Replying to Regush

BY RALPH VALLE

March 5, 1999. Nicholas Regush's estimate of the impact of radical surgery for prostate cancer on Viagra sales is obviously wrong. In the U.S. about 200,000 men are diagnosed with prostate cancer every year and about 30 percent are treated with surgery. Assuming 100 percent impotence (not far from reality) you have 60,000 impotent men a year as a result of surgery for prostate cancer.
       That's a large proportion of those men treated for prostate cancer — but just a tiny fraction of all the men who suffer from erectile dysfunction. Sort of the tip of the iceberg — and for a lot of those men, Viagra won't work, so Pfitzer will not profit from them.
ED Affects Millions of Older Men
       Let's look at the numbers of impotent men not affected by prostate cancer. ED is a common condition among elderly men. At around age 40, 5 percent of men have ED. At 65 and over, 15- 25 per cent of men have it. By age 76 and beyond, half of all men say they have problems with getting an erection. Approximately 50 per cent of men with diabetes have erectile dysfunction. In the USA alone, millions of American men suffer ED and are potential Viagra customers.
     Many elderly men who have health problems other than prostate cancer report ED and also lack of libido (which means that probably Viagra won't work well for them). In a study at a VA hospital, three age-groups of patients were surveyed: men under 65, men 65-75 and men over 75 years of age. Lack of libido was reported by one third of the VA patients under 65 and 47 percent over 75. Erectile dysfunction was reported by 50 per cent of the men over 75. Sexual dysfunction was related to subjective poor health, diabetes mellitus, and incontinence. This study suggested that while the incidence of erectile dysfunction increases with age, it is frequently related to coexisting diseases rather than to age alone.
     Erectile dysfunction is significantly associated with a history of heart attack, urinary incontinence, problems with mobility and the use of sedatives. Roughly half of men with diabetes have erectile dysfunction.
Why Hostility to Treating Prostate Cancer?
      Viagra sales will not depend on more and more doctors promoting radical surgery for prostate cancer. In any case, studies show that Viagra only works for 50 per cent of men treated with surgery — if they had nerve-sparing surgery. My, my, the Viagra contingent among the prostate cancer surgical patients is drastically reduced, no?
       If this is the true situation —  and I believe Regush is aware that it is — what was his fundamental motive in issuing his Viagra comments?
       As I wrote to him by E-mail, he was liberal with his comments about the pain inflicted by screening, but failed to comment on the other side of the coin. What happens when prostate cancer is detected too late? Regush said: "An illness that afflicts mainly men over 50 (most in their 60s), prostate cancer grows slowly and might never spread. But with early detection, many men are subjected to the indelicate emotional and physical impact of biopsies and jump-the-gun surgery when it would have been OK simply to wait and watch for developments."
       Doesn't he know that in Sweden, where they practice watchful waiting, 80 percent of the men diagnosed at age 60 or below die of prostate cancer? How does he justify the above comment? He is pontificating about prostate cancer without basic knowledge of the natural history of prostate cancer, In doing so he is promoting unfounded opinions of gatekeepers and health insurance providers in this country.
       If Regush were correct, prostate cancer would not be the second leading cause of cancer mortality in men. He generalizes by implying that all prostate cancer is equal. It is not. The vast majority of prostate cancer detected through screening protocols is clinically significant. Yes, some cancer that might not need to be treated is detected using screening with PSA and DRE (digital rectal exam). But those are a real minority.
       In the meantime, it seems that the use of the imperfect PSA test along with DRE in combination with aggressive treatment for aggressive disease is paying off by detecting earlier and more treatable stages of prostate cancer. The result has been a reduction of prostate cancer mortality in the past five years. Not bad for aggressive treatment of aggressive disease, no? Not bad for the maligned PSA test. The best cancer marker available!
Patients Must Become Informed
       Viagra sales will not depend on surgical patients. There are plenty of users even among men who don't need it. Viagra will help prostate cancer patients in general who suffer impotence as a consequence of treatment. What is wrong with that?
       I agree that patients need to be informed of the potential consequences of treatment as well as of failure to treat. I see informed consent as a basic premise by which men can make decisions based on sound information, not the scare tactics I see published. There are no randomized clinical trials comparing treatment with no treatment and it seems that we will have to wait for many years to arrive at answer. In the meantime, why not use the natural history of prostate cancer as written in those countries in which watchful waiting is practiced? It is a pretty sad story, which we tend to ignore.
       You accuse Dole and Pfizer of being opportunistic and of profiting from patient's ignorance to sell Viagra; and then you proceed to sell your comments through ABC News without a basic knowledge of the subject. If you are really for informed consent, study both sides of the issue. rather than issue biased commentary that possibly will harm many of your readers. If we don't need Dole and Pfizer confusing the issue, then we don't need you doing so either.

Ralph Valle is fighting incurable prostate cancer because, as he says, "I was never tested with PSA before diagnosis." Ralph is one of the group in Dallas that formed the National Prostate Cancer Coalition (NPCC). He went to MD Anderson and urged them to develop a National PCa research agenda.
       Ralph works as a volunteer for ACS making PCa awareness presentations, He facilitates three separate US TOO PCa supports groups at three hospitals in the Phoenix Metro area.
       As a founding member of the Prostate Cancer Awareness Network (PCAN), he ran the LCA issue in the Pheonix metro area and gathered hundreds of signatures. "I am supposed to be heading PCAN," Ralph says, "but back problems and plain too much going on made me ask Fred Mills to keep it going. Hopefully, I'll get back into it and benefit from the effort."
       Ralph was involved in the first peer review process for the Dept of Defense prostate cancer program in Jan '98. He says:

I work for all these groups and at the same time I am not identified as part of any one of them in particular. You can identify me as a prostate cancer survivor and patient advocate. My main goal is PCa awareness so that men can have a choice one way or the other... Have to run, today is my volunteer day at the hospital. Have a great day and keep up the good work. Godspeed, Ralph ."

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This article is archived from November '99.