual/untreated cancer or, recurrent cancer is detected on follow up, is called a SALVAGE prostatectomy. Residual or recurrent prostate cancer is possible after any previous treatment such as radiation, seeds, proton beam, hifu or cryoablation and, even after the ill-conceived robotic surgery.
However, “salvage” surgery is associated with EVEN MORE COMPLICATIONS than a virgin prostatectomy for cancer and like any prostatectomy still results in great harm and NO significant numbers of lives saved. Even a virgin prostatectomy is associated with 20-40% positive margins or, retained cancer after surgery. Therefore, the proposal that a surgeon can perform a “salvage” prostatectomy with complete removal of the prostate after a previous failed prostate cancer treatment is quite disingenuous. Surgeons commonly fail to remove all the prostate cancer at the best of times so the “salvage” prostatectomy is another prostate cancer myth.
> FALLACY #8, “radical surgery/robotic prostatectomy performed for advanced, extensive localized prostate cancer can offer “hope” by debulking the cancer along with “planned” radiation for the leftover cancer”
Again, there are ZERO scientific evidence based medicine studies to support the contention that removing as much of the prostate cancer as you can (“debulking” or “local control”) does anything for saving lives except to guarantee even more life-long after-effects and complications.
Furthermore, ridiculous self-serving studies using neoadjuvant immunotherapy after the misguided robotic prostatectomy simply attempts to justify the ongoing human experimentation using this toxic surgery.
> FALLACY #9, “radical surgery/robotic prostatectomy allows surgeons to sample the regional lymph nodes (lymphadenectomy) draining the prostate for better cancer staging”
Surgery can sample the pelvic lymph nodes to determine possible regional spread of cancer for cancer staging but the merits of this staging are questionable at best. First, the pelvic lymphadenectomy adds even more risk to the total surgery, second, there are no direct benefits to the patient and third, lymph node spread and or, direct invasion or infiltration of prostate cancer does not kill. It is blood-borne bone marrow spread of HIGH-RISK (NOT THE VERY COMMON LOW-RISK) prostate cancer which kills eventually and only bone marrow aspiration can determine early spread here. Furthermore, the misguided preoccupation with “staging” using bone scans and CT scans has been proven to be worthless and wasteful until the PSA reaches a level of 15 ng/ml or more
> FALLACY #10, “radical surgery/robotic prostatectomy is high tech and therefore a superior treatment”
The fact that robotic prostatectomy may or may not be “superior” is absolutely IMMATERIAL and IRRELEVANT when this radical surgery/robotic prostatectomy clearly FAILS to save significant numbers of lives and the risk of harm from treating the prostate cancer surgically is absolutely unacceptable.
Surgeons will embellish the perceived (but misguided) benefits of robotic prostatectomy by glorifying certain technology advancements with very hopeful sounding terms such as: “minimally invasive” (but still requires hospitalization), “tremor control”, “optical magnification”, “puncture wounds”, “state-of-the-art”, a “shorter” hospital stay, “smaller” incisions and less postoperative “pain”. Like any good snake-oil salesman you will hear additional impressive sounding terms like “superior outcomes”, “meticulous dissection”, “reconstruction” and “nerve sparing”. The application of a “nerve sparing” technique is more fiction than reality as the nerves for erection course in a somewhat predictable fashion only about 50% of the times.
However, despite the fact that robotic surgery cannot IN ANY WAY circumvent the inherent complications associated with excision of the prostate and fails to save significant numbers of lives, surgeons continue the deceptive practice of endorsing this ill-conceived surgical procedure. Aside from being ill-conceived and without significant benefits, surgeons require 100s of “victims” for practice in order to achieve any robotic technology proficiency.
“PHYSICIAN TRUST” AND “PATIENT ADVOCACY”- oxymorons?
Surprisingly, in our era of “modern” medicine, fallacies, folklore and myths still abound.
Much more appalling however, is the intentional use of false hope on men made vulnerable by a
cancer label and then deceiving and exploiting them using outrageous medical fallacies. This so-called “counselling” of patients with unscientific information, flawed medical reasoning and false hope makes the proposition of an informed medical consent, the work of charlatans, amoral and a total sham.
Many physicians have described the great risks and harm associated with the toxic radical surgery/robotic prostatectomy. However, the prostate cancer industry has remained unconscionably, steadfastly and shamefully recalcitrant with respect to undertaking any scientific posttreatment accountability studies to support their premise of surgical benefits.
The following is a partial list of authors who have reviewed some very relevant issues regarding medical conflicts of interest, patient advocacy and the betrayal of trust by physicians:
Bad Medicine, doctors doing harm since Hippocrates, D. Wooten
Bad Pharma, B. Goldacre
Bad Science, B. Goldacre
Bad Surgery, B. Vorstman
How We Do Harm, O.Brawley
Invasion of the Prostate Snatchers, R. Blum and M. Scholz
Overdo$ed America, J. Abramson
Overdiagnosed, making people sick in the pursuit of health, G. Welch
Proton Warriors, H. Dawley
Surviving Prostate Cancer Without Surgery, B. Hennenfent
The Male Lumpectomy, G. Onik
The Big Scare, the business of prostate cancer, A. Horan (over 500 references)
The Health Robbers, S. Barrett and W. Jarvis
The Hippocratic Oath and the Ethics of Medicine, S. Miles
USPSTF report on Prostate Cancer Screening
Worried Sick, N. Hadler
Many other physicians, non physicians and organizations have expressed their concerns about the prostate cancer industry through the web, journals and TV (not referenced here).
As I have outlined at the outset of this blog, instead of physicians seeking truthful answers to the most basic of prostate cancer treatment questions,
> are we saving significant numbers of lives?
> can the treatment be undertaken with acceptable risks and harm?
> a prostate cancer industry befuddled with many conflicts of interest, ownership conflicts, misrepresentations, mischaracterizations, downright falsehoods, over-reaching superlatives, meaningless statistics and an absolute lack of scientific evidence based medicine studies and data
> most, if not all prostate cancer “studies” represent “clinical” trial results severely tainted with bias, gross subjectivity concerns, bundling of various non-validated prostate cancer tumor volumes and Gleason scores as well as embarrassingly obvious self-serving definitions for treatment success and treatment complications
All men, sooner or later, will enter the minefield known as “prostate cancer evaluation
and treatment”. This is a veritable world of DECEPTION
> MEN ARE DECEIVED BY PHYSICIANS about the merits of the high-risk radical surgery/robotic prostatectomy when INSIGNIFICANT numbers of lives are saved (see the embarrassing USPSTF report)
> MEN ARE DECEIVED BY PHYSICIANS regarding the risks and lifelong harm associated with the radical surgery/robotic prostatectomy in that the complications stemming from the surgery are VERY SIGNIFICANT and often life long
> MEN ARE DECEIVED BY PHYSICIANS about WHICH PROSTATE CANCERS ACTUALLY NEED TREATMENT Only the high-risk prostate cancers demand treatment. The most common Gleason 6 (3+3) prostate “cancer” should NOT BE CALLED A CANCER as both CLINICAL and MOLECULAR evidence FAILS to support the ongoing practice of calling the Gleason 6 (3+3) disease a “cancer”
> MEN ARE DECEIVED BY PHYSICIANS about the self-serving campaigns for “screening”, “early” detection and for “early” aggressive surgical treatment when there are ZERO BENEFITS to support wholesale PROSTATE CANCER SCREENING especially for the common Gleason 6 (3+3) prostate disease for which there is ZERO JUSTIFICATION for labelling it a “cancer” or even treating it
> MEN ARE DECEIVED BY PHYSICIANS regarding the importance of the self-serving
PROSTATE CANCER “AWARENESS” campaigns and the well-intentioned PROSTATE CANCER SUPPORT GROUPS. These self-serving campaigns and groups have been hijacked by the prostate cancer industry for the express purpose of exploiting vulnerable men and directing them to a HIGH-RISK surgical treatment which they do NOT NEED
> MEN ARE DECEIVED BY PHYSICIANS about the “reliability” of the PSA blood test.
This PSA test (as well as the many other tests used in prostate cancer evaluation) is HIGHLY UNRELIABLE when used for screening and estimating the probability of prostate cancer. The PSA is useful in posttreatment monitoring
> MEN ARE DECEIVED BY PHYSICIANS about the risks of the office prostate biopsy.
The office prostate needle biopsy is highly risky (but DOES NOT spread cancer) and is unnecessarily uncomfortable
> MEN ARE DECEIVED BY PHYSICIANS about the accuracy of a prostate cancer biopsy diagnosis and the accuracy of the various imaging procedures used for staging. There are very significant subjectivity concerns associated with the pathological diagnosis as well as imaging interpretations, so much so, that all of these studies should be validated by an experienced, reliable, independent source before undergoing a high-risk prostate cancer treatment based on a non-validated diagnosis
> MEN ARE DECEIVED BY PHYSICIANS regarding the “clinical study information” “supporting” radical surgery/robotic treatment. There is ZERO SCIENTIFIC EVIDENCE
BASED MEDICINE DATA to endorse the ongoing use of this ill-conceived, toxic and mutilating robotic surgery for treating prostate cancer
> MEN ARE DECEIVED BY PHYSICIANS about so-called prostate cancer “surgical treatment” information in that much of the severely biased and misrepresented “robotic information” has been supplied to hospitals and surgeons by the robotic equipment companies
> MEN ARE DECEIVED BY SURGEONS about their impending postoperative course in that
postoperatively, unlike what they have been told, many men follow a very stormy course.
So much so that surgeons have resorted to psychological counselling before surgery so the patient does not have “too greater” expectations and can be prepared for his run-in with the many complications seen after the radical surgery/robotic prostatectomy.
As well, they prepare the men for undertaking postoperative penile “rehabilitation” for their impotence and biofeedback therapies for their urinary incontinence. In general, most men will experience a very sorry postoperative state of “limp and leaking” and loss of manhood along with a shortened penis, retained cancer and NO SIGNIFICANT LIFE-SAVING BENEFITS or survivorship
> MEN ARE DECEIVED BY PHYSICIANS regarding the cost-effectiveness of this ill-conceived and misguided robotic prostatectomy. For the common Gleason 6 (3+3) prostate disease there is pervasive unnecessary treatment (OVERTREATMENT). This overtreatment results from flawed medical reasoning, deceptive medical practices, as well as inefficiency of treatment services and contributes to the squandering of precious healthcare dollars. Incredible amounts of healthcare dollars are WASTED by this ill-conceived robotic prostatectomy “treatment” (probably more than for any other treatment for prostate cancer). Even more money is wasted on dealing with the many complications generated by this toxic robotic surgery. The management of these complications leads to additional laboratory and imaging costs, counselling and rehabilitation costs, extra supplies, more travel time, more lost work, more surgery etc. This appalling situation is especially relevant for those men with the Gleason 6 (3+3) prostate “cancer” who NEVER NEEDED TREATMENT (focal therapy or whole gland treatment) to begin with
Never before in any field of medicine has such a pervasive medical deception concerning the knowingly harmful surgical treatment of a cancer been practiced on so many gullible and uninformed men made vulnerable by a “cancer” label
Never before under the guise of “modern medicine” have so many men been deceived and exposed to such false hope, exploitation, risk and mistreatment only to survive the surgical assault, broken, incontinent and robbed of manhood
Never before have physicians intentionally deceived patients regarding cure and survivorship
Never before has such an erosion of physician trust and physician patient advocacy made such a mockery of “best practice guidelines” and “standard of care”
This unending deceptive practice of physicians endorsing the ill-conceived and toxic radical surgical/robotic treatment of prostate cancer knowing full well that it is associated with great harm and saves insignificant numbers of men, is shameful, scandalous and underscores intellectual, professional, academic and medical dishonesty. The insignificant benefits and great harm associated with prostate cancer surgery is a very inconvenient medical truth for physicians and the dictum “primum non nocere” requires urgent rediscovery. Surgical tradition and surgical treatment philosophy can never trump scientific fact.