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Prostate Cancer Screening And The Golden Rule of Humanity by Sir. William Osler
I had worked as urologic surgeon for 30 years. When I was young, I only hoped to become an independent urologic surgeon and to gain as much surgical experience as possible. However, as I myself approached the target age for PSA screening, and having heard the opinions of the USPSTF and Japanese public health physicians, I could no longer recommend PSA screening to my patients. I had just turned 55 years old when I stopped being a urologic surgeon and became a public health physician. "I was told at my checkup that my PSA is elevated, what should I do?" or "I was diagnosed with prostate cancer and recommended to have surgery. Should I get it?" I've often been asked questions like these. "Forget about having a PSA test, and nothing bad can happen to you." I always reply. Lately I have become very aware of frequent urination, especially at night, but I will not see a urologist or get a PSA test.
Being a urologist is already a conflict of interest in discussing PSA screening. This is because a significant part of their salaries is paid for their medical practice in relation to early stage prostate cancer.
What will be the response when they change from being in a position to treat to being treated? We know of one such unfortunate case. Dr. Schellhammer was inadvertently given a PSA test and was diagnosed with prostate cancer. Despite being a urologist himself, the sudden result upset him, he said. Until then, he had been actively treating early-stage prostate cancer, and when he himself was diagnosed with prostate cancer, he began to praise active surveillance. However, the cancer later progressed and he had to undergo surgery, radiotherapy and chemotherapy and all treatments. Regardless of whether he died of cancer or other causes, it means that these tests and treatments were unfortunately not worthwhile. He would have been much happier had he not had the PSA test. He would still have had no clinical symptoms, would have considered himself healthy, would have retained his male function and would have lived his life without any worries. Prostate cancer, even if detected as an advanced case, can be treated successfully with hormonal therapy and the symptoms can be kept under control for an average of two years. He will be given enough time to carry out a list of ten things to do before he dies. Overall survival do not differ between early and late hormonal therapy.
Even in cases that do not have recurrence, neither they nor their families know whether they are one of the 1,000 people who escaped cancer death, as stated in the USPSTF decision aid, or one of the dozens of others who die from other causes that did not require screening and treatment as a result. Dr Aronowitz describes their feelings as "He no longer calls himself a cancer survivor". In the pre-treatment period, they are so upset because they have been diagnosed with cancer, it would be nearly impossible for the general public without any medical knowledge to understand the information given to them about cancer mortality, overall mortality, overdiagnosis, etc. Shared decision making looks good on paper but is very hard to do in practice
In fact, there is a large population of subjects for whom the ideal shared decision making is already in place, with a deep understanding of all the necessary information. It is the urological society of the world. The experts and authorities in the urological community who have vigorously promoted PSA screening since the 1990s, and who have dedicated themselves to refining the various techniques such as surgery, radiotherapy and so on, are now probably between the ages of 55 and 70, or even past those ages, which is the appropriate age for PSA screening. I have heard that some surgeons perform close to 1000 radical prostatectomies a year. They have in-depth knowledge and experience with prostate cancer and its treatment, and many of them are men and have prostates. Ask them if they have aggressively undergone PSA testing, a needle biopsy if it was even slightly elevated, and considered surgery if diagnosed with cancer, not to others, but to themselves. I believe that they are adhering to the Golden Rule of Humanity (“what you do not like when done to yourself, do not do to others”) .
For reference, Perry Hudson, the leader of The Bowery series of notorious and unethical experimental medical practices, lived to be nearly 80 years old, and although PSA screening was already common at the time, he apparently never had a PSA test or surgery himself.
REFERENCE
Schellhammer PF. Treater to target: a urologist's personal experience with prostate cancer. J Natl Cancer Inst Monogr. 2012 Dec;2012(45):143-5. doi: 10.1093/jncimonographs/lgs027.
Schellhammer PF. A Urologist's Personal View of Prostate Cancer. Turk J Urol. 2016 Sep;42(3):121-6. doi: 10.5152/tud.2016.50318.
Aronowitz R, Greene JA. Contingent Knowledge and Looping Effects - A 66-Year-Old Man with PSA-Detected Prostate Cancer and Regrets. N Engl J Med. 2019 Sep 19;381(12):1093-1096. doi: 10.1056/NEJMp1811521.
Takahashi TF. The golden rule: Do not do to others what you do not want done to yourself. Cancer. 2020 May 15;126(10):2319-2320. doi: 10.1002/cncr.32760.
Aronowitz R. From skid row to Main Street: the Bowery series and the transformation of prostate cancer, 1951-1966. Bull Hist Med. 2014 Summer;88(2):287-318. doi: 10.1353/bhm.2014.0037.
Re: Searching for answers: prostate screening in a stretched NHS
Dear Editor
Prostate Cancer Screening And The Golden Rule of Humanity by Sir. William Osler
I had worked as urologic surgeon for 30 years. When I was young, I only hoped to become an independent urologic surgeon and to gain as much surgical experience as possible. However, as I myself approached the target age for PSA screening, and having heard the opinions of the USPSTF and Japanese public health physicians, I could no longer recommend PSA screening to my patients. I had just turned 55 years old when I stopped being a urologic surgeon and became a public health physician. "I was told at my checkup that my PSA is elevated, what should I do?" or "I was diagnosed with prostate cancer and recommended to have surgery. Should I get it?" I've often been asked questions like these. "Forget about having a PSA test, and nothing bad can happen to you." I always reply. Lately I have become very aware of frequent urination, especially at night, but I will not see a urologist or get a PSA test.
Being a urologist is already a conflict of interest in discussing PSA screening. This is because a significant part of their salaries is paid for their medical practice in relation to early stage prostate cancer.
What will be the response when they change from being in a position to treat to being treated? We know of one such unfortunate case. Dr. Schellhammer was inadvertently given a PSA test and was diagnosed with prostate cancer. Despite being a urologist himself, the sudden result upset him, he said. Until then, he had been actively treating early-stage prostate cancer, and when he himself was diagnosed with prostate cancer, he began to praise active surveillance. However, the cancer later progressed and he had to undergo surgery, radiotherapy and chemotherapy and all treatments. Regardless of whether he died of cancer or other causes, it means that these tests and treatments were unfortunately not worthwhile. He would have been much happier had he not had the PSA test. He would still have had no clinical symptoms, would have considered himself healthy, would have retained his male function and would have lived his life without any worries. Prostate cancer, even if detected as an advanced case, can be treated successfully with hormonal therapy and the symptoms can be kept under control for an average of two years. He will be given enough time to carry out a list of ten things to do before he dies. Overall survival do not differ between early and late hormonal therapy.
Even in cases that do not have recurrence, neither they nor their families know whether they are one of the 1,000 people who escaped cancer death, as stated in the USPSTF decision aid, or one of the dozens of others who die from other causes that did not require screening and treatment as a result. Dr Aronowitz describes their feelings as "He no longer calls himself a cancer survivor". In the pre-treatment period, they are so upset because they have been diagnosed with cancer, it would be nearly impossible for the general public without any medical knowledge to understand the information given to them about cancer mortality, overall mortality, overdiagnosis, etc. Shared decision making looks good on paper but is very hard to do in practice
In fact, there is a large population of subjects for whom the ideal shared decision making is already in place, with a deep understanding of all the necessary information. It is the urological society of the world. The experts and authorities in the urological community who have vigorously promoted PSA screening since the 1990s, and who have dedicated themselves to refining the various techniques such as surgery, radiotherapy and so on, are now probably between the ages of 55 and 70, or even past those ages, which is the appropriate age for PSA screening. I have heard that some surgeons perform close to 1000 radical prostatectomies a year. They have in-depth knowledge and experience with prostate cancer and its treatment, and many of them are men and have prostates. Ask them if they have aggressively undergone PSA testing, a needle biopsy if it was even slightly elevated, and considered surgery if diagnosed with cancer, not to others, but to themselves. I believe that they are adhering to the Golden Rule of Humanity (“what you do not like when done to yourself, do not do to others”) .
For reference, Perry Hudson, the leader of The Bowery series of notorious and unethical experimental medical practices, lived to be nearly 80 years old, and although PSA screening was already common at the time, he apparently never had a PSA test or surgery himself.
REFERENCE
Schellhammer PF. Treater to target: a urologist's personal experience with prostate cancer. J Natl Cancer Inst Monogr. 2012 Dec;2012(45):143-5. doi: 10.1093/jncimonographs/lgs027.
Schellhammer PF. A Urologist's Personal View of Prostate Cancer. Turk J Urol. 2016 Sep;42(3):121-6. doi: 10.5152/tud.2016.50318.
Aronowitz R, Greene JA. Contingent Knowledge and Looping Effects - A 66-Year-Old Man with PSA-Detected Prostate Cancer and Regrets. N Engl J Med. 2019 Sep 19;381(12):1093-1096. doi: 10.1056/NEJMp1811521.
Takahashi TF. The golden rule: Do not do to others what you do not want done to yourself. Cancer. 2020 May 15;126(10):2319-2320. doi: 10.1002/cncr.32760.
Aronowitz R. From skid row to Main Street: the Bowery series and the transformation of prostate cancer, 1951-1966. Bull Hist Med. 2014 Summer;88(2):287-318. doi: 10.1353/bhm.2014.0037.
Competing interests: No competing interests