Posted by: Christopher Maloney, Naturopathic Doctor | October 8, 2011

The PSA Is Dead; Long Live The PSA. Alternatives To Surgery.

Age-standardised death rates from Prostate can...

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For almost ten years now I’ve been telling patients to avoid prostate testing unless they have symptoms.  We’ve known for at least a decade that digital rectal examinations do nothing, that PSA fluctuates (drinking beer brings it down, vegetable intake brings it up), and that the biopsies miss the majority of cancers (catching 30%).

But a new government group has finally come on board and recommended what all the data show:  just say no to testing.  The Kennebec Journal covered this recommendation without a comment a few weeks after the end of Prostate Cancer awareness month.  During the month we had the standard recommendation by a patient to get tested.  So from the same news source we have contrary opinions within weeks of each other.

But patients will continue to get a hard sell on prostate cancer from the very people who’s livelihood depends on their ability to perform a routine number of radical prostate surgeries per month.  Is it disclosed on any paperwork that your surgeon receives a salary based on the average of the number of surgeries he performs for the hospital?  That salary can fluctuate dramatically if he does not perform.

In fact, I strongly suspect urologists and PCPs will continue to recommend PSA testing far into the future.   They get paid for the testing, which leads to follow-up testing.  In a very tight medical market, increasing testing on the same number of patients is an easy way to increase revenues.  A hospital system did this just last year.  Patient visits stayed the same, but testing increased by 30%.  The result was a much better looking bottom line.

What does this mean for the average person?  It means he is unlikely to receive unbiased advice.  Twenty years of recommendations do not turn around overnight.  I wrote recently on Quora that, while the scientific process is logical, the application of science is based on belief.  We aren’t likely to see the belief that PSA is somehow helpful go away until a new generation of doctors have been trained.

Here is a letter I wrote nine years ago to a prospective prostate cancer patient.

Dear Sir:

I’m glad you called me about your elevated PSA level test and the fact that your doctor wants to do an immediate TURP (surgical removal of the prostate) without further testing.

Given your age is 68, the normal range of PSA is 0-4.5.  If you were two years older, the normal range stretches from 0-6.5.  Because all men’s prostates grow with age, the PSA rises with age.  Since your PSA is 7.1, multiple tests would be in order because rectal examination, benign prostate hypertrophy, chronic low-grade prostatitis and possibly physical exercise or sexual activity may elevate PSA levels.  More importantly, PSA doubling time (how fast the PSA rises) and the amount of free PSA should be taken, because both are markers are helpful in determining your cancer risk.

Because your brother died of prostate cancer, your risk is 2.62 times higher (from an annual incidence of 58 per 100,000 men).  Unfortunately, being symptom free doesn’t mean for certain that you don’t have any cancerous cells.   The only way to tell if you have cancer is a biopsy.  While highly unpleasant, the biopsy is far preferable to any surgery, and any surgery prior to biopsy would be premature.

Giving a worst case scenario may actually be helpful.

If

you have multiple PSA testing and the PSA is rising, or the free PSA is very high, you need a biopsy.

If

the biopsy (usually four to six needle extractions from the prostate) is positive, you get a Gleason rating for the level of cancer.

If

the cancer is not aggressive, survival for men who do nothing (“watchful waiting” with continued PSA testing) can easily be as high as 90% (Swedish study).  A study of Minnesota men found that, unless the PSA got progressively higher, they only had a  7% chance of dying over a fifteen year period.

If

the cancer is aggressive, surgery or radiation therapy is the first line of defense.  A TURP is the more aggressive surgery, with a radical prostatectomy (RP) being less aggressive and more nerve sparing.  Radiation can also cause the used, with some success.  Newer chemotherapy may also be useful.

Notice there are a number of ifs, and most of them do not lead to an immediate TURP.  You may simply have an elevated PSA that is not rising or which actually falls in the next month.  At that point you are a prime candidate for watchful waiting, monitoring your PSA periodically.  If you choose to have a biopsy done, and unless the Gleason rating says it is an aggressive cancer, you would still be a candidate for watchful waiting.  Only if you had a biopsy and the cancer was aggressive would you need to discuss the various surgeries, radiation therapy, and chemotherapy options.  It concerns me that your doctor has skipped about three steps and has not even discussed surgical options with you before recommending a TURP.  It should be a standard part of your informed consent to surgery.  With due respect, I would consider having another physician monitor you if you choose not to have the surgery.

As a Naturopathic doctor, I was taught and practice an idea called “watchful waiting plus.”  Basically, if you choose to monitor your PSA levels you would not simply be waiting between tests.  Instead, we would be actively trying to lower your PSA levels through a combination of the following:

Dietary modification:  Japanese men have twenty times less clinically apparent prostate cancer than American men.  When they die they have as many localized, non-invasive cancers, but those cancers have never progressed.  When the Japanese immigrate to the US and change diets, clinically apparent prostate cancer risk increases significantly.  Since you also have hypertension, one side effect of dietary modification might be a blood pressure reduction.

Even if you choose to have immediate surgery, dietary change prior to prostate surgery improved outcomes.

Supplements:

Definitely selenium, Vitamin E, avoiding synthetic vitamin A, probably saw palmetto with other herbs.  If you choose more dramatic diet change, supplements may not be necessary.  On the other hand, if you do not wish to do dietary change but would like to explore supplements, a wide range of supplements have shown clinical benefit to the prostate.

Hydrotherapy:  sitz baths trial to see if it affects PSA levels.

Exercise program:  blood flow, lymphatic drainage.

Botanicals:  green tea, flax seeds, and pumpkin seeds.  Other immune modulators on a trial basis.

Homeopathy:  trial of acute therapy for prostate.  Constitutional if interested.

Bodywork:  stretching, specific draining techniques.  Yogic techniques for draining.

Manipulation:  check lumbar tension levels, sacral alignment.  Only important if prostate nerve and blood flow are blocked to some degree.

Community support:  locate support group, or utilize existing support of friends and family.  While not directly prostate related, a support network positively affects surgical outcomes and may double survival times.

I hope this is helpful.

Let me know if you have further questions or would like to schedule an appointment.

Christopher Maloney, ND


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  1. [...] The PSA Is Dead; Long Live The PSA. Alternatives To Surgery. (alternativendhealth.wordpress.com) [...]


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