11.10.2020 Culture

Is Watch and Wait or Early Detection the Best Method for Prostate Cancer?

Dr. Habib Sadeghi
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Because conventional medicine has largely failed at finding cures for all major diseases, the focus has shifted to early detection and quick intervention to save lives. Nowhere is this approach more prevalent than in treating cancer. We often hear about someone who is alive today because the doctors “caught the cancer in time”. In this way, most cancer awareness organizations promote early intervention.

Today, the fight against cancer has largely become a race game. Unfortunately, we’re finding that the early detection screening methods we once held up as the gold standard are seriously flawed and in some cases, entirely inaccurate. This is exactly the situation with the prostate-specific antigen (PSA), the test that since 1994 has been the premier screening for prostate cancer. Now, almost three decades of rushing into treatment is revealing how the lives of tens of millions of men were ruined, fortunes were created, and a healthcare disaster exploded.

A Runaway Mistake

In 1970, Dr. Richard J. Albin, PhD, was a researcher at The State University of New York College at Buffalo. He was attempting to discover an antigen (protein) that was specific to prostate cancer that could be used in diagnosing the condition. Unfortunately, what he found, the prostate-specific antigen (PSA), was present in both the benign (normal) and malignant prostate. There was no way to tell if a man had prostate cancer using the PSA, but with some additional analysis, it was found to be helpful for tracking the prostate for a recurrence of cancer but only after it had already been diagnosed and treatment was administered. As an initial diagnostic tool for cancer, it was useless.

In 1986, the FDA approved the PSA test as a tool to track the recurrence of prostate cancer. The biotech representatives present at the meeting were really after getting approval for initial cancer detection because it would have bolstered their efforts in developing immunotherapy drugs, but it didn’t happen. Although only one biotech lab, San Diego based Hybritech, was authorized to make the PSA test kit, several other labs almost immediately began producing their own off-label versions. The urology market was instantly flooded with PSA test kits that they began using indiscriminately to test men who’d never been officially diagnosed with prostate cancer for the disease. The practice became so widely accepted that by 1994, the FDA officially approved the PSA test for the initial detection of prostate cancer in men through regular testing beginning at age 50.

In a 2010 op-ed article in the New York Times titled, The Great Prostate Mistake, where he poured out his regret over the entire tragic process, Dr. Albin explained that the 1994 approval process hinged on a so-called study that showed PSA could detect a dismal 3.8% of prostate cancers. This happened to be a higher rate than the standard method at the time, digital rectal exam.

In his book, The Great Prostate Hoax: How big medicine hijacked the PSA test and caused a public health disaster, Dr. Albin describes how the 1994 FDA approval committee meeting disintegrated into chaos. Some physicians pointed fingers and screamed that blood would be on the hands of those who voted in favor of PSA being approved for prostate cancer detection. On the other side of the table were those who knew the test didn’t work but yelled back that “millions of men were dying” and the American medical establishment had to do something. As it turned out, there would be a lot of blood on a lot of hands because in the words of the man who invented the test, “With the 78% false positive rate and being wrong 80% of the time, I don’t know how the test was approved.”

In the end, habitual misuse and profit-hungry corporations that wanted to sell a prostate cancer prevention scam won out. It was tens of millions of American men who lost. The truth is that the PSA, which was once so revered and trusted as the definitive test for prostate cancer, has no cutoff for detecting the disease. Men have shown a PSA level as low as 0.5ng/mL and had prostate cancer, while those with a level as high as 11ng/mL have been cancer free. Still, in the early years of screening, any man whose test showed as little as 4ng/mL was immediately sent for a painful biopsy. Regardless of the fact that the test couldn’t decipher between benign or malignant cells, if there was any sign of cancer at all, he was quickly pushed into surgery with radiation to follow along with other harmful treatments. This so-called early detection and quick response happened almost without exception.

Loss & Profit

Considering the facts that the PSA is wrong 80% of the time and that approximately 30 million men each year for the last 26 years had the test, the number of men who have had their lives ruined is staggering. With prostates entirely removed or damaged beyond repair by radiation and chemotherapy, they’ve suffered through decades of urinary incontinence, impotence, hormonal imbalance and the intense depression that comes with such abrupt and severe biological changes.

The tragic truth is that with very rare exceptions, prostate cancer is extremely slow-growing. It’s so slow, in fact, that the vast majority of these men could have lived full, happy lives and never died of prostate cancer. Most men don’t.

Even now, when what has always been known about the PSA has finally become common knowledge, many doctors still don’t want to let go of the test. They still recommend that men get their yearly PSA screening starting at age 50. Perhaps they haven’t read Dr. Ablin’s book or the New England Journal of Medicine ten-year study that showed PSA screening does not reduce prostate cancer death rates in men age 55 and over.

To find out who’s still pushing routine PSA screenings, all you have to do is follow the money. The PSA became so widely used, it created its own mini industry within the healthcare industry. PSA screenings led to millions of unnecessary procedures that benefited surgeons, labs, radiology, pharmaceutical companies, a robotic surgical equipment market specifically for prostate procedures and proton beam development firms. Why else would we, in Albin’s words, “…spend $3 billion [a year] on PSA screening in asymptomatic men using a test that doesn’t do what it’s supposed to do.”

Albin himself has spoken directly to the CEOs of biotech companies explaining why the PSA test doesn’t work for detection. He describes their consistent response this way, “Dick, this is very interesting, but nobody is going to be interested in your story. Too many people are making too much money to stop this.”

The Turning Tide

It’s no surprise that the mainstream media has been largely silent on this crucial healthcare development. Even with the release of his book in 2014, the press wasn’t exactly knocking down Albin’s door. The media sources that weren’t silent did what they tend to do best, confuse the whole issue in the public’s mind by running articles on why the PSA still mattered and the so-called risks of not having a regular screening.

What does seem to be changing minds is an official statement originally made by the United States Preventative Services Task Force (USPSTF) in 2009 and reinforced as their final judgment, published in 2012 in the Annals of Internal Medicine. In their recommendation, the national organization of preventative health experts stated:

“There is convincing evidence that PSA-based screening programs result in the detection of many cases of asymptomatic prostate cancer. There is also convincing evidence that a substantial percentage of men who have asymptomatic cancer detected by PSA screening have a tumor that either will not progress or will progress so slowly that it would have remained asymptomatic for the man’s lifetime. The terms ‘overdiagnosis’ or ‘pseudo-disease’ are used to describe both situations….The precise magnitude of overdiagnosis associated with any screening and treatment program is difficult to determine, but estimates from the 2 largest trials suggest overdiagnosis rates of 17% to 50% for prostate cancer screening.”

“…the USPSTF now recommends against PSA-based screening for prostate cancer in all age groups.”

After the USPSTF made their final recommendation, PSA screenings dropped by up to 50% in some primary care clinics across the country. The biggest drop was in men age 50-70 and yet, some urologists are still wringing their hands with worry. The fact that 8 out of 10 doctors surveyed in Massachusetts said the PSA offered more harm than benefit suggests the tide may be turning.

Awareness Agencies Weigh In

Meanwhile, some major health organizations are choosing a less decisive position, even in light of the overwhelming evidence.

The American Cancer Society now urges “more caution” when pursuing the PSA screening.  The American Urological Association does not recommend PSA screenings for men younger than 54.

African American men, who naturally have a higher risk of prostate cancer, and men with a family history of the disease should make individual decisions as to what’s best for them. Men 55-69 should participate in “shared decision-making” and consider screenings every two years. No screening for men 70 and older. The American College of Preventative Medicine has stated there is insufficient evidence to warrant regular screenings. The National Cancer Institute states that any man considering a PSA screening should be informed of the risks and benefits beforehand.

Watch and Wait

My recommendation is the watch and wait method. Because prostate cancer is so slow-growing, most men will live happy lives and never die of the disease. In the meantime, we can use other, non-invasive, forms of treatment. If the cancer changes in anyway, we can address those issues when the time comes. This is the wisest and most humane approach, especially since American men have only a 16% chance of developing prostate cancer over their lifetime and just a 3% chance of actually dying from it.

Pass this article on to a man you love. National health organizations have a strong influence on the minds of Americans, and it will take time to reverse the blind belief in yearly early detection screenings with the PSA test. In the meantime, practice the early detection of fear-based healthcare recommendations that promote regular testing and fast follow-up treatment, because what you’ll actually be preventing is a decision you might later regret.

For more health insights from Dr. Sadeghi, please visit beingclarity.com to sign up for the monthly newsletter or check out his annual health and well-being journal, MegaZEN here. For daily messages of encouragement and humor, follow him on Instagram at @drhabibsadeghi.

1 Albin, R. (2010) March 9. The New York Times, The great prostate mistake, https://www.nytimes.com/2010/03/10/opinion/10Ablin.html.
2 Ablin RJ, Piana R. The Great Prostate Hoax: How Big Medicine Hijacked the PSA Test and Caused a Public Health Disaster. New York: Macmillan Publishers; 2014.
3 Topol, Eric. (August 8, 2014). PSA test is misused, unreliable, says the antigen’s discoverer. Medscape: news & perspectives. http://www.medscape.com/viewarticle/828854_3
4 Mahar, Maggie. (2010). The doctor who invented psa test calls it “a profit-driven public health disaster” . . . Why this is good news – see more at: http://www. Healthbeatblog. Com/2010/03/the-doctor-who-invented-psa-test-calls-it-a-profitdriven-public-health-disaster-why-this-is-good-new/#sthash. 0nrm87cj. Dpuf. . Health beat, (), http://www.healthbeatblog.com/2010/03/the-doctor-who-invented-psa-test-calls-it-a-profitdriven-public-health-disaster-why-this-is-good-new/. 
5 Andriole, G et al. (2009). Mortality results from a randomized prostate-cancer screening trial. New England Journal of Medicine.  360(13), 1310-1319, doi: 10.1056/NEJMoa0810696  
6 Topol, Eric. (August 8, 2014). PSA test is misused, unreliable, says the antigen’s discoverer. Medscape: news & perspectives. http://www.medscape.com/viewarticle/828854_3  
7 Ibid.
8 Moyer, Virginia. (2012). Screening for prostate cancer: U. S. Preventive services task force recommendation statement.  Annals of Internal Medicine. , 157(2), 120-134. doi:  10.7326/0003-4819-157-2-201207170-00459 
9 Thompson, Dennis. (May 17, 2015). Prostate cancer testing drops off following controversial guidelines. Research News: Prostate Cancer Foundation. https://www.medicinenet.com/script/main/art.asp?articlekey=188520
10 Mahar, Maggie. (2010). The doctor who invented psa test calls it “a profit-driven public health disaster” . . . Why this is good news, https://healthbeatblog.com/2010/03/the-doctor-who-invented-psa-test-calls-it-a-profitdriven-public-health-disaster-why-this-is-good-new/
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