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Prostate Cancer Dilemmas: To Test or Not to Test, To Cut or Not to Cut

The issue of PSA screening has been in the news lately. For instance, an article in USA Today reported the latest recommendations of the US Preventive Services Task Force (USPSTF): doctors should no longer offer the PSA screening test to healthy men, because the associated risks are greater than the benefits. The story was accurate and explained the reasons for that recommendation. The comments on the article were almost uniformly negative. Readers rejected the scientific evidence and recounted stories of how PSA screening saved their lives.

It’s not surprising that the public fails to understand the issue. It’s complicated and it’s counterintuitive. We know screening detects cancers in an early stage when they are more amenable to treatment. Common sense tells us if there is a cancer present, it’s good to know about it and treat it. Unfortunately, common sense is wrong.  Large numbers of men are being harmed by over-diagnosis and unnecessary treatment, and surgery may not offer any advantage over watchful waiting.

The Natural Course of the Disease

The natural course of prostate cancer is different from that of most cancers. It can be aggressive with early metastasis and death; but more often it is small, slow growing, and non-invasive. In the latter case, the patient dies of something else before the prostate cancer ever causes any harm. Autopsy studies of men who died of other causes found a prevalence of prostate cancer that increased with age and was as high as 80%. Obviously those 80% of men would not have benefited from pre-mortem diagnosis or treatment of their cancers. But prostate cancer does kill. Death rates per 100,000 population vary by race and ethnicity from around 10 for Asians to around 50 for blacks.  It would be nice if we could clearly differentiate those cancers likely to kill from those that are harmless. We can’t. So we have felt compelled to treat every cancer we diagnose.

PSA Levels

The PSA test doesn’t give simple yes/no answers. Using a cut-off of 4.0 ng/mL, only about 25% of men who have biopsies for elevated PSA levels are found to have cancer. And 15% of biopsies in men with lower levels of PSA also detect cancer.  PSA levels can be elevated for non-cancer reasons like an enlarged prostate (benign prostatic hypertrophy or BPH), inflammation of the prostate, urinary retention, a recent rectal exam, a recent biopsy, or even recent ejaculation. Most doctors look at repeated tests, the degree of elevation, and increases over time before deciding to biopsy.

Making a Diagnosis

If PSA results are worrisome, the next step is a needle biopsy, usually done through the rectum with ultrasound guidance. Biopsies are not yes/no tests either. Typically 12 areas are sampled. This leaves 99% of the prostate unexamined, so a cancer could easily be missed. The more sites biopsied, the more likely a cancer will be diagnosed and the less likely that the cancer will be one of those likely to kill the patient, so it’s difficult to decide how many biopsies are optimal. When initial biopsy results are negative, repeat biopsies are positive in 25-30% of cases. When cancers are detected, they are assigned a Gleason score based on their microscopic appearance. Gleason scores range from 2 to 10, with 10 having the worst prognosis.

Treatment

For the typical newly diagnosed patient the treatment options are surgery or radiation. There are other treatment options for advanced or metastatic cancer, including hormones and chemotherapy. New treatments being studied include cryosurgery and focused ultrasound.

Radiation can cause impotence, urinary problems, and an increased risk of other cancers. Surgery can cause impotence, incontinence of urine and stool, and for some unknown reason the penis may be 1-2 cm shorter after radical prostatectomy. Despite pre-operative counseling, men tend to be surprised and disappointed when they develop impotence and incontinence. A new study in the Journal of Urology found that  / a year after surgery, 46% reported that incontinence was worse than they had expected and 44% said sexual function was worse than expected.

The No-treatment Option

A recent randomized controlled study in The New England Journal of Medicine followed a group of men with localized prostate cancer for 12 years and compared the outcomes from radical prostatectomy versus observation alone.   They found that overall, surgery did not significantly reduce deaths from prostate cancer or all-cause mortality, although for a subgroup of men with a very high PSA level (over 10 ng/ml) there was a clear benefit from surgery. The study also collected data on the side effects of surgery. Within 30 days of surgery, 1/5 of patients had serious complications including deaths. Two years after surgery, 17% were incontinent, 81% had erectile dysfunction, and 12% had bowel dysfunction.

The USPSTF Recommendations

I won’t review the studies the USPSTF based their recommendations on. They did a thorough review of the literature and explained their findings in detail. They acknowledged that the evidence was conflicting but concluded that PSA screening detects more cases of prostate cancer but results in small to no reduction in mortality while resulting in substantial harm to many men. They recommended against PSA screening.

Not everyone agrees. Catalona et al. wrote about “What the U.S. Preventive Services Missed in Its Prostate Cancer Screening Recommendations” in the Annals of Internal Medicine.  The American Urological Association has also spoken out.  Urologists and family physicians may have different perspectives because they see a different patient population.

A new article in The New England Journal of Medicine,   “Quality-of-Life Effects of Prostate-Specific Antigen Screening,” revisits a large European study that showed a 29% reduction in prostate cancer deaths in men who underwent PSA screening. They used quality-adjusted life-years to measure both harms and benefits. Their findings indicate that the net effect of prostate-cancer screening could be a loss or a gain, depending on patients’ feelings about the downstream consequences of screening (such as the long-term consequences of impotence and incontinence from treatments that may have been unnecessary). Their findings support a shared decision-making process.

Current Practice

Most medical groups have accepted the USPSTF recommendations. If patients request testing, they recommend discussing the pros and cons and jointly making individual decisions based on risk factors and patient preferences. (Risk factors include age, ethnicity, family history, obesity, diet, and possibly smoking.) There are no simple answers, and we wouldn’t want to miss men with PSA levels above 10 ng/mL where treatment would make a difference.

Conclusion

Medicine is complicated.

 

 

 

 

 

 

 

 

Posted in: Cancer

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34 thoughts on “Prostate Cancer Dilemmas: To Test or Not to Test, To Cut or Not to Cut

  1. Good article with a good tone on a complicated issue, a few points:

    - I would agree that most medical groups agree with USPSTF recommendations, but there have been several significant disagreements. For example, the ACOG disagrees with USPSTF recommendations for mammograms, and there are minor differences in screening for pap smears. The AUA disagrees with the USPSTF PSA recommendations (as you pointed out), as do other professional urological organizations. It’s a double edged sword when looking at who disagrees. I would assume that a group of professional urologists would know the most in the world about urology. However, the point gets raised that “of course urologists want PSA screening, they make money from it! [well the biopsy, surgery, etc]“, but that’s not only insulting, it’s falsely accusing people of a criminal act. (I know you didn’t say that, Harriet, I meant certain anti-medicine goobers.)

    - You kind of made this point, but the positive predictive value for the PSA increases as the PSA level increases (ie, a PSA of 10 is very predictive.)

    - Good call on including the article about what the USPSTF missed.

    - It’s important that the lay-reader understands the language of the recommendations. The USPSTF has recommended against screening all male patients with PSA. What that means, is that they believe a doctor should not say “Ok, well, it’s time for your yearly PSA test. Let’s draw some blood and we’ll see what it is.” However, their recommendation does state that doctors should offer the test to patients if the patient wants it, as long as informed consent is given, meaning the patient is given the details of what the test does, what it shows, and what are the possible clinical outcomes (benefits, harms) if you go down that road.

    - The above point emphasizes the “shared decision making” model that medicine is moving towards. It’s rather paternal to say “No, you cannot have the PSA test.” However, if we explain the risk and benefits of PSA screening, and the patient wants it, then yes, it should be offered (and yes, this is in accordance with even the USPSTF guidelines.) People are different. Some are fine with the idea that “well, it’s more likely that you will die of other causes than the prostate cancer that is insidiously growing in your body, and you likely won’t have metastases to your bones that are so painful the only way we can control it is with radiation treatment”, but some people aren’t. And that’s why the recommendations allow for offering the test to individuals if they understand the risk/benefits.

    - The USPSTF is not the be-all end-all of recommendations. While their recommendation may very well be good and be the best possible thing for the patient, it doesn’t mean that all doctors are legally bound to practice medicine in this manner. It does give you a good legal defense though, ie, if a patient is found to have prostate cancer, and you get sued, it means that you have a defense saying “Hey, this guideline says to not screen PSA.” But, as a doctor you are not bound to practice by the USPSTF guidelines, you can practice by the AUA guidelines. I am *IN NO WAY* saying that the AUA guidelines are the correct and that we should pan-screen people for prostate cancer with the PSA.

    - Sincerely, I hope we find a better blood test, or an adjunct to the PSA, that allows us to better identify aggressive prostate cancers. Prostate cancer is the 4th (3rd?) leading cause of cancer death in male patients. That’s pretty significant. We need to find a way to detect it and eradicate it.

    - Out of curiosity, is there any data for how many prostate cancers are missed in a population that does undergo PSA screening?

    - Conclusion: Prostate cancer kills painfully. The PSA testing sucks, but it’s the best we have. Hopefully we can find a way to identify patients that are more high risk for prostate cancer and improve the accuracy of the test. I agree with Harriet that “medicine is complicated.” PSA screening is not as simple as saying “it causes too much harm, don’t ever do it.” (that’s completely wrong.)

    - Note: Please read and understand my post before replying to it saying that I’m an idiot who obviously doesn’t understand science. Also I apologize this is messy, I only have 15 mins in the morning to write.

  2. marilynmann says:

    Actually, radiation is more likely to lead to bowel problems than radical prostatectomy.

    Active surveillance or watchful waiting are options in low risk prostate cancer.

    I don’t find the PIVOT results very compelling. The men were on average 67 and many were in poor health. Half of them died by the end of the trial. Thus, it is not surprising that the trial did not show an overall benefit. In addition, the trial was underpowered. It is quite possible that if the trial had been adequately powered there would have been a benefit. The results of ERSPC showed a small benefit for treating early prostate cancer.

    That said, I agree with the gist of what you are saying. Prostate cancer screening as practiced in the U.S. over the last couple of decades may have done more harm than good. I don’t think PSA screening is going away, though.

    Men need to be better informed about their options. Decisions on screening and treatment need to be individualized. Among other things, men with limited life expectancy are unlikely to benefit.

    Ultimately we need a way to screen for prostate cancer that distinguishes between slow-growing and aggressive cancers.

  3. BillyJoe says:

    “Urologists and family physicians may have different perspectives because they see a different patient population.”

    That sounds suspiciously like making decisions based on “in my experience”.
    It is the reason I find the recommendations of the various Urological colleges unconvincing. They seem to be prejudiced by their collective individual experiences rather than based on the objective evidence.

  4. Janet Camp says:

    The other important point made at the beginning of your post is the outpouring of anecdotes in response to the article in USA Today. It is the same with any health reporting in the NY Times or anywhere else I’ve seen. There is much missing in education, even at the highest levels, as even many MD’s join in and write popular diet/health books. I saw one at the bookstore yesterday with the DR. WHOMEVER in a very large font, with Naturopathic “physician”, (my quotes) in a small font blurb toward the bottom).

    I also find the data on men who apparently do not believe what they are told about surgery outcome and side-effects to be related to the same kind of rather magical thinking that sucks so many into the altie/integrate crowd.

    Lastly, I never thought I’d say this as I’ve always felt that women suffer far more medical indignities than men, BUT, a biopsy with a needle through the rectum?–men have my deepest sympathy on that one!

  5. Ed Uthman says:

    Most large urology groups not only make money from treating prostate cancers detected through PSA screening, but they have branched out into moneymaking opportunities on the patients who don’t even have cancer. These groups have opened their own tissue labs and collect the substantial “technical component” charges for
    processing the biopsies they take as a result of working up a high serum PSA. Since the non-evidence-based “standard of care” dictates that each patient gets 12 separate biopsies, Medicare and other insurers pay the lab at least 12 times what a lab is paid for a breast biopsy on a woman. On top of that, many prostate biopsies require the use of immunostains (for racemase and high-molecular-weight keratin) to make subtle distinctions between low-grade prostate cancers and certain benign conditions that can look like cancer. These immunostains are also handsomely reimbursed.

  6. Ed Uthman says:

    As for the comment above, “PSA is the best we have” to screen for prostate cancer, I suggest that “not doing PSA screening” is better. If, as has been published in several studies, we have to radically treat 30 to 50 men to save one from dying of prostate cancer, that means that for any given man who undergoes definitive treatment (radical prostatectomy or irradiation), there is only a 2-3% probability that it did him any good at all, and a 97-98% probability that he went through all that, including a ridiculously high incidence of permanent disability, for nothing. With those numbers, it amazes me that anyone continues to advocate PSA screening. It grossly violates our Prime Directive: first do no harm.

  7. qetzal says:

    In the absence of PSA testing, how are prostate cancers typically detected?

    If there’s still good evidence for action when PSA > 10, why not maintain PSA screening, but change the action level? I’m guessing it’s because the ‘number needed to test’ to ID one patient with PSA> 10 is excessive, yes?

    More generally, I wonder if part of the acceptance problem relates to statements like “the associated risks [of PSA testing] are greater than the benefits.” The risks of testing per se are miniscule. It’s the actions being taken in response to an elevated PSA level that have excessive risks. The USA Today article explains that, but people have a tendancy to focus on the ‘sound-bite’ statements. Maybe it would be better to say that routine PSA testing isn’t recommended because it doesn’t actually distinguish who needs further testing or treatment and who doesn’t.

  8. Ed, just out of curiosity, do you have any resentment for these urology groups tissue labs potentially taking business away from you? I don’t mean to imply anything, but if you can hint that they do this to make money, then we can just as easily say your opinion is biased because your lab isn’t processing as many tissue samples.

    By the way, your website has a ridiculous amount of personal information on it. Your CV is impressive.

  9. Scott says:

    quetzal’s question is a good one. The conclusion here is not that the risks of screening are greater than the benefits, but that the risks of treatment are greater than the benefits. In other words, the problem is this:

    It would be nice if we could clearly differentiate those cancers likely to kill from those that are harmless. We can’t. So we have felt compelled to treat every cancer we diagnose.

    Doctors should not feel so compelled. If *treatment* were science-based, then the risks of screening would no longer be greater than the benefits, since there is virtually no risk of screening. One could then make the argument that a test with no clinical implications should not be performed on cost grounds.

    One could also envision a system wherein screening is routine but at a longer interval. Those with elevated values get more frequent testing to see if it hits that 10 level. Those who hit it, get treatment. Or something along those lines; obviously such strategies would require testing to see (e.g.) whether testing more often after a 5 really does a better job picking up 10s than testing more often after a 7.

    Regardless, it’s just wrong to take the risks of treatment and attribute them to the screening.

  10. qetzal, the problem with moving to a higher PSA number is that you can still have a PSA of 4.2 and have a high Gleason score prostate cancer. To answer your other question, on how we detect prostate cancer if we don’t detect it via PSA/biopsy, it’s difficult. Early prostate cancer symtpoms are relatively benign, and may or may not mimic benign prostatic hyperplasia. Late prostate cancer will be a patient with low back or other bone pain. In one of the studies Harriet linked above, I believe the one that describes what the USPSTF left out, it stresses the poor outcomes in patients who have metastatic prostate cancer.

  11. @Scott, I am not a urologist, but please see my reply to qetzal. You can have horrible prostate cancer without having a PSA of > 10.

  12. Conclusion: Medicine is complicated. I love it :)

    Part of the complication is the fear of cancer which is driving both treatment and screening decisions in many cases. I have written about this subject in my own blog and invite readers there for additional perspective on the complications.

    http://www.michaelwosnick.com/cancers-to-screen-perchance-to-treat/

    http://www.michaelwosnick.com/screening-for-prostate-cancer-psa-testing-or-not/

  13. qetzal says:

    SH,

    Sure, you can have a horrible prostate cancer with PSA of 4.2, but so what? I’ll bet the same can be true with a PSA of 1.8. What matters for PSA testing is whether any specific cut-off is sufficiently predictive of bad prostate cancer that it warrants further action. If we accept the claims descibed in the post, >4 is not predictive but >10 is. So, we shouldn’t biopsy or treat based only on 4 < PSA 10 really is predictive, so it seems there could be a case to do PSA screening with the higher cut-off. So I wonder if that’s been considered, or if there are valid objections to that.

  14. rork says:

    “You have bone mets Rork, but look on the bright side – we can now recommend treatment with confidence.”
    (Yeah, it’s so easy to complain.)

  15. @Michael, interesting essays. One bone to pick, you wrote how the USPSTF’s guidelines were based on “actual evidence.” But are you ignoring the evidence to the contrary? The AUA, etc, has done a great job of pointing out gigantic flaws (ie, control group individuals that were pre-screened with PSA) in the studies which the USPSTF used as it’s evidence basis. It is controversial, and there isn’t a single answer. But to imply that only the USPSTF’s recommendations are based in evidence is simply not accurate.

  16. Harvey says:

    In SBM discussions of prostate cancer I do not believe I have ever seen anything said about when to operate, or use alternate treatments. In about 2001 or 2002 my primary found, by digital exam, a blip on my prostate gland and sent me to a urologist. Since the ‘blip’ was small and my PSA level was low the urologist did not recommend a biopsy. In 2003 my PSA level was higher, and another trip to the urologist resulted in a biopsy. The result was a 3 and a 4, for a combined Gleason score of 7. My urologist offered me a choice of radiation therapy or surgery, but it seemed to me he favored the latter, so I opted for radical surgery. Since then my PSA level has been undetectable, and I have not regretted my decision. However, I have always wondered whether I made the best choice. Nine years later, at 81, I am in good health, my worst problem is with sciatica. I have an uncle who just turned 92 and an aunt recently died just before her 94th birthday. My mother, their sister, lived to 90, and I have a brother who is 88, so I may have a couple of years left. Would prostate cancer have ended my life by now?

  17. Harvey says:

    I perhaps should have ended that question with ‘without an operation’.

  18. DugganSC says:

    Hmm… the current recommendation is to not push the PSA tests, but to allow them in those who ask. I wonder whether this will eventually get targeted by the cost-benefit ratio people involved in insurance. Even if screening catches that one in a million case that would otherwise slip through, is it worth it to finance it if it’s only saving one person for every million tested? Will it become like the annual physical, something people feel obligated to ask for even when the evidence indicates they don’t need it, because their insurance covers it? That then leads to the question as to whether patients will go for it if it isn’t covered by insurance. I know that lately I’ve been asking my doctors before any test whether it’s one guaranteed covered by my insurance or one that I’ll be hit up for a few hundred dollars a month later when the insurance company decides the test is only to be partially reimbursed, or not at all.

  19. BillyJoe says:

    “Medicine is complicated”

    That certainly is the case. However the conclusion in the case of prostate screening is straight forward. Unless there is a clear benefit form screening, it is not justifiied. There is no clear benefit from prostate screening therefore it should not be done. But we live in a practical word where other factors interfere. The media have made the push for prostate screening and it is difficult to counteract. Patients want to know if they have prostate cancer, to have it diagnosed, and to have it removed. Both the media and the patients don’t think medicine is complicated. As a result they reach the opposite and wrong conclusion. What amazes me is that many, if not most, medically trained professionals also reach the wrong conclusion.

  20. @BJ, did you even bother to read the article that Harriet wrote? The entire point of it is that the “conclusion” of prostate screening is not straight forward.

  21. nybgrus says:

    without jumping into the specifics since it is a complicated topic, one should note carefully the concept and application of screening vs diagnostic testing.

    As the WHO says the principles of screening are:

    1. The condition should be an important health problem.
    2. There should be a treatment for the condition.
    3. Facilities for diagnosis and treatment should be available.
    4. There should be a latent stage of the disease.
    5. There should be a test or examination for the condition.
    6. The test should be acceptable to the population.
    7. The natural history of the disease should be adequately understood.
    8. There should be an agreed policy on whom to treat.
    9. The total cost of finding a case should be economically balanced in relation to medical expenditure as a whole.
    10. Case-finding should be a continuous process, not just a “once and for all” project.

    The issue here is that the natural history is not truly well understood – we know there is a lot of indolence, we don’t know how much, and we can’t differentiate. We also – clearly – cannot agree on whom to treat. Clearly population wide screens are not good, and a specific demographic has not yet been universally decided.

    Additionally, if you look at the “outraged” statement by the AUA:

    “when interpreted appropriately, the PSA test provides important information in the diagnosis, pre-treatment staging or risk assessment and monitoring of prostate cancer patients. ”

    Diagnostic testing and screening testing are different. Also “interpreted properly” is poorly defined. They continue with:

    “The decision to proceed to active treatment or use surveillance for a patient’s prostate cancer is one that men should discuss in detail with their urologists”

    This assumes prostate cancer is diagnosed…. which is not at all what we are talking about. You cannot assume the presumptive point of the test in arguing for the utility of the test.

    In other words, from my reading it seems that the AUA is more discussing a diagnostic use of PSA rather than a screening use and does not seem to define the population for screening beyond “men over 40 with greater than 10 year life expectancy.”

    So the point is that as a screening test PSA does not have evidence to support its use. You can argue that the evidence against its use is not sufficient either. But as a diagnostic test, or even as a screening test in high-risk populations (family history, personal history) nobody is questioning the utility of PSA testing.

  22. pmoran says:

    Yes, the screening of unselected populations has to be a hard-headed matter. It is a huge responsibility to take upon ourselves when we take a “normal” person and suddenly make them (or even perhaps permit them to become) permanently cancer-aware, potentially disrupting their whole lives with difficult decisions and drastic, damaging interventions, all without predictable benefits.

    That is before we consider the waste of resources (as per Nybgrus’s No 9 above) that others have pointed out. Someone has to pay and provide the infrastructure.

  23. @nybgrus,

    So the point is that as a screening test PSA does not have evidence to support its use. You can argue that the evidence against its use is not sufficient either. But as a diagnostic test, or even as a screening test in high-risk populations (family history, personal history) nobody is questioning the utility of PSA testing.

    Written perfectly, 100% agree.

  24. nybgrus says:

    @SH:

    Thanks. I was a tad worried I’d get embroiled in a flame war over this one. It is difficult and controversial. And I do think the AUA’s recommendation of screeninging every “male over 40 with greater than 10 year life expectancy” is definitely not supported by the evidence and I think the evidence demonstrates that using solely that as a criteria is not a good idea.

    If you have an abnormal DRE or other similar finding and then do a PSA diagnostically, that seems to be a no brainer.

    If you have a father and grandfather who had prostate cancer well, that seems like a good person to screen. But there is nuance even there. What if they had prostate cancer at age 70 and died from something else? Does that actually impart a greater risk to you? If it does, does that mean it is more likely to be an indolent cancer? I would argue that any cancer diagnosis after 70 is very likely to not impart much, if any, ncreased risk to your progeny. I don’t have any direct evidence to back that up, and I am sure there are plenty of exceptions, but it seems to make sense based on basic principles and evidence for other cancers and disease states. Does pops having an indolent cancer at 50 mean you are more likely to have an indolent one as well? Who knows. Perhaps yes. Are you willing to take that risk? I probably wouldn’t be.

    The point I am making is that even trying to define who is high risk is tough and the safe bet is to include a larger group than is likely necessary in order to avoid missing truly high risk men. So I agree that family history should be a flag for having a conversation about it. The patient should be informed of the risks and morbidity associated with “positive” test outcome. A strategy should be made in advance as to what the patient would want to do if [XXX]. And then, if the concern in an otherwise healthy male with no findings on physical exam is still high, go ahead and execute the plan.

    But to me, that is not really a “screening” test. Which is exactly what the USPTF says the PSA should not be. And more nuanced than the “outraged” reply from the AUA.

    At least, that’s my $0.02

  25. BillyJoe says:

    SH,

    SH: “@BJ, did you even bother to read the article that Harriet wrote? The entire point of it is that the “conclusion” of prostate screening is not straight forward.”

    Of course I read the article. My point about the conclusion that prostate screening is not straight forward is that it should not be done. Their must be clear benefit.

    nybgrus: “So the point is that as a screening test PSA does not have evidence to support its use. You can argue that the evidence against its use is not sufficient either. But as a diagnostic test, or even as a screening test in high-risk populations (family history, personal history) nobody is questioning the utility of PSA testing.
    SH: “Written perfectly, 100% agree.”

    Nybgrus’ consclusion is the same as mine but you agree with nybgrus and disagree with me.
    To be clear: to justify screening for prostate cancer, there must be evidence to support prostate screening, not just no evidence against prostate screening.
    In other words, prostate screening is not justified.

    (But note the qualifications in my last post regarding media and patient input/interference in medical decision making and what that means for the actual practise of medicine)

  26. BillyJoe says:

    ..sorry, I wrote the last comment quickly before setting off for work. The first response should have read:

    Of course I read the article. My point about the conclusion that prostate screening is not straight forward is that THEREFORE it should not be done. THERE must be clear benefit.

  27. Scepticon says:

    Off topic.
    Thanks for the link to my blog post on Cupping from your recent Slate.com article, Dr Hall.
    Very much appreciated.

  28. Great conclusion, that summarize medicine …

  29. hippiehunter says:

    Been vacillating about commenting on this article.

    I was diagnosed with prostate cancer at age 49, gleason score of 9.
    Surgery or death were my given options, naturally I opted for the former.
    My experience is that the subsequent incontinence is a bit embarrassing but lifelong impotence is perhaps too a price to pay.
    The reality of losing ones sexuality is VERY different to the hypothetical and it is often underplayed by medical and nursing staff who want you to choose the lifesaving option.
    Thats my 2 cents worth !

  30. I want to follow suite and write my anecdote about the patients who have died excruciating painful deaths from prostate cancer, while we watch them literally waste away into nothing, and then finally take their last breath and turn a shade of blue, but I don’t want to take anything away from your anecdote.

  31. hippiehunter says:

    Point taken SkepticalHealth its a shitty situation !

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