Latest / Intellectual Medicine / Is It Really Cancer? Rethinking Prostate Diagnosis and the Gleason Score

Transcript

Is It Really Cancer? Rethinking Prostate Diagnosis and the Gleason Score · Intellectual Medicine

0:00
Gleason score is a historical phenomenon of maybe some
0:05
research based merit, but as a essential metric to decide
0:09
treatment, no what matters the most.
0:12
It's your philosophy. Remember, there are no
0:15
requirements. You are not being reckless if
0:18
you defer and peel off of a conventional recommendation.
0:22
You decide what you value. You decide how important it is
0:26
for you to sleep at night knowing that there are prostate
0:29
cancer cells within the gland. You decide how much your sexual
0:33
vitality matters. Your physical stamina matters.
0:37
You decide how much of A liability it would be if you
0:40
leak urine frequently. Only you can make those
0:43
decisions. The Gleason score does not
0:47
matter, and you should never get a biopsy.
0:51
Now, those are my opinions and I'm going to defend them in the
0:53
next few minutes. What I just shared with you
0:56
folks, it's not the standard of care.
0:59
I think it's better than that. I'm going to explain why.
1:03
I'm going to tell you why the standard of care has evolved.
1:07
What I just said would be considered heretical.
1:11
I think I'm saying that word correctly.
1:12
Anyhow, it's against the mainstream of urologic opinion.
1:16
But things are changing. A recent meeting of experts in
1:19
the field. The proceeds were published in
1:22
the Journal of the National Cancer Institute 2025.
1:26
Fifty experts got together, and you know what?
1:28
They were discussing whether or not a Gleason score should be
1:32
considered cancer or not. I mean, think about that.
1:36
The standard of diagnostic certainty is uncertain.
1:43
Doctors can't agree whether or not certain levels of Gleason
1:47
score are actually cancer. And here's how the debate
1:51
unfolds. About 15% of Gleason scores come
1:55
back with advanced cellular changes.
1:59
The other 85% are early Gleason scores, 6 or 7.
2:05
Those scores do not project out to a horrible ending.
2:11
In fact, most people will never die from prostate cancer without
2:14
score. Thus, the question arises,
2:17
should we even call that cancer? Some doctors would say, well we
2:21
we need another term because it's not behaving like cancer.
2:27
They ultimately concluded that it should still be called
2:30
cancer. The reason they're fearful that
2:35
men will be less inclined to pursue follow up, that is, if
2:40
they don't know or think they have cancer, they're not going
2:43
to acquiesce to the urological recommendations for either
2:47
sequential biopsies or something else, right?
2:51
So think about that. They're worried, I guess, on
2:54
some level, that there won't be enough fear instilled to propel
2:58
action. Whoa, whoa, time out, Time out.
3:01
I just told you Gleason scores don't matter.
3:04
Your urologist will tell you if you have a high PSA, you must
3:09
get a biopsy. Absolutely not.
3:11
Must have to required. Look, last time I checked, guys,
3:16
there's no law that will throw you in prostate biopsy jail
3:21
because you chose not to get the biopsy.
3:24
It is absolutely optional. It's not what the urologist
3:28
recommend for a lot of reasons, some of which you're going to
3:31
learn about, but it's your prerogative.
3:35
You're going to learn the questions that you should ask
3:38
and one important question, one important question, doctor,
3:42
based upon the biopsy result, will it affect your treatment
3:46
recommendations? Another question, doctor.
3:50
Suppose my I suppose I have APSA of 12 and my prostate MRI has a
3:56
pyrides of four and the biopsy comes back negative.
4:01
Would you believe it? I'd be willing to bet they'd say
4:04
no, we want to know the biopsy. But let's back the camera up a
4:07
little bit and look at this from a broader perspective.
4:10
I just stated that the Gleason score is irrelevant.
4:14
That is, it's not important. And yet the urologist will tell
4:18
you that's the only way we can tell if you have an aggressive
4:23
form of cancer or not. I beg to differ.
4:28
Now, aggression is determined by action, movement, change.
4:32
You can't tell at one point in time what's going to happen next
4:38
unless you have another point in time, right?
4:41
If I told you that today the stock market was, I don't know,
4:45
3200, I don't buy stocks, I don't know much about that, but
4:49
you get the point. A #3200.
4:52
And then I asked you, is the market going up or down?
4:54
You say, I don't know. That's just one number.
4:56
That's the point. You need another number.
5:00
Now, those are aficionados of the biopsy would say, oh, no
5:03
problem, we'll get another biopsy.
5:05
Oh, let's stick that needle in you 12 times up through your
5:09
butt. No, thank you.
5:11
And folks, there is absolutely no reassurance that it does not
5:16
'cause metastatic process. Now, the doctor will tell you,
5:20
and this is an accurate statement.
5:23
There's no proof that it causes metastatic disease.
5:28
They never looked. The study's never been done in
5:30
the history of mankind. It's never been studied.
5:34
It's been presumed not to be, so if a study were done that
5:39
actually validated my hypothesis, which is yes, stick
5:44
a needle in cancer, you're more likely to spread it, right?
5:48
A little bit of common sense here, people, as well as medical
5:51
precedent. You can't cut through a skin
5:54
Melanoma, that's malpractice. You don't remove a breast cancer
5:59
lesion by chopping in a little pieces, that's malpractice.
6:04
Can disseminate cancer. So we got problem with biopsies.
6:07
So how did it become so entrenched in what you do in the
6:10
alternative? And where do I come off saying
6:12
that the Gleason score is not important and therefore a biopsy
6:17
is irrelevant. We have to do the biopsy say if
6:19
the the surgeon we have to know how well no aggression is 2
6:24
points on a curve and we can look at non biopsy means of
6:28
assessing that. But let's back up in history.
6:31
The prostate biopsy became somewhat commonplace in the
6:35
1960s and the 1970s. Think about that.
6:41
That's like 40 to 50 years ago. It's hard to change standard of
6:46
care and medicine. It gets petrified by precedent,
6:50
by history, a consensus. A standard of care is quite
6:55
simply what all the other docs are doing in the community.
6:58
Well, if they're all doing the same thing from 50 years ago,
7:01
that becomes a standard of care. It doesn't mean it's the best
7:04
way to go, it just means it's what they do.
7:07
If you're practicing standard of care medicine, you're less
7:11
likely to be sued. That's a fact.
7:14
And you get to a conclusive what they believe to be point more
7:18
quickly. Does a doctor really want to
7:21
talk to you for 30 minutes about the pros and cons and
7:24
alternatives to the biopsy approach?
7:27
No, they have another patient to see.
7:31
This is your responsibility and that's why you're tuning to the
7:33
podcast. So you got to keep that up.
7:36
So there we are 50 years ago. What happened since it was the
7:40
19, I'm sorry, 2010 to 2000 twenties that the prostate
7:46
specific membrane antigen PET scan came on the scene and it
7:51
was around 2015 thereabouts when prostate MRI came around 2015,
8:00
not that long ago the pyrods were was developed.
8:05
That is a means of of grading the MRI of the prostate.
8:10
So now folks, you have a high PSA, do not get a biopsy.
8:15
You should insist on a prostate MRI first.
8:19
That will give a Pyrad score, which is a relative risk of
8:23
cancer being present. What does it look like?
8:26
Are there tumors in the gland and if so, do they look like
8:29
cancer or not? It's not perfect.
8:32
Then again, neither is a biopsy. But it's not invasive.
8:37
It cannot disseminate cancer. And here's a great part, it
8:42
could be done sequentially. You want to know what's
8:44
changing. Pyrids are scored up to 6, up to
8:50
five. I mean, pyrides of 50 to 5:00,
8:53
I've never seen A0A. Pyrides of five means, yeah,
8:57
that's probably cancer. A4 means most likely cancer.
9:00
A3 means we don't know. In either case, it does a very
9:05
good job of determining whether or not the abnormalities have
9:09
left the gland. If they're extending into
9:12
neighboring tissue, that's important.
9:15
So you get an MRI and maybe six months later you do another one,
9:20
see if anything has changed. No biopsy needed.
9:22
What about what about that Gleason score?
9:26
The Gleason score does not discriminate regarding the
9:31
treatment path that a man should take.
9:34
Regardless of what the Gleason score is with six, 7-8 or nine,
9:40
it all comes back to the decision about what are you
9:43
going to do about it and are you going to let them take out your
9:47
prostate gland or are you going to irradiate the prostate or are
9:52
you going to have them castrate you with androgen deprivation
9:56
therapy? I encourage you not to consider
10:00
any of the above, certainly not in the absence of advanced
10:03
symptoms. There is a place for androgen
10:06
deprivation therapy and that is only in my opinion, when the
10:11
disease, if the disease has become metastatic, causing pain
10:15
in bones or abnormality in other organs, that's a separate issue.
10:20
But the vast majority of people, I told you 85% of you are going
10:23
to have relatively early findings.
10:27
I feel good. My PSA is 12 now.
10:29
They want to stick a needle in me.
10:32
Don't let them get the MRI. Look at what it shows, then make
10:36
a decision. I just told you not to get your
10:39
gland removed. Incredible trauma, risks of bad
10:43
things happening. No proof.
10:46
No proof that'll prevent death from prostate cancer.
10:50
Same thing with radiation and therapy.
10:52
So you've got 2 primary treatments that are offered by
10:56
the vast majority of urologists, neither one of which have been
10:59
shown to prevent death from prostate cancer.
11:02
After all these years, we still don't have evidence of tangible
11:07
prevention of death. That's the name of the game.
11:11
We have absolute evidence of harm.
11:15
So all this stuff about you got to know the Gleason score, that
11:18
it's going to help guide thought, it's going to help
11:20
guide decision. Speculative, hypothetical, not
11:24
important sequential MRI. We can discern how things are
11:29
proceeding. If you decide to do nothing,
11:32
absolutely nothing. In my opinion, that's better
11:35
than most of the treatments that are being offered in
11:38
conventional realm. What should we compare it to?
11:43
Well, in most studies they compare prostatectomy to
11:46
radiation to nothing, Literally nothing.
11:51
That's just silly. We all know there are things
11:54
that can be done. We talk about them here.
11:57
The protocol that I've developed incorporates repurposed drugs,
12:01
drugs that have been shown have anti cancer attributes, some
12:05
supplements, lifestyle, how about percent body fat, how
12:09
about nutritional modifications, exercise integration,
12:13
mindfulness. It all matters.
12:17
And furthermore, when you put those pieces together, you get
12:21
collateral benefit. That means you're targeting
12:24
prostate cancer. But in the course of targeting
12:27
it, global health is elevated, vitality elevated.
12:33
Same can't be said for conventional treatment.
12:35
It tears you down. Gleason's score.
12:39
Do not let them fool you into believing it's the end all and
12:43
be all. It has relevance in the minds of
12:48
the pathologist, of the surgeons.
12:51
And yeah, there's some predictive qualities to it, but
12:55
not absolute. Not worth the price of
12:57
admission. Tearing into your prostate
12:59
gland, potentially disseminating those cells.
13:03
Now, we're not going to know if my my hypothesis is correct for
13:07
years, maybe decades. And maybe I'll be posthumously
13:11
famous. I don't know.
13:12
The point is that we first have to preserve vitality to the
13:17
extent a treatment causes harm. Biopsy or otherwise labeling can
13:23
cause harm. Creates fear.
13:25
That's why they want to keep calling it cancer.
13:27
Motivates you guys, right? Oh my God.
13:29
I have cancer. Take it out.
13:31
Take it out, take it out. No, let it be, let it be, let it
13:35
be. Live with it.
13:37
It'll keep it buried in the Glen.
13:39
That's the goal. Now, you compare conventional
13:43
treatment to the protocol, and we're doing this as we speak,
13:47
folks. We are creating our research
13:49
protocol, tracking outcomes, looking at Psas, looking at
13:53
survival, looking at vitality. Do not believe that the Gleason
13:59
score is essential. Therefore, if a Gleason score is
14:02
not essential, neither is the biopsy.
14:06
Its value is diluted. The protocol goes back 50 years.
14:11
Some of what doctors do is knee jerk reflux.
14:15
I'll share with you a brief vignette that highlights that
14:17
point. A patient new to me arrived with
14:20
metastatic disease in the bone already.
14:23
Pain in the skeleton. Metastatic disease, Prostate
14:27
MRI, pyrides of five. Evidence of extension outside
14:30
the gland, Prostate specific membrane Antigen test.
14:34
That's a PET scan where they put a special dye that is attracted
14:39
to prostate cancer cells, uniquely lighting up in the face
14:43
of prostate cancer. It's a fantastic study for those
14:46
who might benefit from it. My patient lit up.
14:50
Pyrides of five, lights up the PSMA.
14:53
I sent him up to a major teaching hospital to get another
14:56
opinion. You men, you owe it to
14:58
yourselves. Yes, I believe in what I'm
15:01
advocating for, but I also believe that you need to take
15:05
time and you need to be skeptical of everything you hear
15:09
and challenge it, you know, including what I say.
15:11
So anyhow, it goes up to the teaching hospital.
15:13
They look at all the information.
15:15
They say, yeah, yeah, that's cancer.
15:17
We want to do a biopsy. So my patient called me back and
15:21
said, what's the point, doc? They know I have cancer, what's
15:25
the point? So I called the oncologist.
15:29
I said, you want to do a biopsy? Tell me why.
15:32
Well, you know, we'd like to know the cell type.
15:35
All right? 99% of prostate cancers are
15:38
adenocarcinoma, about 1%. Maybe other cell types like
15:42
neuroendocrine. So the doc said we want to know
15:45
if it's a neuroendocrine or not. I said, OK, how's it going to
15:48
matter? Well, if it's neuroendocrine,
15:50
we're going to recommend chemotherapy.
15:52
I said, OK, and if it's not neuroendocrine, he said, well,
15:55
we're going to recommend chemotherapy anyhow.
15:58
I said, doc, do you hear what you just said?
16:01
What's the difference? Why traumatize my patient
16:04
further? Why stick needles in a prostate
16:07
gland for academic curiosity when the treatment pathway is
16:12
not altered? That's just one vignette.
16:15
There are others. The biopsy, in my view, is being
16:19
propagated by virtue of inertia, momentum to a certain extent,
16:25
financial and medical, legal considerations and precedent.
16:29
There's not going to be a a wellspring of urologist in the
16:33
near future saying, you know what, this whole biopsy thing,
16:37
yeah, forget about it. We're just going to do the MRI
16:40
and we're going to do the PSMA. We now have the ability folks to
16:44
assess and most importantly follow how this condition
16:49
unfolds without trauma. Gleason's score is a historical
16:55
phenomenon of maybe some research based merit, but as a
17:01
essential metric to decide treatment, no what matters the
17:06
most. It's your philosophy.
17:08
Remember there are no requirements.
17:11
You are not being reckless if you defer and peel off of a
17:15
conventional recommendation. You decide what you value.
17:19
You decide how important it is for you to sleep at night
17:23
knowing that their prostate cancer cells within the gland.
17:26
You decide how much your sexual vitality matters, your physical
17:31
stamina matters. You decide how much of A
17:34
liability it would be if you leak urine frequently.
17:38
Only you can make those decisions.
17:40
Well, I'm here to help at least provide a perspective, so thanks
17:44
for tuning in. We just told you why.
17:46
In my opinion, leasing scores don't matter, therefore biopsies
17:51
don't matter. But there are other opinions out
17:53
there. You should have value yourselves
17:55
of them. Of course, I think I'm right,
17:57
but that's besides the point. It's what you think that matters
17:59
the most, folks. Until next time, thanks for
18:02
spending time with me. We'll talk to you then.