Dr Glatter and Dr Samadi - Together in Forbes!

Dr Robert Glatter is a medical doctor who is a regular contributor to Forbes, a huge global print and on line portal for news and opinion.  

He started writing for Forbes in February 2012 and has been contributing on almost a weekly basis.  It was not until December 2013 that he wrote his first piece on prostate cancer entitled "Inflammation Noted In Repeat Prostate Biopsies Linked To Reduced Future Prostate Cancer Risk".  This was actually quite a well written informative piece.

He next wrote about prostate cancer on 7 March 2014.  All of a sudden, prostate cancer has become the flavour of the month with further articles on 6 April 2014, 10 April 2014, 21 April 2014, 4 June 2014 and the most recent piece on 20 September 2014.  

It seems rather odd that there is this sudden interest in prostate cancer.  He does write a lot of articles on other subject matters but the frequency of prostate cancer topics has been disproportionately higher during the course of this year.  This made me wonder as to whether there was some explanation for this.  The most glaringly obvious common binding feature about all of his articles on prostate cancer this year has been the mention of Dr David Samadi.  

Briefly, Dr Samadi is a celebrity urological surgeon who has a program on the Fox Channel called Housecall.  He cites amazing figures for prostate cancer surgery outcomes that defy the academic literature, particularly with his claims of providing a 97% cure rate from prostate cancer. He also earns a great deal of money and was the highest earning doctor in 2012 according to a New York Post investigation stating "The city’s top earner was urologist and prostate-cancer specialist Dr. David ­Samadi, whose 2012 compensation came to $7.6 million."

Okay, back to Dr Glatter.  Who is he?  I have never met him and only discovered him through reading articles on the Forbes website where my friend and colleague Dr Benjamin Davies is also a contributer. The easiest way to start is Google.  The first hit is his work at Forbes.  The second hit is his twitter account.  His bio states the following:- "Emergency Medicine Physician-Lenox Hill Hospital /Media Spokesperson/Forbes Contributor/WebMD Editor/DR 911 housecall practice" and also provides a link to a website.  

Hang on a second - Lenox Hill Hospital?  Isn't this where Dr Samadi does his work?  I don't know the relationship between Dr Glatter and Dr Samadi but if there is any conflict of interest, it should be declared on the Forbes website.  In particular, the fact that Dr Glatter works at Lennox Hill Hospital is not listed anywhere that I can find on the Forbes website. It may be all innocent but in the context of this sudden increase this year in prostate cancer articles, all of which lavishly cite Dr Samadi, raises questions on transparency.

On a final note, the most recent article from 20 September 2014 is a far cry from Dr Glatter's excellent first article on prostate cancer in December 2013 (incidentally, he does not actually mention Dr Samadi at all in this first article).  Not only does he promote the hashtag #samadichallenge but also makes ridiculous comments such as "In case of a positive diagnosis, urge men to seek Treatment immediately" - this demonstrates a lack of insight of the biology and natural history of prostate cancer.  It goes totally against the direction taken by leading urologists which is to be less aggressive in treating clinically significant prostate cancer.

Statements like "Symptoms of prostate cancer may include changes in urinary function including a burning sensation, blood in the urine or semen, frequent urination, as well as a weak or interrupted flow" only create fear and alarm amongst men with urinary symptoms.  It is uncommon for prostate cancer to cause urinary symptoms when clinically localised - any clinician would know that it is the non-cancerous condition of the prostate called benign prostatic hyperplasia (BPH) that causes the symptoms.  It is these symptoms that lead men to get checked by their doctors who then serendipitously diagnose their cancers.  It is not a cause effect relationship.

The hashtag #samadichallenge with a doctors name in it? Is the aim to achieve awareness about the doctor or about prostate cancer? I am happy to be instructed on this. 

And Dr Glatter, is there any relationship of any sort between yourself and Dr Samadi? If so, be transparent and declare.  If not, state that to be the case.  It is hard otherwise to not be suspicious about the sudden interest in prostate cancer articles where Dr Samadi comes across to me as being featured expert in each of them..

Men with High Gleason Score Prostate Cancer should be given honest appraisals and expectations of outcomes from treatment

Men with a Gleason score 8-10 cancers have a significant chance of not being cured by radical prostatectomy.  Only in very exceptional circumstances would a man with a Gleason score 8-10 cancer be offered surgery if extent of disease scans (typically scans such as a bone scan and CT scan of the abdomen and pelvis) show evidence of spread to other organs.  

The vast majority of men with Gleason score 8-10 prostate cancer are offered surgery because there is no objective sign of cancer spread on scans and provided other factors such as age and concurrent medical problems are not likely to be an issue.  The big BUT is that if such scans fail to show signs of spread, it does not mean that spread has not occurred.  We know for a significant number (at least 30-50%) will have already had microscopic spread that is simply beyond the resolution of the scans to detect.  In other words, let’s say that some cancer cells from the prostate gland have managed to enter into blood vessels or lymphatic vessels and travel all the way to either the bones or lymph glands respectively. Remember that tiny deposits less than a millimetre is size would have no chance of being seen by a scan.  Before operating on such men, we need to be honest with them about this possibility.  They need to recognise that even if we are to successfully remove the prostate and have the prostate specimen margins free of cancer, it does not mean that they have necessarily been cured.  It is simply one of a number of hurdles that have been jumped over.

Having a Gleason score 8-10 prostate cancer is bad enought but if we look at men who have Gleason score 10 cancer in particular, we would regard these men as having a very high (not just high) risk of existing microscopic spread.  When these men undergo radical prostatectomy, a typical expectation is that less than 40% will be alive in 10 years without having signs of detectable spread of the cancer.  Even fewer will be alive with signs of cancer having returned as evidenced by their PSA blood test levels. In other words, most men with Gleason score 10 cancer will not be able to be cured.  This of course does not mean that these men should not be offered treatment with curative intent but it is an indication that appropriate counselling be offered and that men not be given false expectations about their prognosis.  It would be brave to suggest to such men that after surgery for a Gleason score 10 cancer, that they had ‘beaten it’ just because the surgical specimen showed that the excision margins did not have cancer at the edges (also known as positive surgical margins).  Another consideration is that these men who have arguable the worst prognosis, should be offered the opportunity to participate in clinical trials give them access to additional promising treatments that could offer them the best hope of overcoming these cancers. In my opinion, this is less likely to be offered in the setting of treatment by commercially driven surgeons.

There is more to treatment decision making processes than what the Gleason score is found to be on prostate biopsies. This blog piece attempts to show just one aspect of how we consider how we embark upon offering the best for our patients. 

The intention was not to make this blog piece sound like an argument against offering men with the most aggressive prostate cancers any treatment.  I regularly offer men with clinically localised 'high risk' prostate cancer treatment with curative intent.  In spite of our recognition that many will experience signs of failure to cure the disease, treatment offers these men their best chance.  Recent randomised control trial data shows that there is increasing evidence that treatment for this particular group of men makes a clinically relevant impact upon their survival.   

On a final note, I draw attention to a tweet from Dr David Samadi who is a 'celebrity' urologist who claims cure rates of 97% from prostate cancer surgery - he indicates that he has a patient who had just recently undergone surgery who had now ‘beaten the disease’ and is celebrating. You make up your own mind whether the patient has been given realist expectations on what the future holds for his cancer.  When the PSA starts rising, will Dr Samadi look after him now that the surgery is done, or simply refer him to another specialist (medical or radiation oncologist) to manage something that is no longer for him to look after? I do not know the answers to these questions but leave it in your mind to decide.

A Personal Perspective on Testing for Prostate Cancer - 2013

As an urologist who has subspecialized in just the area of prostate disease, I see men with prostate cancer every working day.  Every single consulting session I will see a number of men with advanced prostate cancer who are enduring either the side effects of the palliative drug treatment for advanced prostate cancer or who are battling the complications associated with advanced prostate cancer. 

In Australia, over 3,200 men die from prostate cancer each year.  This is a greater number than the women who succumb to breast cancer each year.  Irrespective of what the denominator is in terms of how many are diagnosed each year, as the second greatest cause of cancer specific deaths in men (after lung cancer), it is continues to astound me that anybody can sweep these facts under the carpet.  But to give the denominator, number of men who are diagnosed with prostate cancer in Australia each year currently sits at just under 20,000. 

It is well recognized that not all men diagnosed with prostate cancer will actually die from their cancer but will instead die from some other cause.  The majority of cancers will follow an indolent slow growing course and will never cause harm. This said, these statistics include men who in spite of dying with prostate cancer (and not from it) have significantly suffered from the effects or treatment for advanced prostate cancer or were successfully treated for prostate cancer that otherwise have lead to a prostate cancer related death.

The overzealous desire to fight prostate cancer has had significant consequences.  Many men who did not need treatment have been unnecessarily treated and of these, some have experienced complications associated with radical treatment.  This has been a huge problem and with its recognition, attempts are being made to rectify this problem.  Significant progress has been made in getting smarter about who needs treatment and also reducing the risks of complications associated with treatment.

Not all men diagnosed with prostate cancer need treatment.  There has been a major shift towards treating early stage prostate cancer conservatively by what we call active surveillance and watchful waiting.  Active surveillance differs from watchful waiting in that curative treatment has not been ruled out.  Active surveillance is a program of monitoring that attempts to strike the right balance between avoiding the overtreatment of prostate cancer yet at the same time attempting to minimize of missing any window of opportunity to deal with the cancer should it subsequently prove itself to be more aggressive than originally anticipated. Protocols for active surveillance vary but contemporary monitoring includes monitoring PSA blood test levels and periodically carrying out MRI scans of the prostate or progress biopsies.  If there is evidence that suggests that the cancer is more aggressive than originally thought or if the disease appears to have progressed, the option of treatment remains on the cards.  Watchful waiting implies that curative treatment has been ruled out and monitoring is carried out until such time that the disease progresses to justify the commencement of palliative drug treatment in the form of androgen deprivation therapy (commonly referred to as hormone therapy).

There has also been a significant improvement in side effects associated with treatment for prostate cancer.  The majority of men with very early stage prostate cancer are candidates for treatment that can spare both urinary and sexual function.  Commonly, detractors against prostate cancer testing attempt to connect urinary incontinence and erectile dysfunction as being consequential certainties associated with prostate cancer testing.

Now on the issue of PSA blood testing, there have been quite polarized views on whether it should be performed or not.   I have tried to avoid the word ‘screening’ because I think that most of us who have in the past supported this approach have moved very much towards selected testing on an individual basis where each man as an individual has the opportunity to participate in the decision to undergo testing or not.

I think that it is time that those who so vehemently oppose PSA testing should acknowledge that an entity that is the second greatest cause of cancer related death in men is a public health problem.  It is also time to stop assertions that if a PSA test is abnormal that it leads to a high risk of complications with the biopsy and that should cancer be confirmed that it some form of aggressive intervention will invariably follow.  Additionally, we have moved on from the outcomes of 20years ago in that treatment is NOT invariably associated with incontinence and erectile dysfunction.

The answer for PSA testing lies somewhere between widespread population screening and totally opposing any form of testing at all.  I am looking forward to those who have vehemently opposed any form of testing for prostate cancer to acknowledge this as well.

Concluding Comments

I am NOT in favor of indiscriminate population screening for prostate cancer.  Men should be risk assessed as to whether the benefits of making a diagnosis of prostate cancer individually outweighs the attendant risks.  Men should NOT be denied the right to participate in any discussion regarding a decision to undergo prostate cancer testing or not.  I completely disagree with any assertion that there should no discussion about prostate cancer testing unless raised by the patient.  When men are counseled on making a decision as to whether or not they wish to be tested, they should be given information that is relevant to their individual circumstances.  The Melbourne Consensus Statement on Prostate Cancer Testing is a good place to start. 

Acknowledgement:  I wish to thank Katy Hanlon for creating the images that accompany this piece.  Katy can be contacted on Twitter @khanlon