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No thanks, I don’t want to be impotent.

At long last men are pushing back against the prostate cancer treatment industry’s decades-long scare tactics.  A really good NYT story documented a rapidly-growing trend among men to practice “watchful waiting” when diagnosed with some forms of prostate cancer. The money quote: “Five years ago, nearly all opted for surgery or radiation; now, nearly half are choosing no treatment at all.”

HealthNewsReview posted a thoughtful piece about the facts, research, and trends – well worth a read.

I’d note that this has long been known, but docs – especially those in private practice – were loathe to discuss non-aggressive treatment with patients.  Couple of points to ponder – is this because remuneration for watchful waiting is paltry compared to aggressive techniques, and/or a fear of litigation?

Key to the trend towards watchful waiting is an understanding that not all cancers are the same.  Especially with prostate cancer.  This is a relatively common condition among older men, with a very high survival rate regardless of whether the patient got aggressive treatment or not.

And, that “aggressive treatment” may result in impotence and/or incontinence.

Another key to this is understanding that the diagnostic and treatment industry is very big, very lucrative, and very willing to use its money to preserve its profits.

After research assessing the effectiveness and outcomes of patients treated with watchful waiting vs aggressive surgery documented no significant difference, it still took years for docs in private practice to get with the program and start discussing the watchful waiting option with patients.

So, what does this mean?

  1. Medicine in this country is a for-profit industry.
  2. That industry is heavily vested in aggressive diagnosis and treatment options.
  3. It is very powerful and very persuasive, and quite willing to advocate potentially harmful treatments.
  4. It takes years to get patients and providers to change, especially when confronted by the lobbying efforts of the medical-industrial industry.
  5. Like anything else, there’s much benefit from the capitalist approach, and much to be worried about.

But we don’t need to be impotent.



5 thoughts on “No thanks, I don’t want to be impotent.”

  1. Joe – My wife (early 30s) had the majority of her thyroid removed last year after a routine checkup found some small, encapsulated nodules. It was a very difficult decision for her to \”wait and watch\” versus removing, but ultimately her endocrinologist convinced her to move ahead with the procedure. Now she is on Synthroid for life, has trouble with weight and emotion, and believes it\’s impacted her ability to get pregnant. Incidentally, she read this NYTimes article last month and now believes she made the wrong decision. One can\’t but help to question the medical necessity of \”watching and waiting\” (as I certainly did at the time and did not want to unduly impact her choice).

  2. Society in the US is also to blame. Take the example of something as minor as a sore throat. We are convinced we need antibiotics, yet studies show the majority of sore throats do not require an antibiotic. We “push for the cure” and if a doctor recommends a more conservative approach and there is a progression as a result, do we sue? I think that may be part of the motivation for the physician to recommend the aggressive cure vs. watch and wait. I am not discounting the profit motive either, but I do think there are other factors at play.

  3. You are right about the different grades of prostate cancer. However, saying one size fits all men, i.e. watchful waiting, can cost someone his life. Each case should be evaluated on the Gleason scores and other diagnostics, etc. A quick comment about residuals of impotence and incontinence-rarely happens in the hands of an expert surgeon, i.e. patients of Dr. Patrick Walsh at Johns Hopkins who pioneered the nerve sparing procedure for particular types of prostate cancer. I can think of 3 personal acquaintances that died untimely deaths from the watchful waiting approach. So please don’t practice scare tactics that all men end up impotent that do require a surgical approach. If the prostate exam is done prior to a PSA being drawn, it will falsely elevate it for weeks. Also, if a tumor is felt on the exam, the cancer has already spread outside the capsule. Dying of prostate cancer that has spread to the bones is really awful. Men with a diagnosis of prostate cancer should get another opinion at a center of excellence for the most appropriate treatment options.

    1. Lynn
      Thanks for the comment.

      I’m not sure where you got the impression that I was advocating “watchful waiting” for every patient. Nowhere did I say that. In fact I noted that this is appropriate for “some” cancers. In contrast the adverse impacts of surgery and other aggressive treatments are very well-documented.

      I’d also suggest that defining which surgeons are “expert” is a rather difficult – and quite unscientific – task.

      Id suggest that scare tactics were precisely the method employed by many to get surgical and other procedures that not only weren’t warranted but had significant risks that were not disclosed fully, if at all.

  4. Any thoughts on why women have been so accepting of industry\’s aggressive promotion of mammography, breast biopsy, and treatment of indolent dysplasias?

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Joe Paduda is the principal of Health Strategy Associates



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