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A World of Hope and Dreams
– Early Detection A Very Painful Story What I am about to tell you has generated more hate mail to me than any other subject I have ever talked about. If you are one of those people who would rather live in a world of hopes and dreams, than learn the hard, but sometimes painful, facts, then please stop reading this article. One day on my daily radio show several years ago I announced that I was going to have a special guest; one of the world’s experts on breast cancer, a famous surgeon and author, Dr.Robert Kradjian, from Seaton Medical Center in Daly City, California (near San Francisco). My original plan was to talk to him about his new book on diet and breast cancer – Save Yourself from Breast Cancer. I was in a challenging mood that day, and decided to change the focus of the show. I questioned him for the hour on the early detection and treatment of breast cancer. Those 60 gut-wrenching minutes angered my guest and some of my radio audience. A few days following the show, I received a letter telling me, “I will never listen to your show again. You ruined the lives of four of my best friends with breast cancer. I asked them to tune in to hear about diet and breast cancer. You and your guest told them that they were going to die of cancer, suffer needlessly from painful and disfiguring treatments, and that their doctors had essentially lied to them. You took away all of their hopes.” And that is certainly one way to look at what I had done. This letter hurt me – I could feel the pain that I had caused for these women and others, who possibly for the first time had learned the truth about cancer. I read the letter on my radio show, and asked my listening audience for their responses. All of the calls I received for that hour were from women and they were unanimous, “Tell us the truth – no matter how much it hurts.” So here is the truth. However, to take some of the emotional edge from the subject I have chosen prostate cancer as my example – the subject of breast cancer is just too disturbing for many people – but the story is the same – breast cancer in women is essentially the same disease as prostate cancer is in men.1 We’re Losing the War on Cancer I would love to be able to tell you that we are winning the war on cancer – believe me, I do not want to see people suffer. Unfortunately, with the present day strategies of early detection, surgery, radiation, and chemotherapy, we are definitely not. In fact, your risk of dying from cancer (adjusted for your age) has increased by 6 percent from 1970 to 1994 (189.6 vs. 200.9 per 100,000 people).2 According to Dr. John Bailar, from the Department of Health Studies, University of Chicago, author of a landmark 1997 New England Journal of Medicine article, “The war against cancer is far from over. Observed changes in mortality due to cancer primarily reflect changing incidence or early detection. The effect of new treatments for cancer on mortality has been largely disappointing. The most promising approach to the control of cancer is a national commitment to prevention, with a concomitant rebalancing of the focus and funding of research.” (As you will learn soon, the principle way early detection changes mortality figures is by finding cancer earlier – making it appear people live longer – but not actually changing the day of a person’s death.) The failure to make a difference is not because of lack of money. The National Cancer Institute’s budget has increased 20-fold since passage of the 1971 National Cancer Act. Unfortunately, the funding for research and public information on primary prevention of cancer has been minimal.3 According to Samuel Epstein, MD, Professor of Occupational and Environmental Medicine, University of Illinois School of Public Health, “The cancer establishment bears major responsibility for the cancer epidemic, due to its overwhelming fixation on damage control--screening, diagnosis, treatment, and related molecular research--and indifference to preventing a wide range of avoidable causes of cancer, other than faulty lifestyle, particularly smoking.” You see – some of the most respected experts in the country understand, and are willing to publicly admit, that early detection and treatments for cancer fail, and that the right course of action is through prevention by a healthy diet and lifestyle. Early Detection for Prostate Cancer: PSA and DRE There are two tests that are commonly recommended by doctors for the early detection of prostate cancer: The PSA and DRE. Prostatic Specific Antigen (PSA) is a substance made exclusively by the prostate gland. Chemically, it is a sugar and a protein molecule (glycoprotein), which naturally leaks out into the bloodstream. The PSA test measures the level of this substance in a man’s blood. Inflammation (prostatitis), enlargement (benign prostatic hypertrophy), and cancer of the prostate can result in elevated test results. The PSA test is not foolproof and can rise without there being cancer present. It can also be normal when there is cancer. Approximately 2 out of 3 men with an elevated PSA level will not have prostate cancer.4 The higher the level of PSA, the more likely the problem is to be cancer. A cancer must grow to the size of 1 centimeter (cm) or about a half inch – before it is large enough to make the PSA rise above normal levels (above 4 ng/ml).5,6 (Remember this fact.) The digital rectal examination (DRE) is a physical examination of the rectum performed by the examiner’s finger. Through the wall of the rectum the doctor can feel the prostate gland in a man. In most cases, the cancer must be the size of a small marble (1 cm) for the doctor to feel an abnormality. (Remember this fact.) Startling (But Honest) Recommendations for Screening with PSA and DRE The U.S. Preventive Services Task Force, in December of 2002, published their guidelines and said, “The USPSTF does not recommend for or against routine screening for prostate cancer using DRE or PSA testing… The USPSTF concludes that evidence is insufficient to determine whether the benefits outweigh the harms for a screened population.”7 The European Union Advisory Committee on Cancer Prevention concludes (August 2002), “As long as randomised studies have not shown an advantage on prostate cancer mortality or related quality of life, screening for prostate cancer is not recommended as a healthcare policy.”8 The Canadian Urological Association discourages the practice of screening for prostate cancer.9 American College of Preventive Medicine (July 1998) recommends against routine population screening with DRE and PSA.10 The American College of Physicians (this is the official organization for Internal Medicine specialists – I belong to this organization) writes, “Despite its time-honored place as part of a complete physical examination, routine digital examination has not been shown to reduce a patient’s chance of dying of prostate cancer or to improve quality of life.” About PSA they say, “Routine measurement of PSA has not been proven to reduce the overall or disease specific mortality rate or to improve health-related quality of life.”11 The list goes on with most organizations worldwide recommending against routine screening for prostate cancer with a PSA or DRE. There are a few organizations, like the American Cancer Society, the American Urological Association, and the American College of Radiology that recommend these screenings – I believe these trade organizations have placed the physician’s financial interests ahead of patient’s well being. The evidence that early detection fails is so convincing that Dr. Mack Ruffin from the University of Michigan Medical Center wrote in the April 1995 issue of the Journal of the American Medical Association, “As a part of the informed consent discussion, physicians should disclose to patients that DRE, PSA, and TRUS (ultrasound) are unproven screening procedures. To do otherwise is deceptive and harmful to the trusting physician-patient relationship”12 “A cynical reading of ‘free prostate screening’ by urological practices suggests an underlying motive of income substitution -- from transurethral prostatectomies to ultrasound plus biopsy. We question the ethics of physicians using their trusted positions of authority to recommend unproven screening procedures for financial gain.” Patients are subjected everyday to free PSA tests as part of “Prostate Cancer Awareness,” an industry-sponsored advertising campaign which began in 1989 and has been targeted to men older than 50 years.13 Two Kinds of Prostate Cancer: Worldwide the incidence of prostate cancer, as found by microscopic examination of the prostate at autopsy, occurs in about 30% of men over the age of 50 years.14,15 In the USA the rate of microscopic prostate cancer is even higher at all ages; 30% of men in their 30s, 50% of men in their 50s, and more than 75% of men older than 85 years.16 However, for most men these cells that look like cancer never spread, and therefore never threaten a man’s life. These kinds of cancer are referred to as latent cancers. The cancers that kill are referred to as advanced cancer. I believe the rich Western diet is the determining factor that changes latent cancer into life-threatening, advanced cancer. Unfortunately, doctors cannot tell by looking at the prostate tissues under the microscope whether or not the cancer will ever become life-threatening. As a result, most men found with either type of cancer will be treated aggressively – surgery, radiation, castration, and/or chemotherapy – for a discovery (latent cancer) that would have never threatened their life. Just as tragic is the fact that those men who have the aggressive form of this disease also fail to benefit from treatment because in this case the discovery is far too late to be of any help. You will know why after you learn about the natural history of this disease. The Natural History of Cancer17 The next few paragraphs are probably more than you ever wanted to know about cancer – but for you to understand the truth about cancer you need to know how cancer grows and spreads. The argument for early detection of prostate cancer rests on the belief that the test can discover cancer in its early stages – before it has spread to other parts of the body. Unfortunately, the argument is groundless. Many lay people, and very few physicians, believe that prostate cancer goes through a series of steps in which it remains within the prostate for some time period until it spreads to the lymph nodes and then to the rest of the body. In their minds the process looks something like this:
Unfortunately, this step-by-step progression from a harmless mass to a body full of disease almost never occurs. Rather, cancer spreads to other parts of the body via the bloodstream in the very early stages of its development. The spread of cancer to the lymph nodes actually occurs simultaneously with the spread of the cancer to other parts of the body. Normal, healthy cells multiply only when necessary, such as during the growth of tissue or repair after an injury. Cancer cells, however, divide at their own free will and spread to other parts of the body where they continue this uncontrolled growth without respect for the body as a whole. This is how they transform a major organ into a non-functioning cancerous mass and eventually kill the patient. Like most other cancers, prostate cancer begins with the mutation of a single healthy cell into a malignant one. Once this transformation occurs, the single cell begins to replicate, or divide. The time it takes one cell to divide and become two cells is called the doubling time. The average doubling time for prostate cancer cells (as well as for most other solid tumors) is approximately 100 days. This means that in 100 days, a single cancer cell will have become two cancer cells. In 200 days, that one cell will now have become four cells in a prostate that consists of about 100 billion healthy cells. After one year, that tumor now contains twelve malignant cells. At this doubling rate, it takes about six years for the single cancer cell to become one million malignant cells, which together form a tumor that is about the size of the tip of a lead pencil. A mass of this size is less than one millimeter in diameter, and is undetectable by digital rectal examination (DRE), or by PSA. Even though the cancer is so tiny that it cannot be detected, it nevertheless has already spread, or metastasized (in medical terminology), to other parts of the body in virtually every case of true cancer (as opposed to the latent form of cancer). It is the cancer cells that have spread to, say, the liver, lungs, bones, and brain, that kill the patient, and not the cancer cells confined to the prostate. After about 10 years of growth, the average cancerous mass inside the prostate is about one centimeter in diameter, or about the size of an eraser on the end of a pencil, and consists of about one billion cells. This is the earliest stage at which most tumors can be felt by the physician’s probing finger. Also, the tumor must reach a similar mass of one centimeter before it begins to elevate the PSA level into the abnormal range (above 4 ng/ml).5,6 As you can see, early detection is a misnomer -- three-quarters of the disease has already happened unbeknownst to the patient or his doctor. A Very Positive Note: Please let me add, you now understand the natural history of prostate cancer so you know how changing to a healthy low-fat, plant-based (McDougall type) diet can save a patient’s life. The average doubling time for a cancer cell is 100 days. However, in some cases the cells double every 24 days – at the other extreme, cancer cells may double every 800 days for a specific patient. The goal is to slow the doubling time so he would have to live to be 175 years old to die of prostate cancer. Diet is the key to slowing the doubling time. Treatment for those Who Don’t Need It It is commonly quoted that “many more men die with prostate cancer than from it.”18 Considering that 30% of men over age 50 years have prostate cancer as determined by microscopic examination, and only 3% die of it, there is great potential for over-diagnosis and over-treatment with resulting harm to the patient.14,15,19 Radical prostate surgery rates have increased six-fold between 1984 and 1990, since the development of the PSA test, yet the death rate from prostate cancer has remained essentially unchanged for the past 30 years.20 The consequences of over-diagnosis are serious. Just knowing you have cancer is life-changing. You and your family now worry about you dying, you can no longer get health and life insurance, and sometimes this knowledge may keep you from your choice of employment. The consequences of over-treatment can be impotence, and incontinence (requiring a diaper or permanent catheter), and occasionally death. Because the treatments sometimes do kill, especially in populations of older men, there is even the argument that cancer screening will actually increase the number of deaths in older men. According to one letter in the Journal of the American Medical Association, a PSA campaign to screen 50,000 men age 75 and older is estimated to result in 123 more deaths than the 436 men that would be expected to die without surgery.21 According to Otis Brawley of the National Cancer Institute, “The benefits of screening and early detection, although theoretically possible, are yet unknown, whereas the risks and harms of screening and resultant treatment are definite.” And he put it another way, “Although it (screening) may truly cure a few men who need to be cured, this benefit may be achieved at the cost of causing a large number of men with prostate carcinoma to undergo unnecessary treatment and resultant morbidity (illness).”22 There are two large trials underway in the US by the National Cancer Institute, and in Europe by the European Cancer Programme, that will add further to our understanding of benefits and harms of early detection. However, except for the hype that follows the release of the study results, I don’t expect the facts will change much. Your Prostate is For Sale Four years ago I was a guest on the Charlie Brennan morning talk show on KMOX radio from St. Louis, Missouri (one of the nation’s most powerful radio stations). I briefly mentioned a few facts about prostate cancer and PSA tests – explaining why I felt men should avoid this test and how a healthy diet is where they should put their energies (see the February 2003 McDougall Newsletter for more about diet). Following the show I received a call from the producer saying that another doctor had complained vigorously about my comments – and said I was doing great harm to men. I suggested a debate and asked, “Who had made the complaint?” William J. Catalona, M.D., professor of surgery and director of the Division of Urologic Surgery at George Washington University Medical School. We met on a Friday morning – both of us on the phone with our hosts on the Charlie Brennan radio show. I presented many of the facts you have just finished reading. He countered with “Thousands of men die of prostate cancer every year and our only hope is to detect it early.” How could I contradict decades of brainwashing? I was losing. So I tried a desperation move. I said, “I would like to state that I have no financial ties with prostate cancer. Would my opponent admit to any connection that might influence his opinion? This information is vital for people to understand the disparity in our views on the use of the PSA test.” He would not answer, and the host (Carol Daniel) did not insist on a full disclosure. But, Dr. Catalona immediately changed his attitude toward the discussion and said, “Everything Dr. McDougall has said is true.” One point ahead for me – but not for long. He won the audience back by appealing to what they had always learned to be true – detecting cancer early is the only way to save your life. I could not counter years of education from the cancer business. Finally, at the end of the show he was confronted by the host, “Before we end, would you like to answer Dr. McDougall’s question concerning your financial ties to the prostate cancer business?” He began with a denial. Then I interrupted, “Dr. Catalona, do you know anything about a company called Hybritech, Inc., of San Diego, California? Doesn’t this company pay for your research? Do you receive money to speak for this company?” Hybritech, Inc. manufactures PSA tests, and he admitted this company paid for his research and for him to speak on its behalf – but added that this had no influence on his research outcomes or opinions. Only the careful listener understood the importance of this admission. Money – not honest scientific evidence – determines the medical care you receive and ultimately the quality and length of your life, and your family’s welfare and happiness. [If you want to learn the information on early detection and breast cancer – mammography and breast self-examination – please read the McDougall Program for Women book and the February 2002 McDougall Newsletter.] References: 1. Coffey DS..
Similarities of prostate and breast cancer: Evolution, diet, and
estrogens. 2. Bailar JC 3rd. Cancer undefeated. N Engl J Med. 1997 May 29;336(22):1569-74. 3. Epstein SS. The crisis in U.S. and international cancer policy. Int J Health Serv. 2002;32(4):669-707. 4. Woolf SH. Screening for prostate cancer with prostate-specific antigen. An examination of the evidence. N Engl J Med. 1995 Nov 23;333(21):1401-5. 5. McNaughton C. Early detection of prostate cancer. Serendipity strikes again. JAMA. 1997 Nov 12;278(18):1516-9. 6. Brawn PN. Prostate-specific antigen levels from completely sectioned, clinically benign, whole prostates. Cancer. 1991 Oct 1;68(7):1592-9. 7. Harris R . Screening for prostate cancer: an update of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002 Dec 3;137(11):917-29. 8. Advisory Committee on Cancer Prevention. Recommendations on cancer screening in the European Union. Eur J Cancer. 2000;36:1473-8. 9. Ramsey EW. Early detection of prostate cancer. Recommendations from the Canadian Urological Association. Can J Oncol. 1994 Nov;4 Suppl 1:82-5. 10. Ferrini R . American College of Preventive Medicine practice policy. Screening for prostate cancer in American men. Am J Prev Med. 1998 Jul;15(1):81-4. 11. Coley CM. Early detection of prostate cancer. Part I: Prior probability and effectiveness of tests. The American College of Physicians. Ann Intern Med. 1997 Mar 1;126(5):394-406. 12. Ruffin MT 4th. Screening for prostate cancer. JAMA. 1995 Apr 19;273(15):1175. 13. http://www.pcaw.com/about/index.asp 14. Franks LM.
Proceedings: Etiology, epidemiology, and pathology of prostatic cancer. 15. Holund B. Latent prostatic cancer in a consecutive autopsy series. Scand J Urol Nephrol. 1980;14(1):29-35. 16. Sakr WA . The frequency of carcinoma and intraepithelial neoplasia of the prostate in young male patients. J Urol. 1993 Aug;150(2 Pt 1):379-85. 17. Friberg S. On the growth rates of human malignant tumors: implications for medical decision making. J Surg Oncol. 1997 Aug;65(4):284-97. 18. Selley S .
Diagnosis, management and screening of early localised prostate cancer. 19. Ries L. SEER cancer stastics review, 1973-1997. Bethesda, MD.: National Cancer Institute, 2000 (NIH Publication no. 00-2789.) 20. Lu-Yao GL. Changes in prostate cancer incidence and treatment in USA. Lancet. 1994 Jan 29;343(8892):251-4. 21. Robbins AS. PSA and the detection of prostate cancer. JAMA. 1994 Jan 19;271(3):192-3. 22. Brawley OW. Prostate carcinoma incidence and patient mortality: the effects of screening and early detection. Cancer. 1997 Nov 1;80(9):1857-63.
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