Over the last four years, it has become abundantly clear that any consumer of medical advice really must do their own homework on issues that impact them.
COVID made it crystal clear that getting a “second opinion” from a doctor does not qualify as doing your own research into your health. Doctors, medical systems and insurance companies all may be blindly biased and absolutely misinformed. Yet, this problem existed before COVID.
Jose Marti said, “The first duty of a man is to think for himself.” I agree with that 100%.
If you gain nothing more from this e-mail, I want you to clearly understand that just as there is an art to being a physician, there is an art to being a patient . . . You must choose wisely when to submit and when to assert yourself.
Let’s take for example testing and screening for prostate cancer.
The Prostate Specific Antigen (PSA) test was approved by the FDA for use as a monitoring tool for the progression of men with prostate cancer in 1986. Then, suddenly in 1994, the PSA test was approved by the FDA to screen for prostate cancer in conjunction with a digital rectal exam (DRE) to detect prostate cancer in me over the age of 50.
However, the FDA was made fully aware by the man who designed the PSA test of the fact that the PSA test has a 78% false positive rate.
This means that if you ask me for a PSA test, there is an almost 80% chance it will come back with a false positive. This false positive can occur for a number of reasons:
1. Prostatitis (inflammation or infection of the prostate)
2. Ejaculation within 48 hours of PSA testing [1]
3. A Recent Digital Retal Exam (DRE) with 48-72 hours of PSA test
4. Regular Riding of a Bicycle
5. Benign Prostate Enlargement (BPH)
6. Hemorrhoids
7. Use of Excess Testosterone
Why would I ever what to use test for screening that has near 80% of being falsely positive? Oh wait, the COVID tests were falsely positive 50% of the time.
If the PSA is elevated, then most urologists feel obligated to biopsy the prostate for prostate cancer. The problem is that a prostate biopsy comes with a 20% chance of permanent erectile dysfunction (ED) and loss of urination control.
Yes, you read that right. 20% of time that prostate biopsy is going to leave you unable to pitch a tent in the bedroom, permanently.
Why would you take the risk on a biopsy with a one in five chance of permeant ED and urinary leaking when a test is wrong 78% of the time?
I ask the same question of patients, yet they still insist on getting the PSA tested.
The reason, I suspect, is that no one wants to hear the words, “it’s cancer.” The word cancer is likely among the top words in our language that is considered the most distressing.
In the last two months I’ve had three patients, and their wives, who insisted on getting their PSA’s checked and now they are in my office anxious about their elevated PSA levels and concerned that their friendly neighborhood urologist now wants to biopsy their prostate to rule out cancer. The patients, or their wives, insisted that we check a PSA test after age 65 years old. And, as expected one in three men will have an elevated PSA test after age 65.
When I was training in my medical residency back in 2000 with a very prominent urology group in Phoenix, both the urologist told me on two separate occasions in no uncertain terms, “Dr. Nally, if you ever check my prostate or PSA after age 65, I will cut your fingers off!”
And, they were not joking. Both urologists had been in practice for nearly 30 years at the time. They had seen their share of elevated PSA tests and had followed these men for years.
Why would they tell me that?
Because, 500,000 men in the US and Europe are diagnosed with prostate cancer every year [2,3]. Yet, of the 75,000 radical prostatectomies performed every year in the United States, more than 40,000 of them are unnecessary.
This is important to understand because sexual function, frequent night time urination and bowel function are dramatically worsened by surgery, radiation therapy and medications used to treat prostate cancer. Quality of life is adversely affected dramatically [4, 5].
When the PSA test was approved in 1994, suddenly institutions around the country started mandating a PSA test yearly to screen for prostate cancer.
Sadly, thousands of men had falsely positive PSA’s and ended up getting very costly prostate biopsies. The led to a significant number of men having side effects from the biopsies. Yet, it became a VERY lucrative industry for the urologist.
In fact, the man who actually invented the PSA test, Dr. Harold Markovitz and the chairman of the FDA’s approval committee 1994, said, “I am afraid of this test. If it is approved, it comes out with the imprimatur of the committee . . . as pointed out, you can’t wash your hands of guilt . . . all this does is threaten a whole lot of men with prostate biopsies . . .it’s dangerous.”
Medicare decided that they wouldn’t pay for a PSA screening after age 65, unless the man was “symptomatic” with prostate enlargement, urinary frequency or other urinary symptoms. The FDA approved the PSA test conditionally. However, those conditions have since been ignored.
And since 1994, the PSA test has become celebrated as the elixir of salvation from prostate cancer. In fact, the US Postal Service even circulated a stamp promoting yearly PSA tests in 1999, the year I graduated from medical school.
I always say “follow the money.” Quite a few people became very wealth and well-known at the Hybritech company, thanks to the Tendem-R PSA test, their most lucrative product.
I understand, very clearly, that a cancer diagnosis creates tremendous anxiety, yet prostate cancer is one of the slowest growing cancers of them all when compared to other cancers and rarely poses an imminent threat to life.
In the overwhelming majority of cases, patients with prostate cancer do not die from cancer, but die from something else, whether or not they are treated.
In a 2023 article about this issue titled “To Treat or Not to Treat,” the author reports the results of a 15-year study of prostate cancer patients in the New England Journal of Medicine. Only 3% of the men with prostate cancer in the study died of the prostate cancer, and getting radiation or radical surgery for this cancer did not seem to offer much statistical benefit over “active surveillance” (watchful waiting) [7].
Data shows that men who get radiation and surgery for prostate cancer with low and intermediate risk reduce their mortality from the disease by only 1-2% and those with high risk only reduce their mortality by less than 10% [7].
Today, prostate surgery is still a dangerous treatment choice, but is still very widely recommended by urologists around the world. Sadly, it is often unnecessary.
Mass PSA screening campaigns over the last 20 years have resulted in a huge increase in radical prostatectomies. It’s been very lucrative for the average urologist. Yet, there is little evidence for improved survival outcomes in men in the recent years.
But, wait Dr. Nally, my urologist told me I’d likely be dead in 2 years if I didn’t get prostate surgery, one patient told me.
This is why I wrote this article . . .
Likely means 3% chance of death in 15 years. That’s the average statistic in a 15-year study of 2600 men with prostate cancer published in 2023 [7].
1 in 600 prostate surgeries result in death of the patient. 20 men out of 100 will have permanent impotence, urinary leaking, loss of bowel control and chronic bleeding after surgery. The psychological effect of these side effects is not a minor problem.
If your PSA is elevated, we are suddenly obligated to chase it. And, according to Dr. Scholz, “the urology world has a persistent overtreatment mindset” [6]. Much like COVID, there is, and has been for 20 years, a dramatic case of medical overkill.
In the words of Winston Churchill, “When I look back on all these worries, I remember the story of the old man who said on his death bed that he had a lot of trouble in his life, most of which never happened.”
We know that prostate cancer is made worse by insulin resistance. We also know that obesity is associated with a higher-grade cancer [8]. In my experience, ketogenic and carnivorous diets have superior impact on reversing obesity, insulin resistance and playing a major role in prevention and prognosis of prostate cancer.
And, we know that the high carbohydrate levels found in the standard American diet stimulate high estrogen levels and suppress testosterone in men which have been implicated in the cause and development of prostate cancer [9, 10].
So, my recommendation to you is, give the bread and fruit to the neighbor you don’t like, and have more bacon, brisket and burgers.
To Your Health, Happiness & Longevity,
Adam Nally, DO
Adam S Nally, D.O. 14800 W MOUNTAIN VIEW BLVD Suite 250 SURPRISE, Arizona 85374 United States (623) 584-7805
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