Most prostate cancer is relatively harmless — and the treatment is what wrecks men
A student of mine, 67, emailed me terrified last spring. His PSA had ticked up to 5.8. His urologist had ordered a biopsy. The biopsy found three small foci of Gleason 6 cancer.
The urologist sat him down and walked him through the options. Surgery. Radiation. Brachytherapy which is putting a radioactive seed in there.
He asked what would happen if he did nothing.
The urologist did not really answer.
The student emailed me from the parking lot.
I’ll tell you what I told him in a minute. First I want to tell you something most men have never heard.
By the time an American man is 60 years old, there is roughly a 2 in 3 chance he is already walking around with a prostate cancer in his body.
He doesn’t know it. His doctor doesn’t know it. It has never bled into his urine, never caused him pain, never shown up on any imaging.
It is microscopic.
It will, in all likelihood, never kill him or even bother him.
But if some doctor cores his prostate with 12 biopsy needles in search of it, the doctor WILL find it.
And then the whole machine starts moving.
I’ve been coaching men for twenty years. I’ve watched this system chew through men I love.
Today I want to tell you what the actual research says.
About how common prostate cancer really is. About what biopsies actually do to men. About whether radiation and surgery and chemo actually save lives.
And about what I believe is the real upstream driver of the prostate cancers that DO turn dangerous.
Because if you understand that last part, you can do something about it.
Settle in. This one matters.
What they find when they take prostates apart
In 1993, a pathologist at Wayne State University in Detroit named Wahib Sakr was running autopsies.
Trauma deaths mostly. Men who got hit by cars, men who were shot, men who died young of accidents.
Sakr decided to do something unusual.
He took 152 prostates from young men ages 10 to 49, stepped them all the way through in thin slices, and looked at every slice under a microscope.
He was not screening for cancer. He was running a population-level histology survey.
What he found upended the official narrative.
In men in their 30s, 27 percent had a prostate cancer at autopsy.
In men in their 40s, 34 percent did.
These were men who died young of unrelated causes. They had no symptoms. Most of them would have lived another 40 or 50 years and never known.
Sakr later expanded the work to older men in a 249-prostate autopsy series in the Journal In Vivo.
In men in their 50s, the rate was 55 percent.
In men in their 60s, 64 percent.
Roughly 2 in 3 men in their 60s already carry a (often very small; not always small) prostate cancer at autopsy.
A pathologist named Ryuichi Yatani did the same kind of work in five different populations.
He compared US Black men, US white men, Colombian men, Japanese men in Hawaii, and Japanese men in Japan.
The rates of “latent” prostate cancer at autopsy in men over 50:
US Black: 36.9 percent.
US white: 34.6 percent.
Colombian: 31.5 percent.
Japanese in Hawaii: 25.6 percent.
Japanese in Japan: 20.5 percent.
Roughly 1 in 3 American men over 50 already have a prostate cancer that will never show itself.
Yatani went back later and ran the same autopsy method on Japanese men 20 years apart.
In 1965 to 1979, the rate was 22.5 percent.
In 1982 to 1986, the rate was 34.6 percent.
In two decades, latent prostate cancer in Japanese men rose by 50 percent — as the diet Westernized and lifestyle changed.
That fact alone should tell you something.
Prostate cancer is not genetic destiny. It is being driven by something in modern life.
I’ll come back to what that something is.
Now do you see why I have been telling my students to be very careful about chasing PSA numbers?
The screening problem nobody talks about
Most prostate cancer is biological noise.
Tiny clones of misbehaving cells that the immune system has walled off and that will sit there, harmless, for decades.
But here is the thing about PSA screening. PSA does not distinguish between the noise and the signal.
It just tells you something is going on in the prostate.
It’s a test of prostate stress, basically.
PSA — prostate specific antigen — is a protein the prostate releases into the blood. The level rises with inflammation, infection, recent ejaculation, vigorous cycling, age, an enlarged prostate, and yes, sometimes with cancer.
So based on that PSA, the doctor orders a biopsy.
Now we have to talk about what that does.
What the biopsy needles actually do
A German urologist named Florian Wagenlehner ran a prospective study across 84 centers in 30 countries, tracking 521 men through prostate biopsy.
Every single man got prophylactic antibiotics before the procedure.
He tracked them for 30 days.
5.2 percent — 27 of 521 — developed symptomatic urinary tract infections.
3.5 percent — 18 of 521 — developed febrile infections, meaning fever-and-shaking-chills sepsis.
3.1 percent — 16 of 521 — had to be hospitalized.
This was WITH antibiotics. Sixty percent of the bacterial isolates were already resistant to fluoroquinolones, the standard prophylaxis.
Even with the best protocol money can buy, 1 in 20 men gets a bad infection from biopsy, and 1 in 30 ends up in the hospital.
A Canadian group led by Robert Nam at the University of Toronto ran a population-level analysis of every prostate biopsy in Ontario from 1996 to 2005.
They had 75,190 men in the dataset.
In 1996, 1.0 percent were admitted to a hospital within 30 days of biopsy.
By 2005, that number was 4.1 percent — a quadrupling.
The reason was simple. Antibiotic-resistant gut bacteria had become more common. The needle pushes through the rectal wall to reach the prostate, and it drags those bacteria with it.
About 1 in 25 prostate biopsies sent a Canadian man to the hospital.
With antibiotics.
You don’t hear this in the urologist’s office.
Then there is the question of what biopsy does to sexual function.
A urology group at Kansas led by Katie Murray ran a prospective study tracking 220 men through biopsy.
They scored erectile function on the IIEF-5 — a standard 5-question survey — at baseline, one week out, one month out, three months out.
Baseline score: 18.2.
One week after biopsy: 15.5.
One month after biopsy: 17.3.
Three months after biopsy: 16.9 — still significantly worse than baseline.
The authors called the prior literature “an underestimation” of biopsy’s sexual side effects.
Twelve needles through a man’s prostate gland leave behind twelve little tracks of injury and inflammation.
Three months later, the gland still hasn’t fully recovered.
And we haven’t even gotten to the worst part.
The needle that drags cancer with it
When you push a hollow biopsy needle into a tumor and pull it back out, what comes out of the gland?
Some of the tumor.
A urology group at Cambridge led by Dimitrios Volanis reviewed every case in the published literature where a man developed prostate cancer along the track of the biopsy needle.
In the rectum wall. In the perineum. In the abdominal muscle.
He found 42 documented cases across 26 publications.
42 in the entire published literature is rare. The incidence is estimated at less than 1 percent.
But “rare” is not “never.”
And the men in those 42 cases tell a chilling story.
A urology group at Walter Reed led by Judd Moul published a series of 2,107 perineal biopsies done at their center between 1975 and 1986.
Of the 502 men who had cancer found, 5 of them developed visible tumors at the biopsy site afterward.
All 5 developed distant metastases within 16 months.
Every one of them.
Median survival after the seeding diagnosis was 36 months.
These were men who would likely have had localized disease, sometimes never-detected disease.
Instead they got a needle dragged from their tumor through fresh tissue and seeded clones into places the cancer had no business being.
Read that and decide how relaxed you want to be about a biopsy.
I tell my students two things.
First, if you have a tiny PSA elevation, get a second PSA before you do anything. PSA fluctuates. Stress, sex, cycling, infection — all push it up.
Second, if you do go further, push hard for MRI imaging FIRST.
A good multi-parametric MRI of the prostate can identify whether there is anything worth investigating. If the MRI is clean, the needles can wait.
The needles are not benign.
The trial that proves doing nothing usually wins
In the late 1990s a urologist at Sunnybrook Hospital in Toronto named Laurence Klotz did something the rest of urology was not doing.
He told men with favorable-risk prostate cancer that they did not have to be treated.
He offered them a structured monitoring program. PSA every three months. MRI on a schedule. Repeat biopsy only if the numbers moved.
He called it active surveillance.
He enrolled 993 men.
He tracked them for 15 years.
After 15 years, more than HALF of the men — 55 percent — had still not needed any treatment.
The other 45 percent had crossed some threshold that triggered surgery or radiation later, often years into the protocol.
Of all 993 men, 15 died of prostate cancer.
15 out of 993. That is 1.5 percent.
The 15-year prostate-cancer-specific survival in his cohort was 94.3 percent.
At Johns Hopkins, a urologist named Jonathan Tosoian ran the same kind of program with 1,298 men.
10-year cancer-specific survival: 99.9 percent.
999 of every 1,000 men alive without prostate-cancer death at 10 years.
By doing nothing.
Now do you see what I mean about prostate cancer treatment being mostly noise?
The trial that should have ended American urology as we know it
In 2001 a British urology group led by Freddie Hamdy and Jenny Donovan started one of the most important randomized trials in modern medicine.
They identified 1,643 men with localized PSA-detected prostate cancer — exactly the kind of patient the American screening system produces daily.
They randomized those men to one of three arms. Active monitoring (n=545). Radical prostatectomy (n=553). External-beam radiotherapy (n=545).
Then they followed them for 10 years. Then 15.
At 10 years, the surgery arm had fewer metastases than the monitoring arm — 4.7 percent versus 9.4 percent. Half as many men developed visible spread.
But overall mortality was identical across all three arms.
Surgery and radiation did NOT extend men’s lives at 10 years.
At 15 years, Hamdy and Donovan published the long-term follow-up.
Prostate-cancer deaths over 15 years.
Monitoring: 17 of 545 (3.1 percent).
Surgery: 12 of 553 (2.2 percent).
Radiation: 16 of 545 (2.9 percent).
In the entire trial of 1,643 men with PSA-detected localized prostate cancer, only 45 men died of prostate cancer in 15 years. 2.7 percent.
The difference between doing nothing and getting cut open or radiated was less than 1 percentage point in cancer-specific survival.
read the rest at mattcook.substack.com