This newsletter is a rebuttal to an article, “What’s the Truth About Prostate Cancer,” an article framing the entire field of prostate cancer management as a financially driven "hoax." Their accusations don't match the reality of how urologists practice prostate cancer screening and management today.
Also, incase anyone was wondering how a pathologist arrives at calling something cancer that they are looking at under the microscope should watch this video. According to these pathologists it is not a "black and white" call. There is a list of many factors a malignant neoplasm must pass to be considered a malignancy. Which is what we lay people call a cancer. Watch the video and decide for yourself.....According to these pathologists G6 in the end does not meet the final criteria for how they define a malignancy in prostate or other cancers.....and this is regardless of the genetics G6 might share with higher grade cancers.....
One last note......even Epstein says he would change the name of post-RP pure G6 PCa to not cancer if they can examine the entire prostate to see there is no other higher grade disease.....
and BTW Intra Ductal Prostate cancer has a basal cell layer......yet IDC is malignant....so this is one criteria this author mentions as a qualifier for calling G6 a cancer that evidently does not apply........I think you have to throw lack of basal cell layer out as qualifier for prostate PCa...
Several interesting points in this article. What always seems to amaze me is that all the claims of G6 being capable of evolving to higher grade cancers are made purely on "clonal" associations. I would like to know if anyone has ever taken G6 cells, put them in a dish and watched them evolve to higher grade PCa. Until then there is no hard proof of this happening. The pathologist in the video below has a different view of this theory that you claim there is hard evidence for.
The claim that pure G6 never causes death or metastazies is based patients who were observed over 15-20 year period that showed no higher grade cancers during that time. Most men diagnosed with PCa are diagnosed in the mid 60's and will die of something else in the next 15-20 years.....Given PCa overall is slow progressing by nature this is an over rated statement. Especially the "most men die with PCa and not from." I was diagnosed at 42 years and had RP. My post-op pathology was pure G6 by today's standards. I had my RP slides re-reviewed this year. However, there are no studies that go 30-45 years out for PCa to prove out the claim of G6, if it does not evolve to a higher grade, never causing death. So, if all the claims of pure G6 not causing death and should not be called a cancer then why isn't anyone telling me that I am cured since it was proven that after my RP all I had was G6? Nobody will make that claim to me.....
Thank you for your comment and for sharing your personal story. The questions you’re asking are excellent, and they get to the center of what makes prostate cancer so confusing for many men.
You asked if anyone has ever watched a Gleason 6 (G6) cancer cell turn into a higher grade in a lab dish. Growing cancer in a lab is tricky because a tumor’s environment inside the body is very complex and hard to copy. However, the evidence we have for cancer evolution is very strong, and it’s based on a detailed DNA fingerprint.
One of the studies I mentioned found that a G3 tumor (the pattern in Gleason 6 cancer) and a more aggressive G4 tumor right next to it had the exact same rare genetic fingerprint. This is solid proof that they both came from the same original cancer cell.
Another study I mentioned showed that even G3 and the most aggressive G5 patterns often shared the same genetic ancestor.
I watched the video of Dr. Alastair Lamb. His work is very important and aligns with the main idea of my article, which is that Gleason 6 prostate cancers are not all the same. He points out that the type of Gleason 6 found in his study would not be able to spread. This doesn't conflict with the other studies I mentioned, but shows that there are different types of Gleason 6 cancers.
Some may be harmless, while others have the tools to evolve. The problem is telling them apart when they are first found. Thankfully, the vast majority of Gleason 6 cancers don’t progress.
However, we can’t ignore the evidence from other studies I mentioned (ERG, CNA, and PTEN), which show that these genomic alterations occur in some Gleason 6 tumors and are associated with shorter cancer survival, an increased risk of recurrence, and tumor upgrading at prostatectomy.
Your second point about your own experience is very powerful. You ask an excellent question. If pure G6 is harmless, why won’t any doctor tell you that you are cured?
Doctors rarely use the word "cured" because it sounds like a 100% promise that the cancer can never come back. For any cancer, there’s always a very, very small statistical chance of recurrence. After surgery for a pure G6 tumor, that chance is tiny, but because it’s not zero, doctors are very careful with their words.
You are also right that we don't have studies that follow men for 30 or 40 years. The clonal evolution tests scientists use today are too new for that.
Experts agree that prostate cancer is a dynamically evolving disease characterized by clonal evolution. We don’t know the exact degree to which this occurs for each Grade Group, but thankfully, it appears to be very rare for G6.
I am also a retired Urologist with widely metastatic prostate cancer. As I have written in my Substack, sure more men die with prostate cancer, but I am in the group that most likely will die from prostate cancer. Yes, men (and families) need data and good medical information to make informed medical decisions. To think that we as Urologists only screen men to make money is a bit insulting to our years of study and our profession.
Thank you for taking the time and effort to write this balanced, evidence-based, clear rebuttal, Keith. It's much appreciated, as we've several friends and family with rising PSA levels.
I'm always wary of sweeping generalisations and become concerned when it starts feeling like 'listen to me, trust me' rather than evidence-based science/trial data. There are no absolutes when it comes to humans.
Your article is reassuring and reinforces my instinct about that article. Thank you.
Thanks for all excellent rebuttal to their post, which made me incredibly angry. I had RARP in September 2024 and will never regret it. I'm grateful for your insights and affirmation.
I don't know where these prognosis of a 3-5 year survival rate for advanced Gleason 8-10. I'm a Gleason 8 and am approaching my 5th year. I'm quite healthy. I'm on ADT with abiraterone and a quarterly injection of elegard. My PSA is in the undectable range as is my testosterone level. I know men with similar treatment that are in their 8-10th year. I've had 6 radiation treatments to shrink th tumour.
I didn't quote any Gleason 8-10 survival rates in the article. I mentioned some median overall survival rates for metastatic HSPC. But all those men had very advanced disease with metastases and the mOS only represented half the men in that specific clinical trial. The other half of the mean are living much longer.
I'm a prostate cancer survivor. As a carpenter I couldn't understand a lot of the technical terms, but it's a wonderfully-organized essay. I can't understand anyone's objections to a PSA test. It's a tiny needle prick in the arm once a year to draw blood. Four years after my prostatectomy, rising PSA and "suspicious dark spots" on my PET and MRI had my radiology doctor (at a major Comprehensive Cancer Center) ordering radiation and 2 years of hormone therapy. I went to U. of Wisconsin medical center for a second opinion, expecting the two doctors there to show only superficial interest and to simply rubber stamp my original doctor's diagnosis. Was I ever wrong. They spent lots of time with me, rejected my doctor's treatment plan and it's urgency, explained their reasoning in great detail, and ordered a new PET scan with more advanced imaging capability. Not that I think my original doctor's diagnosis was a scam, just that his mission to protect me from cancer ignored the quality-of-life factor when putting a 78-yeat old man on 2 years of ADT. It is indeed a fine needle to thread. I am deeply grateful to the physicians and nurses who have worked hard to serve people like me, when the stress and pressures on them are coming from every direction.
Hi Keith, Among probably two dozen other books and memoirs about prostate cancer I've owned this author's sole controversial book too since I was diagnosed in 2019. Since I was diagnosed as a G9/10, it has been hard to take seriously opinions recommending ignoring the PSA biomarker and other newer methods of monitoring prostate cancer disease progression. We fight wars with the weapons that we have available, and Keith your explanation is perfectly explained and presented. Thank you for taking the time to write your essay so clearly.
Also, incase anyone was wondering how a pathologist arrives at calling something cancer that they are looking at under the microscope should watch this video. According to these pathologists it is not a "black and white" call. There is a list of many factors a malignant neoplasm must pass to be considered a malignancy. Which is what we lay people call a cancer. Watch the video and decide for yourself.....According to these pathologists G6 in the end does not meet the final criteria for how they define a malignancy in prostate or other cancers.....and this is regardless of the genetics G6 might share with higher grade cancers.....
https://www.urotoday.com/video-lectures/cancer-or-not-cancer-evaluating-and-reconsidering-gg1-prostate-cancer-cancer-gg1/video/mediaitem/4216-redefining-prostate-cancer-the-debate-on-grade-group-1-classification-discussion.html
One last note......even Epstein says he would change the name of post-RP pure G6 PCa to not cancer if they can examine the entire prostate to see there is no other higher grade disease.....
and BTW Intra Ductal Prostate cancer has a basal cell layer......yet IDC is malignant....so this is one criteria this author mentions as a qualifier for calling G6 a cancer that evidently does not apply........I think you have to throw lack of basal cell layer out as qualifier for prostate PCa...
Thanks for the information about ICD and the basal cell layer. I'll edit the article to clarify that issue.
Several interesting points in this article. What always seems to amaze me is that all the claims of G6 being capable of evolving to higher grade cancers are made purely on "clonal" associations. I would like to know if anyone has ever taken G6 cells, put them in a dish and watched them evolve to higher grade PCa. Until then there is no hard proof of this happening. The pathologist in the video below has a different view of this theory that you claim there is hard evidence for.
https://www.urotoday.com/video-lectures/cancer-or-not-cancer-evaluating-and-reconsidering-gg1-prostate-cancer-cancer-gg1/video/mediaitem/4191-where-to-draw-the-line-the-spatial-molecular-continuum-from-normal-to-gg1-to-gg2-prostate-cancer-presentation-alastair-lamb.html
The claim that pure G6 never causes death or metastazies is based patients who were observed over 15-20 year period that showed no higher grade cancers during that time. Most men diagnosed with PCa are diagnosed in the mid 60's and will die of something else in the next 15-20 years.....Given PCa overall is slow progressing by nature this is an over rated statement. Especially the "most men die with PCa and not from." I was diagnosed at 42 years and had RP. My post-op pathology was pure G6 by today's standards. I had my RP slides re-reviewed this year. However, there are no studies that go 30-45 years out for PCa to prove out the claim of G6, if it does not evolve to a higher grade, never causing death. So, if all the claims of pure G6 not causing death and should not be called a cancer then why isn't anyone telling me that I am cured since it was proven that after my RP all I had was G6? Nobody will make that claim to me.....
Thank you for your comment and for sharing your personal story. The questions you’re asking are excellent, and they get to the center of what makes prostate cancer so confusing for many men.
You asked if anyone has ever watched a Gleason 6 (G6) cancer cell turn into a higher grade in a lab dish. Growing cancer in a lab is tricky because a tumor’s environment inside the body is very complex and hard to copy. However, the evidence we have for cancer evolution is very strong, and it’s based on a detailed DNA fingerprint.
One of the studies I mentioned found that a G3 tumor (the pattern in Gleason 6 cancer) and a more aggressive G4 tumor right next to it had the exact same rare genetic fingerprint. This is solid proof that they both came from the same original cancer cell.
Another study I mentioned showed that even G3 and the most aggressive G5 patterns often shared the same genetic ancestor.
I watched the video of Dr. Alastair Lamb. His work is very important and aligns with the main idea of my article, which is that Gleason 6 prostate cancers are not all the same. He points out that the type of Gleason 6 found in his study would not be able to spread. This doesn't conflict with the other studies I mentioned, but shows that there are different types of Gleason 6 cancers.
Some may be harmless, while others have the tools to evolve. The problem is telling them apart when they are first found. Thankfully, the vast majority of Gleason 6 cancers don’t progress.
However, we can’t ignore the evidence from other studies I mentioned (ERG, CNA, and PTEN), which show that these genomic alterations occur in some Gleason 6 tumors and are associated with shorter cancer survival, an increased risk of recurrence, and tumor upgrading at prostatectomy.
Your second point about your own experience is very powerful. You ask an excellent question. If pure G6 is harmless, why won’t any doctor tell you that you are cured?
Doctors rarely use the word "cured" because it sounds like a 100% promise that the cancer can never come back. For any cancer, there’s always a very, very small statistical chance of recurrence. After surgery for a pure G6 tumor, that chance is tiny, but because it’s not zero, doctors are very careful with their words.
You are also right that we don't have studies that follow men for 30 or 40 years. The clonal evolution tests scientists use today are too new for that.
Experts agree that prostate cancer is a dynamically evolving disease characterized by clonal evolution. We don’t know the exact degree to which this occurs for each Grade Group, but thankfully, it appears to be very rare for G6.
Thanks again for sharing your thoughts.
I am also a retired Urologist with widely metastatic prostate cancer. As I have written in my Substack, sure more men die with prostate cancer, but I am in the group that most likely will die from prostate cancer. Yes, men (and families) need data and good medical information to make informed medical decisions. To think that we as Urologists only screen men to make money is a bit insulting to our years of study and our profession.
I agree with you Sir.
Thank you for taking the time and effort to write this balanced, evidence-based, clear rebuttal, Keith. It's much appreciated, as we've several friends and family with rising PSA levels.
I'm always wary of sweeping generalisations and become concerned when it starts feeling like 'listen to me, trust me' rather than evidence-based science/trial data. There are no absolutes when it comes to humans.
Your article is reassuring and reinforces my instinct about that article. Thank you.
Thanks for all excellent rebuttal to their post, which made me incredibly angry. I had RARP in September 2024 and will never regret it. I'm grateful for your insights and affirmation.
Hi Steve. You are so welcome. I don't think I'd be here if I hadn't had my RARP in 2018.
I don't know where these prognosis of a 3-5 year survival rate for advanced Gleason 8-10. I'm a Gleason 8 and am approaching my 5th year. I'm quite healthy. I'm on ADT with abiraterone and a quarterly injection of elegard. My PSA is in the undectable range as is my testosterone level. I know men with similar treatment that are in their 8-10th year. I've had 6 radiation treatments to shrink th tumour.
I didn't quote any Gleason 8-10 survival rates in the article. I mentioned some median overall survival rates for metastatic HSPC. But all those men had very advanced disease with metastases and the mOS only represented half the men in that specific clinical trial. The other half of the mean are living much longer.
Hi Kurt. It sounds like you are doing really well. Keep up the great work!
I'm a prostate cancer survivor. As a carpenter I couldn't understand a lot of the technical terms, but it's a wonderfully-organized essay. I can't understand anyone's objections to a PSA test. It's a tiny needle prick in the arm once a year to draw blood. Four years after my prostatectomy, rising PSA and "suspicious dark spots" on my PET and MRI had my radiology doctor (at a major Comprehensive Cancer Center) ordering radiation and 2 years of hormone therapy. I went to U. of Wisconsin medical center for a second opinion, expecting the two doctors there to show only superficial interest and to simply rubber stamp my original doctor's diagnosis. Was I ever wrong. They spent lots of time with me, rejected my doctor's treatment plan and it's urgency, explained their reasoning in great detail, and ordered a new PET scan with more advanced imaging capability. Not that I think my original doctor's diagnosis was a scam, just that his mission to protect me from cancer ignored the quality-of-life factor when putting a 78-yeat old man on 2 years of ADT. It is indeed a fine needle to thread. I am deeply grateful to the physicians and nurses who have worked hard to serve people like me, when the stress and pressures on them are coming from every direction.
Hi Keith, Among probably two dozen other books and memoirs about prostate cancer I've owned this author's sole controversial book too since I was diagnosed in 2019. Since I was diagnosed as a G9/10, it has been hard to take seriously opinions recommending ignoring the PSA biomarker and other newer methods of monitoring prostate cancer disease progression. We fight wars with the weapons that we have available, and Keith your explanation is perfectly explained and presented. Thank you for taking the time to write your essay so clearly.
Thanks Jeff!
Excellent rebuttal. I was very disturbed by original article when I read it. Following their advice my husband would probably not be here.
Thanks Kathy.