the art of “getting away with it”, prostate cancer and Lorenzo Q. Squarf (you couldn’t pay to have a name like that!)

life is a lot like playing cards-it's not about the hand you are given, it's about how you play the cards you're dealt

The “art of getting away with it” is a favorite medical saying of mine. If I remove a ureteral stone and don’t place a stent and risk extravasation of urine into the patient’s retroperitoneum and the patient does just fine….what does that mean? Does it mean that I was brilliant, used seasoned medical judgement, or did I just “gamble with the patient’s money” and just “got away with it?” Did Mr. S just “get away with it?”

Submitted to Prostate Diaries on 2011/03/26 at 10:53 pm

I am the above referenced Squarf. My health is perfect, my urologicals are so splendid that I shall leave them to the National Bureau of Standards when I keel over. My Dr. Doom will die of sclerosis of his personality before anything takes me down. Prostate cancer is the biggest boondoggle in the history of medicine. You may quote me.
-Lorenzo Q. Squarf, Flamekeeper of Western Civilization

Used Cars and Mr. Squarf

Mr. Squarf-Fool or Guru?

After I wrote my book I began to explore fun ways to promote it using social media. In my twenty years or so of practicing urology I had never gone on the internet to search anything related to urology, much less prostate cancer. I have a subscription to the Journal of Urology and that is my usual resource for researching something. I have found over the years that the articles there often legitimize something that I have already been doing for years. An example would be the transobturator sling. We had been doing them for years with very nice results for stress incontinence in women and then I see an article saying that slings are effective.

So when I search around the internet I was surprised to find so much angst out there about urologists (money hungry will only operated and make you leak urine and impotent), the PSA how it has ruined patients lives and made the drug companies rich (Mr. Richard Albin), and people who are so angry about doctors, PSA’s, prostate biopsies that they “threw out the baby with the bath water” and totally went “naked.” There is an interview with the head guy of the American Cancer Society and he said something to the effect that he disagreed with prostate screening and then asked if he’d had a PSA , he said no and that ” I won’t be getting one.” Nihilism comes to mind.

Now to Mr. Squarf…I like him but I don’t know him. He’d be a caricature in my book on the types of prostate patients and how “who they are” determines which treatment, or lack thereof, they choose. You really need to read his thoughts on PSAs, urologists, and prostate biopsies. I did re read his stuff, but as I remember he had an elevated PSA and elected to not follow the value closely or to have a prostate biopsy. (He was not going to let the system us him for their financial gain or play into a urologist’s sadochistic tests. The little knowledge is a dangerous thing mixed with the clever by half patient. That’s going to be a tough caricature for my wife to draw. )

  • The most common symptom of prostate cancer is…no symptoms. So Mr. Squarf recommendation to wait until symptoms I would disagree with rather strongly.
  • Repeat PSA’s with a rectal exam and pursue a biopsy if it changes with time…is reasonable.
  • Mr. Squarf story is what we call in the business “an anecdotal account.” We know that about 20% of elevated PSA’s result in the diagnosis. Not all of those diagnosed need to be treated, some do. That’s where research and “who are you factors” come in. At age 65 a lot of what Mr. Squarf recommends makes sense. It might not to a 60 year old in better health.
  • Mr. Squarf “got a way with it” his PSA was high and elected to do nothing and he did not have prostate cancer. He was the 80%.  Good for him…but to advise that all do what he did and a say, “don’t let them biopsy you unless you have symptoms” may be harmful to certain patients.
  • His decision seems to driven more by angst at the system than a smart medical choice-reminds me of Otis Brawley….making a medical stance to make a point.
  • Mr. Squarf was I wrong to have a biopsy and then have my prostate removed. I was 52, 3 of 16 positive, and there were elements of Gleason’s 7. Was I foolish? Was I duped by my self? What was going to be the pathologic future of my cancer? At what point does an elevated PSA associated with known prostate cancer change from being local or confined to the prostate and the point when it moves to a lymph node (metastasize).
  • Mr Albin’s father presented with symptoms, just like you suggested he do, he could not void and had prostate cancer in his bones. He died about a year later. Is this perfect scenario that your recommendations allude to?
  • Did Frank Zappa play it just right? He waited for symptoms to occur he. He died about three years after diagnosis at age 54 or so.
  • Do you feel that the American Urological Assoc recommendations regarding PSAs and screening are driven solely by the love of money?
  • Do you what would have happen to me if I had done what you did? I mean…do you know for sure?

So….these are just questions. That’s all, just questions. Mr. Squarf made a decision, based on research and suspicion of the medical community, and he was right. He gambled with his money and ” he got away with it.”

I love his irreverence, humor and those big words. And now he’s kinda rubbing his decision in our faces….be careful Mr. Squarf….you just might influence someone to do what you did and he was not the 80% but the 20%. He also may be that prostate cancer patient (and I have had many, including a close friend of mine) in whom the gland remained normal, the elevated PSA did not change and yet a biopsy showed every core of the prostate positive for prostate cancer. He was 58 or so and I think that finding his cancer and treating it made a difference. (This is anecdotal as well.)

Mr. S…..great to hear from you and I eagerly await a concise rebuttal of sorts in a mildly vociferous fashion.

11 Replies to “the art of “getting away with it”, prostate cancer and Lorenzo Q. Squarf (you couldn’t pay to have a name like that!)”

  1. So nice to see Squarf back on his horse!

    It was so helpful to me when I was diagnosed at age 54 and decided not to have invasive therapy to find someone who, like Tom Feeney, presented another point of view. This in contrast to the standard and inaccurate warning comparing what was then termed Watchful waiting as “Waiting is like playing Russian Roulette.” When queries were raised about the wisdom of surgery in men who might not benefit from this – and Stamey was already saying that more than 50% of men did not benefit from surgery the sterile answer was ” Dead men don’t get erections”. A foolish chant that is still used today.

    Just a couple of specific comments:

    1. ” Do you what would have happen to me if I had done what you did? I mean…do you know for sure?” Of course no one knows for sure what will happen in the future. Even Nostradamus is only accurate once the events have passed. But one can look at the broad brush data available to know that half the men whose death is marked down as ‘ prostate cancer’ are over the age of 80 and that this hasn’t changed signficantly despite the flurry of overtreeatment. We also know from the WHO statistics that

    ” At age 65 a lot of what Mr. Squarf recommends makes sense. It might not to a 60 year old in better health.”


  2. Don’t know what happened there. My words were suddenly posted and I could not edit them. As I was saying

    1. We also know from the WHO statistics that the percentage of male deaths in the US expressed as a percentage of total male deaths is about 12% higher in 2005 (latest figures available) than they were in 1979 (first figures available). So all the billions of dollars spent on research, all the hundreds of thousands of men treated for no benefit (New England Journal of Medicine has suggested over one million) hasn’t made a bit of real difference.

    2. “Did Frank Zappa play it just right? He waited for symptoms to occur he. He died about three years after diagnosis at age 54 or so.” Does anyone know precisely what Zappa’s diagnosis was? Did his lifestyle influence the ability of his body to fight a disease? Did he perchance have the most aggressive form of the disease which cannot be ‘ cured’ ? To quote Whitmore “Is cure possible? Is cure necessary? Is cure possible only when it is not necessary?”

    3. ”At age 65 a lot of what Mr. Squarf recommends makes sense. It might not to a 60 year old in better health.” This seems a very fine distinction. What of the 61 year old in apparently good health? What of the 59 year old in better health than the 60 year old? Who can define anything in such minute terms given the very rough and ready tests we use for diagnosis? When pathologists cannot agree on the grade of the samples dug out of the prostate? When the definition of the disease is changed so that what was once ‘ cancer’ is now ‘ atypical cells’ ?

    I could rabbit on, but having objected previously to some of the McHugh wisdom (whilst still recommending that visitors to my site should use the McHugh cheat sheets) with no direct response I am minded of the Biblical injunction ” Truly there are none so deaf as those who will not hear.”


  3. There are good and bad professionals in every arena. Unfortunately it is the bad eggs that destroy the good eggs.


  4. PSA 3 in 1993, 422 on 3/14/13. Except for tolerable urine flow reduction, no symptoms til moderate continuous abdominal pain 3/14/13. Went to ER. HUGE BLADDER caused pain, but relieved in a few hours with catheter. TURP in April, Firmagon shots in May June & July. PSA 14 in June, PSA 2 in Sept. TURP showed 20% prostate cancer Gleason 9, 80% BHP. No previous biopsies. PSA doubling times were 4-5 YEARS 1993-2008. Saw oncologist in 2009 when PSA doubled in a year…PSA was 200+ in 2010, 3 year doubling to 422 3/14/13. Overall, 1993-3/14/13 PSA doubling was 3 years. Have had bone scans, CTscans and PET scan. Anyone want more details?


  5. Yoo-hoo! Everybody! L.Q. Squarf at the helm on Wednesday, May 21, 2014: I turned 82 years old a week or so ago and my urologicals are still utterly splendid to the best of my personal knowledge… in the off chance that you are interested.
    Dr. McHough, how do you do? You, too, Mrs. McHough? Hi there! Life is a finite journey during which we try to avoid stepping on the lines. Seven or so years ago doctor/doctor wanted to replace one of my hips. I told him no. He replied by saying that he would also say no. WHAT? A year ago or so a different doctor/doctor said that I needed to replace BOTH hips. I gently declined his invitation to become a bona fide invalid. So my hips are a bit iffy. Big deal. No pain. I get around okay for a guy whose knees are also beginning to complain. I think the whole thing is funny and I make dramatic sounds of pseudo anguish when I overdo… and then, invariably, burst out laughing. Why? because it is hilarious! I used to be Superman, but I can’t take steps two at a time any more. Remember, there are no survivors on planet earth. Actually, I feel great, and am utterly unafraid, and love being alive. Aye, there’s the issue for so many! Fear. Mere bagatelle, if you have the right perspective. I wish everyone happiness and good health. Happiness first.
    -Lorenzo Q. Squarf


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