Invasion of the Prostate Snatchers

NOTE TO READERS: This post, which is below the fold, is intended for older men, men around my age, as we face one of the scourges of our time, the threat of prostate cancer. If you are younger, you’re invincible, and will not benefit from reading this.

Richard J. Albin (1940-2023), a professor of pathology at University of Arizona College of Medicine, discovered the prostate-specific antigen (PSA) in 1970, and for nearly as long, he argued that it should not be used for routine screening. He and science writer Richard Piana wrote The Great Prostate Hoax: How Big Medicine Hijacked the PSA Test and Caused a Public Health Disaster in 2014. I purchased and read the book, and then passed it on to a man my age, thus guaranteeing that 1) it would never be read again by anyone, and 2) I would never see it again. I will never, however, forget the opening pages wherein Albin informs us that having an elevated PSA can mean many things, for instance, having had a vigorous workout at the gym, having driven a bumpy road, or having had a recent sexual encounter. The medical profession at that time, however, had one way of reading it – CANCER.

The book caught my eye because my older brother, who had unwarranted and unquestioning faith in doctors, had an elevated PSA, and thereafter underwent a biopsy (this was perhaps 2008 or so), and thereafter underwent a prostatectomy. I don’t know what he expected, but he was surprised at how hard the surgery hit him. Not long after, he developed a cancer in his intestines, and in 2011 died of a hardened lower intestine, toxins leaking throughout his body and killing him. Prior to death he fought that cancer with all his will, but eventually realized it was going to get him, telling me one time as we walked astride that he thought he was “looking down that tunnel.” What do you say? I said “It’s been so long since we’ve had good news from you.”

I had the temerity to ask him one time later if he thought there was a connection between the prostatectomy and the intestinal cancer, and he almost cut me off mid-sentence. “No!” Ah, I thought. He’s suspicious too.

I just read another book, Invasion of the Prostate Snatchers, from 2021, and keep that date in mind, as it could be that in the intervening years there have been further advances than those detailed in the book in treating (or ignoring) prostate cancer. Every year in the US, 200,000 men will be diagnosed. In my brother’s time, probably now too, 25-30,000 of those men men would die from prostate cancer. Of the remaining 170-175,000 men, well, they are going to die, of course, but not OF prostate cancer, but merely WITH it. In the majority of cases, it is so slow moving that it can be thought to be benign. I remember reading years ago that between the US and Great Britain, where in the US doctors aggressively treated prostate cancer using their severely intrusive methods, while British doctors merely monitored it, the death statistics in each country were virtually identical. This is why Albin called it a Hoax, as treatment by urologists was a lucrative field.

Some time closer to 2010 than 2020, I had a routine physical, my last, and was told I had an elevated PSA. Having read the Albin book, I noted at the time that that very morning I had worked out at the gym, and the night before, well, you know, so that my elevated PSA was probably situational. But no, the doctor was insistent that I visit a urologist. I did not. The odds heavily favored doing nothing. It is now late 2025, over a decade later, and I have to pee each night around 1AM. That interrupts sleep, but I do go back to it. Whatever set off the PSA all those years ago has not yet killed me, or even really affected me, though I am not so foolish as to imagine I’ve outsmarted anyone. I am just playing the odds and avoiding doctors, biopsies, radiation, surgery, and premature death. I much prefer the death that awaits me further down the road than the one that prostatectomy cannot prevent anyway.

I went through the book Invasion of the Prostate Snatchers, mentioned above, and recorded some of the more pertinent passages. They follow below. I assure you that having read those, which are brief in comparison to the length of the book, that you will have effectively read the book and will be as well-schooled in the risks of prostate cancer as anyone else outside the medical profession. Inside the profession? Who knows?

Every word that follows from here to the end is cited exactly from the book, with page numbers. You’ll sense two voices, a doctor, and his friend who is a patient at time of writing.

“The first duty of a man is to think for himself.” (José Marti)  (Page 3)

One of the most important discoveries in the last 15 years is that aggressive types of prostate cancer can be clearly distinguished from the Low-Risk types that don’t spread. These Low-Risk forms and some types of Intermediate-Risk prostate cancer are best managed with observation alone. With this new awareness, the old-fashioned-treat-everyone approach is obsolete.

The tragedy is most men don’t know this.

In other words, out of the 75,000 radical prostatectomies performed every year in the United States, more than 40,000 are unnecessary. In its heyday surgery was called the “gold standard.” However, research now confirms that many who were “cured” by surgery had a form of the disease that was never destined to threaten them anyway. (Page 3)

“I believe that when the final chapter of this disease is written, it will prove that never in the history of oncology will so many men have been so over-treated for one disease. [Thomas Stamey, MD, Former Chief of Urology at Stamford and developer of the PSA blood test] (Page 15)

When your PSA is elevated, rather than seeing a urologist to undergo a 12-core random biopsy, the industry standard, ask your family doctor about doing a prostate scan with a three-Tesla multiparametric MRI (MP-MRI, chapter 8]. Although I am absolutely in favor of doing targeted biopsy when it is appropriate, one of the reasons I agreed to write this book with Ralph was my concern about the vast number of random biopsies performed – not to mention the number of unnecessary surgeries that follow. (Page 19)

The point being that early-stage prostate cancer grows too slowly to cause death before such patients die of old age. Why put someone through the risks of surgery if it won’t extend his life? (Page 19)

[A patient’s] decision to forego treatment in those early years was his choice, not mine. I was aware of studies from Europe documenting that untreated prostate cancer could remains stable for decades, but those studies were in men much older than John, and I was initially hesitant to support his decision. But knowing how damaging treatment could be to his quality of life, I decided to follow his lead while being sure to keep a close eye on him. John was able to stay on a monitoring protocol for 20 years before finally undergoing radiation treatment.(Page 53)

Considering how well these men appeared, perhaps watching selected types of cancer is not as crazy as it sounds. The statistics are certainly compelling. Each year in the US almost 200,000 men are diagnosed with prostate cancer. 40,000 of them will undergo prostatectomy. Between 25,000 and 30,000 of them will die from prostate cancer at some point in the future. So what happens to the other 170,000 or so who will die from some other cause? Statistics show that over time, 25,000 of them will develop multistases. However, even though their cancer spreads, it still grows too slowly to cause death before other causes intervene and they succumb to old age or something else. They die with prostate cancer but not from it.

Therefore, continuing our calculations, that leaves at least 140,000 men every year who join the prostate cancer club but never develop metastasis or die of it. Liberal use of surgery and radiation can’t explain such high survival rates, because studies indicate that these treatments reduce mortality rates in men with Low-and Intermediate-Risk disease by only 1% to 2% and by less than 10% in men with High-Risk disease. (Page 55)

Perhaps because I was in my 70s, and to paraphrase Oliver Wendell Holmes, there is something to be said for the kind of simplicity that is found on the far side of complexity. I’m sure it helped that Jeannie and I are friends as well as lovers, and that her main concern was for my survival, not whether I could get a hard on.

Then it hit me: although my PSA had dropped to 0.05, essentially undetectable, and the tumor had shrunk, I still have prostate cancer. And it had been drummed into me that testosterone is the high-octane fuel for any cancer cells with an undiminished urge to travel, to migrate, to colonize. Yet I had actually been hoping that my testosterone numbers would bounce back to 300, 400, the higher the better. Was I out of my mind? It was the kind of paradox Jeannie and I used to laugh about, calling ourselves “The O. Henry’s,” the prototype O. Henry paradox being the one in the story “The Gift of the Magi,” where the husband sells his cherished watch to buy Combs for his wife’s lovely hair, and she cuts and sells her hair to buy a chain for his watch. I was hoping my testosterone would make a dramatic recovery, and yet if it did, it was a real risk that the cancer might take off, spread to my lymph nodes, into the bones. Good thinking! (Pages 65-66)

To confuse the situation, non bacterial prostatitis can also cause PSA elevation. Many men with this problem have no symptoms, and antibiotics have no impact. These men run chronically high PSA levels, so there is always the nagging question, “Is there a cancer working on a corner of the prostate that has somehow been missed?” Until recently, all it could be done is to pursue a thorough diagnostic workup with good imaging and selective biopsy. Now, however, the new PSMA PET scans give us an excellent way to double check to ensure cancer is not being overlooked. (Chapter 12). (Page 69)

In 2012, the government task force tried to address the problem of doctors over treating Low-Risk prostate cancer. Their strategy was to discourage PSA testing, which would reduce the number of men undergoing random biopsy, leading to fewer men being diagnosed with Low-Risk disease. In hindsight, the decision to disparage PSA testing was a terrible blunder. PSA is the only way to detect High-Risk prostate cancer before it spreads. So in 2016, the task force rescinded its recommendation against PSA testing. Also, now that we have better imaging, men with elevated PSA can be scanned rather than rushing into immediate biopsy. (Page 70)

So how can patients sidestep their urologist’s recommendation to do a random biopsy? Simply request a prescription for a three-Tesla multiparametric MRI (MP-MRI) of the prostate. Well-performed, randomized, double-blind studies clearly show that imaging is more accurate at diagnosing High-Risk prostate cancer than random biopsy. And MP-MRI is less likely to diagnose Low-Risk prostate cancer. In addition, imaging is far safer considering there is no risk of infection or impotence. If a high-quality scan shows nothing suspicious, assuming there are no other concerns – such as an abnormal digital rectal exam (DRE) or an elevated PSA density – men can forgo biopsy altogether. They can simply repeat the  MP-MRI in a year to keep an eye on things. However, if the MRI uncovers a suspicious lesion, a targeted biopsy is necessary. Targeted biopsy is usually only require two or three sticks instead of a dozen. The needles are aimed directly at the lesion, so targeted biopsy is much more accurate, less uncomfortable and less likely to cause infection or erectile dysfunction (ED).(Page 70)

As you know by now, I am no fan of biopsies. Despite the party line the trauma and bleeding from a biopsy will not spread cancer, I have a profound mistrust of having needles stuck in the my body to remove tissue samples, and an instinctual fear that biopsy can spread the cancer. As far as I’m concerned biopsies are a necessary evil, but under no circumstances should men allow themselves to be rushed into having one before less invasive diagnostic methods have been explored. One thing I remember, by the way, about Pandora’s box: once all the ills that affect humanity throughout, one thing remained, and that was Hope. (Page 73)

Modern radiation, called intensity modulated radiation therapy (IMRT), allows the width of the radiation beam to be reduced to mere millimeters. This means that radiation beams of variable intensity can be distributed throughout the prostate with great precision. Exposure to the rectum and bladder is greatly reduced, even eliminated, and the dose inside the gland can now be safely increased enough to eradicate the cancer. Complementary advances, like SpaceOAR, an absorbable gel place between the rectum and the prostate, provide even better protection. Progress is occurring on many fronts, and these improvements being much better cure rates with far less risk. (Pages 85-86)

Now, however, dramatically more accurate new technology called PSMA PET scanning has become available. This technology utilizes a radioactive agent injected into the bloodstream that floats around the body until it reaches onto prostate cancer cells. These scans can detect tumors as smallest 2 mm in diameter. This highly upgraded technology may be worth considering for men to allow them to continue pursuing active surveillance as long as their annual PSMA PET show that the cancer remains localized in the prostate. (Page 101)