My letter to the New York Times in regards to Richard Albin discoverer of PSA-(Not accepted)

What do Robert Benjamin Ablin and Frank Zappa have in common?

Richard J. Ablin Ph.D. first observed the antigen PSA forty years ago. T. Ming Chu of the Roswell Park Cancer Institute developed the process to test for it. Urologists Cooner and Scardino did the clinical studies that resulted in the recommendation that screening, digital exams and the PSA would help detect prostate cancer earlier. Although I have been a practicing urologist for over twenty years, I was unaware of Richard Ablin until his Op-ed in the New York Times recently. What got my attention in his piece, in addition to all the emotional rhetoric such as “painful prostate biopsy,” “pushed to surgery,” and “damaging treatments,” is that Ablin Ph.D. mentioned that he discovered PSA on two occasions. Then all the remarks that bespeak of a man that is angry, ill-informed regarding the clinical side of prostate cancer, and one seeking attention by highlighting the very discovery he disdains. The American Urologic Association “shamefully” recommending prostate screening, the use of PSA as a “profit driven” public disaster,  and drug companies “peddling the test” all are emotional remarks  used by a professor who does not actually treat prostate cancer attempting to be relevant two score years after his fifteen minutes of fame. The article and the tone of Ablin’s voice prompted my curiosity. I then happened upon the Robert B. Ablin Foundation for Cancer Research.

The Foundation is dedicated to Ablin’s father Robert who died of prostate cancer. On the surface it all fits together quite nicely; the discoverer of PSA, an interest in cancer, and a family member that dies of prostate cancer. But to the discerning eye of a urologist a glaring irony jumps off the website. We learn that Robert Ablin went into urinary retention (could not urinate) and upon evaluation was found to have metastatic prostate cancer in 1978. He died one year later of his disease. In other words, his prostate cancer quietly progressed extensively until it was found very late and only because he had voiding symptoms. The irony of this is that Robert Benjamin Ablin is the very person that would have benefited from a prostate screening and PSA that his son so vehemently abhors. It is well recognized among urologic circles that if you diagnose prostate cancer when there are symptoms or as an asymptomatic palpable abnormality on rectal exam, you have diagnosed prostate cancer too late. Mr. Robert Ablin, the elder, is the very type of patient that I and other urologists are so diligently cognizant of diagnosing earlier today. Just as his touting his discovering the PSA repeatedly in the Times arouses suspicion, so too is another statement on the Ablin’s Foundation website. The website states regarding Robert Ablin’s death,” This was in 1978, in an era of limited ability to diagnose prostate cancer. He was diagnosed in a late stage of his disease; he died one year later, in August 1979.” Well, I was a Urology resident in 1978, and there is very little we were not doing then that we are doing now save the PSA. Before you protest,” But don’t you use an ultrasound to do the biopsies now?” Yes urologists use the ultrasound to facilitate the biopsy; it has not helped us to make the diagnosis any sooner. In 1978 we still recommended rectal exams in men at age 50 or older but we only did biopsies, finger guided, on palpable nodules. With the advent of PSA, biopsies are performed well before there are palpable abnormalities of the prostate and if prostate cancer is found, it is more likely to be found early and more likely to be cured. Robert Ablin presented well beyond a palpable nodule. Urinary retention suggests a prostate cancer that was locally extensive and the metastatic bone cancer that ultimately caused his death was asymptomatic. This is the rub that is prostate cancer and it is as true today as it was in Robert Ablin’s time. How do I know these things and yet I don’t know Robert Ablin? I have seen scores of Mr. Robert Ablin’s in my career. I have watched the whole agonizing process from an elevated PSA through death. I have seen and been with the families, and I have been to the funerals of their loved ones who have succumbed to prostate cancer. I have seen the face of prostate cancer in my patients and then…had to deal with it myself. My prostate cancer was found only because of an elevated PSA.

I really did not understand the dual nature of prostate cancer until I learned of Frank Zappa. He was found to have prostate cancer in his mid-fifties and died three years later. Then a friend of mine, whose father was doctor, was diagnosed in September and died in June. Mr. Ablin’s father too unfortunately fell into this category of patients, diagnosed too late to cure. Is the PSA perfect? No. Has it saved lives? Yes. In time we will find a marker that will indicate those who we should biopsy and whose cancer kills quickly, but until we do, the PSA is the best we have and remains an invaluable tool for the family physician and urologist.

I have a question for Richard Ablin Ph.D. the discoverer of the PSA. If it were 1974, about four years before your father presented with metastatic prostate cancer, would you want your father to be screened yearly with a rectal exam and PSA even if he had no symptoms or family history of prostate cancer? I think we all know the answer to that question, and that is how the issue should be viewed, in a personal sense, not in terms of public health cost estimates and emotional verbiage.

John C. McHugh M.D.

Board Certified Urologist

Author of “The Decision: Your prostate biopsy shows cancer now what?”

Gainesville, Georgia

Theprostatedecision.com


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33 Replies to “My letter to the New York Times in regards to Richard Albin discoverer of PSA-(Not accepted)”

  1. Hi Dr. McHugh
    I just read both the Ablin article in the NYTimes from 3/10/10 and your “Letter to the NYTimes.” My father (61 y.o.) had a rising PSA a few years back and at the time his Urologist would not do a biopsy until my parents decided they needed to get a second opinion and pursued the biopsy. It turned out that my father DID have Prostate Cancer and as a result had his prostate removed via radical prostectomy. He then had some radiation because the margins were not clear. Ever since, his PSA has been taken every 3 months and it often flucatates, SIGNIFICANTLY (i.e., .57 in Jan to 3.5 in April). We have questioned stress, medications, infection, weight, etc. Richard Ablin did make mention about there being a correlation between drugs (i.e., ibuprofen) and I want to know where and how I find out if specific drugs can/do elevate the PSA. Specifically, my father has a bad hip and has been taking Voltarin, and since then his PSA has risen, however, as I mentioned earlier, his PSA has bounced around before so it is a direct result of the medication or not? The last time he went for his PSA and it was high, the Dr ordered him to take bone scans and other scans, and luckily all was clear. They are now suggesting scans once again due to an elevated PSA. I would greatly appreciate you getting back to me with your insight or with referrals to Drs/research/clinics that may be able to answer my questions. Thank you very much for your time and assistance.

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    1. In general the PSA can flucuate for a number of reasons if a man has not been treated for prostate cancer. If the prostate has been removed, persistence of PSA suggests prostate cells somewhere. The PSA is very reliable as a marker for prostate cancer after treatment.
      It sounds to me that your father’s doctor is on top of things. Without getting too specific, I hope this small caveat about the PSA helps you.

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  2. My physician and urologist recommended a biopsy when my score hit a 5 at age 55. Nothing there. Later, when my score was a 6 another biopsy was recommended. Nothing there…again. Once I had a 9.9 and two months later it was a 6. My latest score, the eighth since 2006, is a 7.3. I’m 61 yrs. old now and my prostate is sized “…between 40 and 60”. Oddly, neither of my previous two urologist EVER mentioned that a bigger prostate will produce more enzyme. So, why was I being unnecessarily frightened by the urologists while being compared to those men with a prostate size around 15g? No DRE has ever inidicated any nodules in my prostate. The PSA test is not an indication of anything other than the presence of the enzyme. A fried seafood dinner and sex the night before can elevate the score. (Unfortunately, I was not told that by any doctor.) I’m sorry, but after my second biopsy I couldn’t help but remember what caught my eye on the way out of the urologist’s office: his shiny black Porsche Carrera Turbo. After my latest score my current urologist’s nurse (by phone) has urged me in strongly worded suggestions to consider “talking to the doctors” at my earliest convenience. I’ve heard this story before and patients like myself are tired of hearing the alarm, paying the money, and suffering the biopsies, simply because the PSA chemoluminescence indicates something above a 4. Urologists need to stop frightening us by using an incredibly fallible test as a basis for doing so. Urologists need to donate a portion of their income and book sales to research that can find a better test.

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  3. I have not heard any discussion of the value of “free PSA” testing. Is this not another layer that can enhance the clinical interpretation of elevated scores ?

    Jules M. Elias, PhD
    Emeritus Professor of Clinical Health Sciences
    SUNY @ Stony Brook, Stony Brook, NY

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    1. you are correct….two points…from the standpoint of the task force and cost concerns…the free psa takes the total psa and breaks it down into that which is bound and unbound (free) in the blood – a high free psa has a lower likelihood of a positive biopsy and a low free psa a higher chance of a positive biopsy…in the end it is still a % given and the diagnosis still depending on a biopsy… i have had a patient with the highest % of free psa (which should have indicated a low chance of cancer or positive biopsy) and all of his samples harbored cancer. i used the free psa myself to prompt the biopsy on me…..from the cost standpoint…it adds to the cost of things and since the results give you a % chance of cancer and you have to do the biopsy anyway…the government folks uspstf won’t be a big fan of this…..i use the free psa in my patients who have an elevated psa and are not sure they want to have a biopsy….in them, if the free psa is very low i.e. 5% this then give them and me more grounds to recommend a biopsy more firmly…. hope that helps jm

      https://theprostatedecision.wordpress.com/2011/05/10/for-prostate-cancer-the-free-psa-is-helpful-but-not-fool-proof-and-is-only-one-of-the-arrows-in-your-prostate-cancer-decision-making-quiver/

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  4. Its amazing how Urologist can simply ignore years of medical scientific tradition of believing the results of randomized controlled trials as the Gold Standard for informing medical decisions. The fact is the only 2 large RCTs ever conducted to evaluate PSA show without a doubt that PSA screening does not decrease your chance of dying from prostate cancer. But I guess we should ignore the fact that they make millions of dollars from treating positive PSA results and just take their world for it that they know best because they have so much experience treating patients with this. The US preventive service taskforce, a body that has no financial incentive in this issue recommends against PSA screening as do most European countries. But our US urologist know best. Sure.

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      1. Dr. McHugh, thank you for your view on PSA. I hear and read many posts that scoff at PSA testing because “they make millions of dollars treating positive PSA results.” I received treatment as the result of rectal examination, PSA testing during “watchful waiting,” and then a biopsy when my PSA reached over 9. This was done by the VA absolutely free to me as a Veteran. So, what’s their motivation? My urologist gave me three options: 1) low radiation treatment, 2) low radiation followed by radio-active seeds, 3) prostate removal. I chose #2. That was 2009. Today, 2014, I am tested every 6 months and have a PSA of 0.01 since 2010. I hear many scoffers and complaints, but it all boils down to being responsible for you own health and request certain tests when you reach a suggested age for the test. I am a collaborator in maintaining my health with my health care providers. We all have a choice.

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  5. It would have been detected early but that’s the point, the evidence shows that early detection does not mean better survival it does however mean lots of side effects from the surgery and unnecessary suffering without improved survival. Evidence is evidence hard to argue with it

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    1. Fair enough. If it were you and you had what Mr. Albin had and Frank Zappa had (metastatic bone disease at the time of diagnosis) would you have liked to have been diagnosed three years Not statistics or epidemiological studies. If we’re you or your father- which would you prefer. J

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  6. Great point, and I agree that it’s always more difficult when it’s personalized. And because I have hot had to deal with it personally it’s difficult to answer your question. However, as a physician I would think that what I would want and what patients would want is to have good medical care and to not suffer unnecessarily. The fact is that both Mr. Zappa and Mr. Albin would likely have not had better survival from early detection and I truly believe their suffering would have been augmented by the surgeries and other invasive procedures that undoubtedly accompany a positive test.

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  7. I started getting an annual PSA test when I turned 40 as my father had had prostate cancer. My PSA elevated gradually each year until I was 54 and my doctor noticed an abnormality on annual prostate digital exam. Referral to urology and a biopsy revealed cancer. Had a radical prostatectomy and five years later PSA is undetectable. Incontinence was never an issue, however normal erectile function did not return, although I am pleased with sexual sensation and sexual satisfaction is more intense than before surgery. I am now 60 years old and have never regretted surgery and am thankful annual PSAs were done and the cancer was found. I would not want to be that guy who never gets a PSA test and finds out by the time the digital exam reveals something and further testing is done that the cancer has escaped the prostate and is advanced.

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  8. Well I could be wrong but a group in CA has created a test strip that does in fact detect cancer cells based on some affect they have on proteins. Should be out soon. Then we can all pee and test for cancer just like women do for pregnancy.

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  9. I might add, then there will be no reasons for all the other tests and procedures and just guessing in many cases if one has cancer or not. Besides a less than 5 percent detection rate, historically, is not very good. This new test will be 90% accurate. Can’t wait.

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  10. Richard Albin’s position is that based on factual evidence of prostrate cancer in more than two-thirds of men at the time of their deaths from all causes, and that 15% are diagnosed with prostrate cancer but only 3% have the form that kills, and that PSA tests cannot predict what type of cancer the individual has, why effectively castrate anyone with a high PSA reading on a test? There is the matter of quality of life that is so commonly ignored as it is by John McHugh. ED and incontinence are all to frequently the by product of prostrate surgery but this is the sort of information that is not provided to their patients or mentioned as a remote possibility and not to worry about it.

    The other aspect that is ignored by McHugh is the profit motivation of a healthcare industry that enjoys more than $3 billion annually in PSA testing revenue as well as the money from all the services and drugs involved in the treatment for something that is a false positive at least 80% of the time. Whatever happened to the concept contained in the Hippocratic Oath of to first do no harm to the patient.

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  11. Can’t argue with you. For years I’ve known that Albin stated he was sorry he ever came up with the 4.0 baseline since the industry used it so incorrectly.
    Hippocratic? Hypocritical is what it is.
    I hope they all get PC. The bad kind.

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  12. Not angry. Just tired of being one of the ones that has no control over such large things as medical care, taxes, etc.
    I had 5 doctors in the family, now only 4, one passed away at 85+ of natural causes, so I have no problems with doctors. The ones I have trouble with are the corporate ones, the ones that set the false standards, and cost us all in the end.
    I see you never argued the point of Dr Albin reversed his 4.0 benchmark. Makes me glad to know I’m right, but sad that so many men went under the knife for fraudulent reasons.
    So, I’m not mad. Just saddened by corporate America.

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    1. My feeling is that the 4 is the result of clinical trials (I.e. What is normal in the average male) conducted by doctors years after Albin ” discovered ” the antigen. The test known by us as PSA was developed by others. I would appreciate your research into this and then report back. This particular caveat clarification will be helpful to all of us. JM

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      1. Read Ablin’s book “The Great Prostate Hoax”. He didn’t come up with the reading of 4 as being significant. He quotes the doctor who DID come up with the 4 number as saying he did it arbitrarily.
        Upon autopsies of men in their 50’s who died of other causes – 43% had cancer found in their prostates. Of men in their 60’s – 65% had cancer in their prostates. Of men in their 70’s – 79% had cancer in their prostates! And when you divide the number of PC deaths among these different age groups the result is 3% of men who have PC end up dying from it! The other 97% evidently had “indolent” cancer.
        Please read this book.

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  13. Well I wrote the doctor that was noted in wiki to have been the 4.0 benchmark creator when/while he lived in CA. I wrote him via email. He didn’t seem to want to go into huge depth but noted that the letter/statement/correspondence/interview/whatever it’s called that he did was in fact correct.
    The industry has gone wrong headed. He has treated persons with a 12 psa that had no cancer. He has treated persons with a 1.5 that did. He was frustrated that the 4.0 had been used as the ‘benchmark’ and that doctors were using it as a bludgeoning tool to get persons under the knife.
    He also went on to state that when asked, 66% of urologists would not have a prostatectomy. They would first wait and see, then they would use freezing and or pellets. They would only use a prostatectomy as a last ditch effort. Yet, they push patients into surgery every day. That is what he felt was an injustice and I have to agree.
    We all want to live forever. We seem to come into this world yelling ‘giddyup’ but go out screaming ‘woah’. It would be better if we just lived, lived right, treated others like we expected to be treated and accepted death as part of life and hoped we’d get rewarded for being a good person while here for such a ‘moment’ in time.

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  14. In my opinion (as a former cured prostate cancer patient) the whole PSA debate is rather silly. As most doctors in most civilized countries know there are far more sophisticated and accurate tests available for prostate screening in addition to PSA. While I don’t recall their names while writing, one is a urine test the other is a blood test. One of these predictors assessed my risk of having prostate cancer was at 59% and thereafter I had a biopsy So if one has an elevated PSA they can take either or both of the two test to help with diagnosis. So in conclusion anyone who would rely strictly on the PSA test in deciding whether to get a biopsy is excluding far more accurate screening techniques available today.

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  15. 59yo just got a 4.9. Had long discussion with the Dr. about why he even ordered the test as the preventative task force rates it a “D” for not recommended.

    With that reading, there is a 75% chance of actually having nothing and a 19% chance of having something so low-grade that some researchers assert should not even be called “cancer.” Yet the urologist would render me impotent and incontinent for that 19%, oh yes, and the $20K they would get for the surgery.

    I pointed out that a biopsy is not a trivial procedure and can have complications.

    I said I no intention of a follow up test in 3 months and he said okay just wait until next year. Said I might not even have it done then. He said that was okay, it was my decision.

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  16. Would you be interested in having a discussion with a research scientist who has prostate cancer [Gleason 9,5+4] that has been unresponsive to surgery,salvage radiation treatment, and an aggressive trial with medical marijuana, who is using his PSA kinetics to drive a data-based clinical decision making process.
    From your letter to the NY Times, and your subsequent comments to readers on your blog, that you have a good understanding of PSA as it pertains to monitoring treatment outcomes.
    My direct e mail address is
    pfadtag@aol.com
    Al Pfadt

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