to once again [inaudible] >> one thing that amazes me i would like to ask you guys about i've been here five years and the thing that blows my mind is here senator dole is 86 now and i look forward to playing golf and stuff like that when i'm 86. since i've been at the institute the last five years he has gotten a award from west point, the french legion of honor award taking a big role you just described in the health care debate and went to normandy to the president the past june, he took the lead on the world war ii memorial and got the dedicated. he was involved in the dole institute.

it's been two weeks since we last spoke on the floor on this issue and there's a lot that's been written in the press and a lot of things that have been

said. and i'll reiterate what i said earlier in that debate before we took an inappropriate spring break, and that's the fact that everybody thinks, those that are -- thinks that those who are unemployed should be getting an unemployment check. that's not a partisan issue. it's a fact that we want to support those who need help right now. the real question, however, is what will we do to make sure that that effort is an effort that has some real meaning behind it and that there's not just hollow words. you know, the debate around here becomes partisan and labels get applied and -- and i would admit i'm partisan, but not from a

party standpoint. i'm partisan for our children. and the question isn't whether we should make sure that we the unemployment benefits are there. the question isn't whether people can get health insurance and -- and -- under cobra. the question isn't whether we ought to do the right thing for those that are depending on us. the question is: is where do we get the money? it's really simple. we have two options. one option says time-out. this is so important that it doesn't matter where we get the money, we've got to supply it. the other option is -- and, by the way, the first option, belies the fact that we have any

waste in the federal government. i don't think we could do a poll that would come so close to unanimity as a poll if we asked people if the federal government is efficient and effective. i doubt we can get anybody on the ledger side of saying yes on that. the real question becomes: do we have the goodwill and presence of mind to do this in a way that doesn't jeopardize our children? you see, we're not just fighting about unemployment benefits. we're not debating the issue of unemployment benefits. we're debating the issue of whether or not we take from those that come after us and give to those today. many times i've used this poster of this young lady.

and her name is madeliene. and madeliene was caught here in d.c. wearing this poster. and i have gone over the numbers. when she wore the poster her debt was $38,085. her debt now is over $45,000. we have competing priorities. we have the priority of making sure that we help those that need our help in a time of economic decline. and then we have the priority of makmaking sure that we have not mortgaged opportunity and freedom for children such as madeliene. who will fight for the

madelienes? who will stand up for the grandchildren and say we can find $9.2 billion out of an almost $4 trillion budget and pay for it and not charge it to the madelienes of the world. because that's what we're doing when we declare something an emergency. and i'd also make the point, we passed a nine-month extension for many of these programs, and it was paid for. in other words, we didn't add to the debt when we passed the bill that would extend this for nine months. the senate did its work. that bill hadn't come back for us because the congress is unlikely to pass it with the pay fors in it and several would have it for the health care bill that passed. who will protect the madelienes of the world?

since the beginning of this year and the famed passage after statute called paygo, which say that's we will no longer create new spending without cutting the spending somewhere else, we've spent $120 billion of madeliene's future and every madeliene that's out there, every 3-year-old and 4-year-old that's out there. and we've done it by waiving the new statute that says you've got to pay as you go. you know, congress and senate specifically, we increased our budget 5.6% this year in a year where true costs were down we increased our own budget. and, yet, we refused to go and look at the hard choices that are necessary for us to make a future for the madelienes of

this world. what happens if we continue this? what happens if we continue to say we'll borrow future instead of making the tough choices now? well, i'll tell you what happens. as madeliene's future, her opportunities for prosperity are mortgaged. we tend to think in the short run. and what the vision of our founders had us thinking in the long term. so where do we fin find $9.2 billion? if i get an opportunity i'm going to offer five separate amendments that will pay for this. and i would wager that ordinary a person would -- a person would not miss this. we could -- they have at

least $50 billion worth of waste in the defense department. but, no, we won't go there. we've got $700 billion in unobligated balances of which well over 20% has been sitting there for two years. that's $140 billion. we could pay por this thing for a year -- pay for this thing for a year, but we won't go there. we've got ineffective spending in the stimulus bill that hadn't been rolled out yet that i would put forward as a greater priority than what the money intended left in the stimulus bill is for. but we're not going to go there. what we're going to do -- and we will pass a motion to proceed today to this bill. but what we're going to do is we're going to take the easy, soft road of not paying for it. we can't continue to do that. last year -- and we will continue this year -- of every

penny that the federal government spent, we borrowed 43% of it. so 43 cents out of every dollar that the federal government spent last year, we borrowed. we ended up with a real deficit of close to $1.6 trillion by the time you get out of the counting -- indicating gimmicks that washington uses, that's what we added to the madelienes of the world. and we're going to do that again this year. as a matter of fact, last month's deficit, the february deficit, was the highest on record ever for the federal government. so we're going to have an excessive $1.4 trillion, probably a $1.6 trillion deficit this year and we're going to add another $9.2 billion with this bill. how's it fair? how is it right that in this country that we can't do two right things much we can only do

one right and one wrong. i would pause it that stealing money from our kids' future and mortgaging their fruit sewer morally -- future is morally wrong. i would pause it that helping people who need help on unemployment benefits is morally right. why can we not do both? we ought to be able to do both. i sent a letter, and i'd like to ask for it to be entered into the record, to the minority leader as well as the majority leader when this bill first came up. and i'm going to read it because i think it's important to understand the thinking on why we should pay for this. realizing that we did pass a nine hch month extension -- nine-month extension that was paid for and realizing that because the house hasn't acted,

we don't have an obligation to protect the madelienes of world. i would like to be consulted on any unanimous consent agreements regarding h.r. 4851, the continuing extension act of 2010 would extend federal programs for one month. no one is arguing that no one unemployed should not have their unemployment payments extended. congress is refusing a way to find the offset, th the $9.15 billion cost which cuts -- with cuts to less important federal spending. time and time again, congress intentionally waits until the last minute to consider important legislation then declares the billions of dollars in foreseeable costs as emergency spending in order to avoid having to find a way to pay for the bill's price tag. in the last six months, congress has passed four major extension bills. h.r. 4851 will be the fifth such bill. the total cost of these bills is

over $30 billion. additionally, over the last year, congress has increased funding totaling $64.9 billion for the highway and unemployment insurance trust funds without any offsets whatsoever. the shortsightedness sticks taxpayers with billions of dollars in additional debt and treats the unemployed, doctors and medicare patients, hard-working men and women who help make our roads and bridges safe, and others relying on federal funds as pawns in congress's borrowing and spending sprees. when the previous last-minute one-month extension was brought up days before the funding, authority for numerous programs, including employment insurance trust fund which expired in july of 2010, a united states senator was attacked for objecting to attack the bill without any debate or amendments because the bill was unpaid for and added $10 billion to our nation's debt. in other words, there was something wrong with senator bunning raising the question of

whether or not we ought to pay for it. as always, those who prefer to borrow to avoid making the tough budget decisions won out and the taxpayers were stuck with an additional $10 billion in debt. the madeleines of the world. congress has continually resisted the need to act like every family in the united states of america and to budget and live within its means. our debt today stands at over $12.6 trillion. the 2010 deficit is projected to be at a minimum $1.3 trillion and we're borrowing 43 cents on every dollar we spend, yet congress continues to increase spending without any correlating spending cuts. congress's inability to prioritize and manage national needs results in real consequences for americans, whether it be furloughs, market uncertainty that leads to lower investment and job losses, or americans being saddled with higher debt and taxes.

if congress keeps approving temporary extension bills throughout the calendar year without finding offsets, congress will have added an additional $120 billion to our national debt. additionally, the senate has already approved more than $120 billion in new federal spending not yet offset even though it passed paygo legislation over the -- over one month ago claiming to prohibit such activity. in the house, chairman of appropriations committee, david obey, has indicated some new spending needs to be offset with unused, unobligated funds. chairman obey suggested rescinding $362 million in reserve stimulus funds for the women's, infant and children's nutrition program, $112 million from a commerce department program designed to provide coupons to households designed to help them buy digital to analog converter boxes. $103 million from usda rural development programs and $44 million from the

transportation department's consumer assistance recycle and save program. to offset the costs of a different spending bill. the senate should likewise find a way to offset this one-month extension bill and create a sustainable precedent. the senate could start with federal unobligated balances. according to the white house, in fiscal year 2011, 33% of all federal funds were unused and obligated. the total dollar amount of these unobligated balances was estimated at $703 billion. rescinding only discretionary funding that has been available for more than two years would result in $100 billion in offsetable costs. the senate could also tap into $228 billion in unobligated stimulus funds, as chairman obey has suggested. at the very least, congress should reconsider transferring the almost $100 billion -- correction, $100 million budget increase it approved for itself in the 2010 to offset the cost

of additional spending. congress should not be increasing its budget when our economy shrunk by 2.4% and inflation was less than 1%. i've also detailed through numerous oversight hearings, reports and legislation how the federal government wastes more than $300 billion every year. i've suggested hundreds of offsets to new spending, including consolidating duplicative programs and eliminating federal programs that address simply parochial concernsment we all think our americans in need of financial assistance are worth the $9 billion cost, but do we think our children and grandchildren are worth paying for these costs upfront rather than passing the costs to them? thank you for protecting my rights regarding this legislation." i ask unanimous consent that this be entered as part of the record. the presiding officer: without objection.

mr. coburn: so what are we going to do? we have before us a need. it's a good need. it's something we ought to do. we're going to continue to spend 43 cents out of every dollar that we spend this year we're going to borrow. we're going to put the madeleines of this world in the position that by 2020, this number isn't going to be $45,0 $45,000. it's going to be $95,000. that's where she's going to be. that's every man, woman and child in terms of what they owe in terms of the direct national debt. can we continue on this pace?

we hear that we'll fix it later. later isn't good enough for the madeleines of this world. later is today. now is the time for us to do the very hard work. it's not easy to come with spending offsets. it's not easy to not increase the national debt. it is very easy to simply put the credit card into the machine and say because they're out of sight and out of mind -- the madeleines of the world -- we'll just charge it to them. and that's what's being proposed here. and if you oppose that, all of a sudden you don't care about the people that are unemployed. i can't tell you how many times i've heard that in the last two weeks. that it's obstruction that you

want to pay for it. should we be working hard to secure the future of the children such as madeleine? you know, we're told that over the next nine years, we're going to borrow an additional $9.8 $9.8 trillion based on the budget projections that are out there. of that $9.8 trillion, almost half of it is money we're going to borrow and turn around to pay interest on what we already owe. that's eerily close to those of us who get in trouble with credit cards. we go get another credit card, borrow the max on it to pay off the other credit cards and then we get in trouble with that one and then we get another one, and then pretty soon we can't pay anything. the chinese now own over $900

billion of our bonds. the russians, $800 billion. have we considered the fact that our problems in terms of our foreign policy with iran and our ability to put sharp, tough sanctions on somebody that wants to use and develop nuclear weapons could possibly be inhibited by the fact that two of the people opposing those strong, tough sanctions own a lot of our bonds and that we're dependent on them? or could it also be that week before last, treasury auction, when it was very soft because the chinese didn't participate, that that's a warning bow across -- a warning shot across our bow? we're in waters that this country has never seen before. and with this bill, if we pass

this bill and we continue to pass more bills not having made the tough choices, we are steaming towards a catastrophe. and what will that look like? it's not that we can't fix the problem. it's not like we couldn't go and find $9.2 billion out of a nearly $4 trillion budget. it's that we refuse to. it's not that it's impossible. we refuse to. we refuse to do the same things that families across this country do every day. and that's make a choice about priorities. you know, my office just last week, with the help of the congressional research service and the g.a.o., identified 70

duplicate programs on nutrition across three federal departmen departments. so we now have 70 programs for food and nutrition across three departments with thousands upon thousands of federal employees, thousands upon thousands of pages of bureaucratic gobbledygook and regulations, and i would propose that probably we ought to have one good program on food and nutrition. we don't address that. the authorizing committees don't. the appropriating committees don't. we have 105 programs that encourage people to go into math, science, technology and engineering across six different agencies. 105 programs. there is not one agency that does not have considerable waste in it, and there's probably not one american that wouldn't think

that we couldn't cut 1% or 2% or 3% from every agency and drive efficiency. but we won't do that. and the real question is: why won't we? we'll beat people up because they won't agree to spend madeleine's money and her future, but we won't agree to trim the waste, the fat, duplication and the fraud out of the federal government. it's no wonder the public has such a poor image of congress. because we're actually not doing what they're asking us to do. you know, it would be different if there wasn't waste in the federal government, if everything was fine-tuned, effective and efficient, you could make an argument for borrowing this money. but nobody that i know of

believes the federal government is efficient and effective throughout its myriad of departments and agencies. and if the majority might feel that way, that it's not, why would we not do the hard work of paying for this bill? what does it mean to borrow $9.2 billion this month and $10 billion last month and $10 million before and the three months, $120 billion that we passed in the first three months of this second session of the 111th congress? what's it mean? it means that we don't think we have to play by the same rules as the rest of the american public. we have a tilted sense of reality. there's no obligation on us to eliminate waste to provide a good for those people that are

depending on us. and so we'll go forward this evening on a motion to proceed to this bill unpaid for, charged to the madeleines of this world. and all you have to do is take $9.2 billion -- it's not much in washingtonspeak. it's twice the size of oklahoma's budget for a year -- and we'll charge it, the credit card, it our kids. but ultimately what we're doing is stealing a college education from our kids. we're stealing a job opportunity from our kids. we're stealing the ability for our kids to own a home and to provide for their children what

was provided for them. you see, the heritage that we have that built this country was one of sacrifice. or that we make decisions that require us to make sacrifice to create opportunity. when you turn that upside down, the american experiment fails. when we steal opportunity from the future so we can benefit for today, we eliminate the genius that made this country great. it's time we reversed that. it's not really a partisan issue. i know the press is going to say that. you know, it's partisan for our future. it's partisan for our kids. and we can do both. we can find $9 moi 2 billion that -- we can find $9.2 billion

that isn't spend on cobra insurance or flood insurance or fixing the s.g.r. pho a short period of time. we can do that. but we will won't. -- but we won't. because we're in the habit of not making hard choices. we're in the habit of doing the least best thing rather than the best thing. and the best thing for our budget, the best thing for our future, the best thing for our children's future is for us to say x, y, and z are not as important as uninsurance benefits, are not as important as cobra best benefits, are not as important as fixing the s.g.r. for a short period of time. when will we muscle up the courage to start making those

kinds of decisions? we can't continue doing what we're doing. we can't go to $20 trillion worth of debt. over 100% of our g.d.p. at the late we're going, in 2010 we will have $23 trillion worth of debt. $24 trillion. at 6% interest, that's $1.5 trillion a year in interest payments. we can't make it. we cannot handle that. and the reality will only come home when it's too late.

senator reid, when we passed the paygo, said that it was a new start. said that we're going to open our billfold, if the money is there, we'll be able to spend it. but we won't spend money that's in this our billgold, to paraphrase his quote. well, this bill goes to an empty billfold. the money is not there. so we can either increase our debt, which will make life for the madeleines of this world tougher, or we can actually take on some tough decision making as a body in the senate and actually eliminate lower-priority programs. will that have some impact on some folks? yeah. we could actually take a 1

1%-across-the-board cut and come up with $30 billion. easily. americans know we could get 1% out of the federal agencies. we're not going to do that either. the question is, when will we start acting in the responsible role that we're charged with? when will we start thinking with a long-term perspective about what's going to happen to our country if in fact we don't start making the hard choices now? no matter how much scorn, no matter how much derisive -- how many derisive statements are made, the madeleines of the world are worth it.

when we sat and relaxed and think that this is not as big a problem as we described, we fall into the same trap as every other republic in history, and they all collapsed. no republic has survived more than 250 years. and they all -- they all collapsed for the same reason. they all collapsed ultimately because they lost control of their fiscal policy, fiscal policy -- taxes, spending, priorities. so we have a choice in front of us, and this isn't the first time we're going to have this choice, and it won't be the last. but a question i think the american people ought to be asking is, when is the congress going to start acting in a responsible manner?

when are they going to start following the guidelines that every other prudent financial decision-maker makes whether telecommunication the head of a household -- whether it be the head of a household, a major westerner, a small business, a small nonprofit. they all live within a budget. and what they do is they say, here's the most important priority and here's the least, and they go down the line. and when the money runs out, they either generate efficiency to allow that money to be more effective and more efficient in how it's spent, or they eliminate the lower-priority items. it would be a wonderful search for people to go on thomas.gov to find out the number of programs that have been eliminated versus the number of programs that have been created in the last two years. i guarantee you they'll outnumber it 200 or 300 to 1. in judiciary committee this week, we're going to have two

bills up that duplicate existing programs. and i'll have the same fight in the judiciary committee, and i'll lose, and we'll extend new programs that are doing the same thing other programs are doing, and yet i'll lose the battle, and we'll create new programs to do the same thing that we already have government programs doing. and why is that? because you cannot manage what you do not measure. and we do put metrics on hardly anything in the federal government programs. and conveniently so, therefore, we can say, well, we can't know whether they're efficient or not. the time for our comfort with where we find ourselves financially is over. the american people already understand that. 72% in a recent poll said their number-one issue is debt and spending.

they already get it. they're wondering when we're going to catch up with them. they're for supporting unemployment insurance benefits but not charging it to their children. they're for us toi making the hd choices. so as we go forward, the hope would be that we would get out of the short-term thinking that we find ourselves in and start looking down the road to what's coming. i've been quoted say, i think we have less than five years to fix our ship. i think that's probably generous. i don't think there's one problem in front of our country that we can't fix. however, if we ignore the realities of our financial situation, if the elected leaders in this country fail to

make priority decisions, which means you're going to offend some of the supporters of the lower-priority programs, then we're not going to solve the problems that are in front of us. if our focus is parochial only -- in other words, only the concerns with our own state rather than that of our nation as a whole -- we're not going fitch the problems thr in -- we're not going to fitch the problems that are in front of us. i have five grandchildren and i often think, thinking forward, what'll things be like for them? abdz i think backwards when i was 17, 18, going to college for the first year, the tremendous vision -- horizon i saw in front of me. i could go to school. i had parents that could afford to pay for my children college. and it was wherever i wanted to

go, whatever i wntsed to do was out there. that's a limited ability today. is it going to be a possibility for the madeleines of the world? if you think forward, if you take everybody that's 25 years of age and younger in this country and go forward 20 years, here's where they'll be: that group 45 and younger will be responsible for $1,113,000 wonch debt and unfunded liabilities -- worth of debt and unfunded liabilities. every one of them. if we're on the same course that we're on today. take 6% on that, and you'll see that they're going to have to come up with about $67,000 a year just to pay the interest costs on that defnlt that's before they pay income taxes.

that's before they pay rent or pay a mortgage. that's before they pay for a car or car payment of that's before we put food on the table. that's before they clothe their kids and themselves. that's before they goif a charity or their church. we're stealing the american dream every fipple w time we fae cognizant before we change course. so the debate is about when are we going to change course? when are we going to start recognizing the need to live within our means? we're going to hear that we've always done it this way, that we passed three other short-term extensions understand that we called them emergencies -- and that we called them emergencies

so that we could not have to pay for them. i would say, it is the time we not always do it the way we've always done it because the way we've always done it has gouts $12.6 trillion in debt, and -- has got us $12.6 trillion in debt and is send us out to sea without a rudder and without enough fuel oil to get back to shore. my hope is that our debate will focus on what the real problems are in our country. the real long-term problems, because you really solve short-term problems when you start attacking the long-term problems, when we really start to make the decisions. and i say to my colleague from montana, as head of the finance committee, he knows what would happen if we sent a signal that we were going to get tough about our budget. he knows what would happen to bond rates. he knows what would happen to our ability to lead in the world, if we all of a sudden

became cognizant and acting in a way that was fiscally responsible. investment would come flowing back into this country, bond yields would go down be, not up, the cost of our debt would go down. it would be a home run every way we look at it. and it would be a home run for the madeleines, and it would be a home run for those that are unemployed. if you read the financial news, you've been seeing what's happening to greece. greece got rescued just in the last week, partly through the i.m.f., but mainly the money is going to come from germany and france. and they're going to get to borrow for a short pire period f time at 5%. i would put out, that there's no germ or france to bail us out. there's not anybody that's going

0 come bail america out. and it's highly doubtful greece has the political will to do what it has to to get out of its own problems. the question is, in two or three years, are they going to be saying the same thing about our country? do we have the political will to dig out of the hole that we in fact have put ourselves in? when i say "we," i am neat talking about the american public. i am talking about the congress of the united states. you can't blame it on any president. you can't blame it on the courts. the blame nor our financial situation -- the blame for our financial situation lies solely with the u.s. congress, whether it is the lack of oversight of financial firms, of freddie mac and fannie mae, whether it is the sack of oversight of the s.e.c., whether it is the tremendous amount of waste, fraud, and abuse in the federal budget, $300 billion at least year, it lies with us.

we're going to hear lot of reasons why we should pass this and just pass the charges on to our kids. my hope is that the american people reject that. because when they accept that we just charge it to our kids, what they're going to do is condition us to continue to do the same, continuing to spend the future opportunities of our children and grandchildren. our heritage is much greater than that. our kids and grandkids are worth much more than that. let it not be said of this congress that we failed to act in a time when now is when the tough get going, and we make the hard decisions about not increasing the debt, streamlining the government, eliminating some of the $300 billion worth of waste, fraud, abuse and duplication that's in the federal government. and with that, i yield the

floor. mr.aucus: mr. president? the presiding officer: the senator from montana. mr. baucus: mr. president, we are starting to come out of the worst recession since the great depression. a little more than a year ago, in the fourth quarter of 2008, the economy declined at an annual rate of more than 5%. a year later the fourth quarter of 2009, the gross domestic product grew at an annual rate of nearly 6%. last month manufacturing activity increased at the fastest rate in five and a half years. last month the service sector expanded at the fastest the rate in more than two years. and last month the economy added 162,000 jobs. the economy has taken its first steps toward recovery. the economists say that part of

the reason why the economy is starting to come back is what we did here. one of the first things that president obama did in office was to press for bold action to prevent another great depression. what did he do? one of the first bills that congress enacted in the new administration was the recovery act. economists say that it's working. the nonpartisan congressional budget office says that in the fourth quarter of 2009, the recovery act increased the number of full-time equivalent jobs by between 1.4 million and 3 million jobs. and the congressional budget office also estimates that the real gross domestic product was .5% to 3.5% in the fourth quarter than it would have been without the recovery act. so there are some encouraging signs. but we still face major challenges in the economy. there's still work to do

creating jobs. the unemployment rate stands at 9.7%, almost a tenth of the labor force is unemployed. more than 15 million americans out of work. first-time claims for unemployment benefits rose the week before last. businesses are still laying off workers. and companies remain tentative in hiring new employees. the economists call unemployment a lagging indicator. employers can be slow to rehire when business begins to pick up. the congressional budget office expects that unemployment rate to remain above 8% until 2012. c.b.o. does not expect unemployment to reach what they call its natural state of 5% until 2016. c.b.o. does not expect the gap between actual output and potential output will close until the end of 2014. that's why we need to pass a

temporary extension of unemployment benefits. jobless benefits are a powerful way to bolster demand during times of high unemployment. households receiving unemployment benefits spend their additional benefits right away. that spurs demand for goods and services. that boosts production and that leads businesses to hire more employees. the congressional budget office looked at different ways that we can help the economy to grow, and the c.b.o. says that extending additional unemployment benefits would have one of the largest effects on economic output on employment per dollar spent. and because benefits are often spent quickly, extending unemployment benefits will promote a timely boost to the economy. a temporary extension will also provide immediate assistance to millions of americans struggling to feed their families and pay the bills. according to officials in my home state of montana, if we do

not pass this extension when thousands of montanans could lose their unemployment benefits, we'll have significant difficulties. thousands is a significant number when you consider the population of my state. an extension of unemployment benefits is essential but it's not enough. also consider unemployment insurance reforms that could help create more jobs. in that vein, i plan to hold a hearing in the finance committee on wednesday to explore ways to use tphouplt insurance. -- unemployment insurance. states and experts have a lost ideas, ideas about how it can save and create more jobs and wednesday they will discuss commonsense innovations with a panel of experts while also addressing the challenge of state solvency. right now it's essential that we pass a temporary extension of unemployment benefits. an extension will help workers to get by as they search or retrain for a new job.

an extension will also provide a much-needed boost to the economy. and so, let us help the families who are struggling in this difficult economic time. let us help to spur demand and economic growth, and let u ,,

the committee will come to order. good morning. thank you for being here. prostate cancer is the second most common type of cancer found in american men. the first being skin cancer it is also among the leading cause of cancer death in men secondly too long cancer to get one man out of six will get prostate cancer in his lifetime, and one man in the 35 will die from it. the good news is that the death rate of prostate cancer is declining. the bad news is that we still don't know what causes it. we still don't know why african-american men are more likely to get and we still don't know why it seems to be most prevalent in north america and

europe. but most importantly for today there is still controversy over whether minn should be screened or prostate cancer and there are questions which should be treated. we are hoping to shed light on these questions today. before we begin i would like to acknowledge the important role of my colleagues representative elijah cummings from maryland as has requested this hearing and also helping to insure these issues get the attention they deserve and i would like to give them a special thanks for that as well. i also want to welcome to the hearing today the new york native. he is very well known for his working in the film industry and has been widely recognized as one of the great actors of our time. what isn't well known is that he has been diagnosed with prostate cancer. he has agreed to testify today

to help bring attention to the issue. i want to thank you for that as well. we also have this ditty gallo, widow of a former congressman dean gallo why served with who die from prostate cancer and we have with us also mr. thomas farrington, tin your prostate cancer survivor who has done a lot of work in this area as well. there's a high degree of public awareness of the need for regular screens for certain kinds of cancer. notably breast cancer, prostate cancer and colon cancer. however this widespread belief is now being debated. a few months ago "the new york times" devoted some scientists have concluded the benefits of the cancer especially breast and prostate cancer have been overstated and that regular screening might not do as much parma -- might do as much harm

as good. this has caused widespread confusion which we hope to correct today. to help us do that we have some of the leading medical experts in the country to discuss the latest thinking on screening and treatment of prostate cancer. i look forward to your testimony today because this is a very important issue and again i thank my colleague, elijah cummings, for making certain that we move forward with this discussion. malae jeal to the gentleman from california for his opening statement, congressman issa. >> thank you for holding this important hearing today. and i would like to echo your comments about our colleague mr. cummings. last year he approached me to ask us to work together on a bipartisan basis on this legislation. i accepted and again thank him for his leadership. as the chairman said, prostate cancer affects 2 million american men living here every

day including one of our witnesses. more importantly, when there is confusion as to what to do about eight, even after decades of the improvement and survivability as the rays with prostate cancer and also breast cancer, it's very clear the congress has a role to hold these types of hearings and in fact finding to reach if at all possible either consensus on and off, were consensus on direction. i hope today is the beginning of that process so that we can provide guidance to the administration and health care industry about what the message should be read we are not healthcare professionals here at the top. we do not intend to become that. what we do intend is to try to help make the message clear and understandable to 306 million americans come slightly less than half of whom are men that all of whom are concerned with the effects that will happen to themselves or loved ones and the possibility of preventing it or

early detection leading to a cure. with that i looked forward to the witnesses and yelled back. >> mr. chairman, thank you very much. i want to thank you and the ranking member. i realize we have witnesses that have been waiting for a while so mr. chairman, i will submit by written statement but again, thank you for addressing this crucial issue. >>ho so ordered. >> we always spare our witnesses in so please stand and raise your right hand. do you solemnly swear to affirm to tell the truth, the whole truth and nothing but the truth? if so, answer in the affirmative. >> yes. >> you may be seated. let the record reflect the weakness is all answered in the affirmative. so, dr. deweese, we will start with you first a. >> chairman towns, ranking

member issa and honorable members of the committee, good afternoon and thank you for the opportunity to testify at today's hearing and let me also say thank you, mr. chairman, for accommodating my schedule. i do need to get back to baltimore to see a prostate cancer this eckert as i do appreciate this. i do care about my patients with prostate cancer and am committed to doing what i can to improve their health and life. by way of background, i am a professor and chairman of the radiation of a quality at the johns hopkins university and professor of urology and oncology. for more than 15 years i've dedicated my life to the treatment of men with prostate cancer and have treated over 2,000 in diagnosed with this disease. i also have direct a laboratory of johns hopkins over the same period of time and intimately involved in research to develop new test to diagnose prostate cancer and therapy toward effectively treating the disease. i published more than 150 scientific articles, abstracts in these areas and i believe

these experiences provide me a unique perspective on the problem of prostate cancer and the need for improvement in imaging, genetic analysis to enhance prostate cancer care. my goal today is to provide a brief background on the gaps and the screening and treatment approaches and explain why more robust research funding is needed in order to help our present and future patients. major events supported by federal funding have been made in the past 25 years to improve the care of patients with prostate cancer. the development of the psa blood test has been one of the most important advances and serves as the primary means of screening men for the disease. the problem is that the psas and cantor specific. it is only prostate specific, such the changes in the psa can occur for both cancers and on cancerous reasons such as infection. moreover it typically does not indicate exactly how aggressive the cancer will be in any

individual patient. this particular problem has produced great confusion for physicians and patients alike. and while advances in understanding of how to properly use the psa test made, significant changes in the psa level typically result in a biopsy to determine if cancer is present. this is problem number one. some may and do not need to be biopsy because they really do not have cancer only an abnormal psa. however we cannot tell which patients have cancer from those that do not. and for those patients with cancer, we cannot tell which have the aggressive types that can be deadly. while the psa test allows us to find some cancer earlier than we might without using the test, we find many cancers that would never have been a problem for the patient and do not need treatment of any sort. put another way, prostate cancer comes in two general types. one is analogous to a domesticated to ten and the other two are dangerous lions.

but right now we cannot easily tell them apart. this is not to say our present screening and a biopsy that its are useless. in fact many men have had cancer detected early enough to receive care that was lifesaving. but this has been at a cost of finding many more men with cancer that never needed treatment. this approach is problematic because it exposes man to unnecessary risk of treatment related side effects. that is to say we must find a way to ignore the kittens and focus our treatment on the deadly lion. at present, a biopsy of the prostate is the only definitive way to determine if the patient has prostate cancer and needles are placed through the rectum and to the prostate to obtain that tissue. this is the second problem. biopsies of the prostate or down in a blinded fashion. unlike virtually any other organ we biopsy for cancer, we do not have effective damaging to guide the biopsy may become needles to suspicious areas of the prostate. we cannot see the cancer, thus

it is very possible needles pasted to the prostate might miss the cancer cells. even if the needle hit cancer cells in one area the needles might miss a more aggressive cancer elsewhere in the prostate which then goes undiagnosed and thus the appropriate management for the aggressive cancer cannot be used. these facts demonstrate the present approach can result in the over diagnosis and over treatment for many patients. the under diagnosis in some men resulting in a less optimal therapy because an aggressive prostate cancer was biopsied while some patients are left undiagnosed because the biopsy completely missed the cancer. finally our ability to accurately determine which prostate cancers in which patients are likely to be lethal is limited. taken together a strong case can be made that significantly improves prostate cancer imaging and genetic markers. such imaging would allow us to avoid blindly by of seeing the prostate. instead they would be used to

help guide the placing of biopsy needle to the suspicious sites. in addition advanced imaging and analyses of blood and urine allow us to determine if the patient has a type of prostate cancer that will never cause harm avoiding treatment for such men while allowing us to direct more aggressive treatment to those that will benefit. so despite the concerns i am quite optimistic about the opportunities for the present prostate cancer imaging and genomic analysis that they will afford. positive steps forward i believe policy planners should consider include increase in nih research funding to support prostate cancer imaging, genetic and by yo marker research and clinical trial development by at least 100% in the areas of the next two fiscal years. support the creation of an nih request for proposal but what specifically encouraged the study of damaging, by all markers and genetic analysis from patients in large penchant networks so that the young for analysis of these techniques to ocher and lastly to urge the nih

to make these initiatives a priority and request a public report on progress by 2011 involves on-site experts. in closing i will say i had the great privilege of working with thousands of men including distinguished members of congress. it's been a blessing for me, frankly, to see most of these men are alive and doing well. however not all of my patients have been so fortunate and i wonder how much better their lives might have been if i had better imaging and diagnostic tools to take care of them. a bus on their behalf volume compelled to ask you to support legislation that increases research funding for prostate cancer screening, and imaging, genetic analysis and therapy and i think you all for your attention and for your consideration. mr. chairman, thank you. >> thank you, very much dr. deweese. mr. farrington, good to see you.

[inaudible] >> chairman towns and members of the house on oversight government reform, i am honored to appear before you today to address the nation's prostate cancer crisis as a tin your prostate cancer survivor and having witnessed the death of my father and both grandfathers from this killer disease. since my treatment for prostate cancer in 2000 i've worked nonstop to help educate others about this disease including a founding fi cristello education and work in 2003 with a focus on african american men who have the highest risk for being diagnosed with and dying from prostate cancer. there is an urgent need for clarity in the fight against prostate cancer today. the debates sparked by the screenings released last year have caused quite a bit of confusion elevating the risk of than most vulnerable to the disease. this confusion comes at a time when we have witnessed a steady

decline in the prostate cancer death rates the past decade which most attribute to earlier detection of the disease through psa screenings. these are some positions concerns and recommendations for the committee. the study and would approach shot a 10% of men at high risk of prostate cancer which would be analogous to the study of lung cancer which includes only 10% of smokers. because of this and other factors in the conduct of the study, we do not believe that the results should be the definitive basis on prostate cancer but important data to be included with what is already known. we strongly support the early detection and just as strongly disagree with policies that would advocate a gamble with their prostate and their lives buy not monitoring and numbing their prostate health through the use of the available tools. today those tools include screening by the psa test and digital rectal examination. the federal budget for prostate cancer is inadequate to meet the

education and awareness outreach needs and research needed when dee dee cut for the new detection procedures that are mandatory to move us beyond today's confusion. we recommend that the budget be equivalent to that of breast cancer. a disease with compatible incident and death rates for women. lack of access to treatment and lack of equal treatment where there is access to critical factor in the higher african-american death rate that need to be addressed. expanded educational efforts for the public and for doctors should be undertaken to address the problem of over treatment of prostate cancer. prostate cancer is a medical, political and economic issues. we are concerned that the short term political and economical factors not be allowed to overwhelm and penalize the medical needs. prostate cancer can be beaten and also a disease that can end in tragedy which can oftentimes be prevented. my personal experience

illustrates this. i was treated for prostate cancer after the regular pc testing. every six months since i treatment i would get a psa test and in 2009, i had a disease recurrence. however, because of the early detection of this occurrence and my knowledge about the treatment options, i am free of prostate cancer in 2010. i have been blessed with no side effects for many of my treatment because early detection and knowledge. ironically, because of the confusion about the screening, some survivors along for believe they should be screened after treatment. a major step backwards and placing the risk to those men who should be the most on guard. while battling last year i lost two additional members of my family to prostate cancer. one of my age did not get annual psa testing. the other, my uncle, because his age was told by his doctor he would die of something else before prostate cancer.

they both suffered horribly and needlessly. i also have another uncle diagnosed and treated successfully for the disease during this time. unfortunately my family situation is not unique but represents the real and chaotic multigenerational to the station with high standards that cost the country today. america is suffering prostate cancer epidemic. if the disease is detected and with what knowledge determine whether we live or die and leave with a we have a good or qualit and priority

within the government our nation can save countless lives dramatically reduce suffering and overall impact of the disease. thank you. >> thank you very much. mr. gosset. >> thank you for accepting me here. i'm not a politician so i haven't prepared any speeches. i have spoken in a lot of executives in the committee meetings in the black caucus and the universities across america. i think that at this stage if i don't know it, i never will. i trust my heart and my experience and i've been represented. thank you for accepting the year. ali went public with the fact

that i have prostate cancer. i had cancer in my kidney, i lost a kidney. the operation took 20 minutes and they said the other kidney would increase in size and it did and a week later i was in the gym and fought everything was fine but now since i've gotten it again, i've done things to take care of the cancer and died of a lot of appointments [inaudible] to dispel the talks i went public. i did gentleman of service these days and serve all of the people who have prostate cancer who like to keep it secret. i can out of the closet and said so and hopefully it helped a great deal. i got a great deal of e-mails from gentleman across the country thanking me for being courageous to come out of the public service and encourage

them to take care of the doctors. an ironic thing happened in some of them because some of them are not louisiana and california and new york and different places went to find a doctor they could afford but couldn't find one. there is a percentage of african-american men who do get it and cannot afford to see a doctor. my heart goes out to these men. i remember last time we had a problem like this when i was a child i remember the polio epidemic and what we did for the polio epidemic we went to them with a kind of -- there was no debate in congress about whether it was pro or con. we took everybody in america. now this year i believe the playing field must be level. i think we're going that direction any way. so we must take care of every

one in an equal american way. i am concerned these facts have been told and the other meanings are true that we lose an african-american man or to every day. to prostate cancer. i think it should be modernized. i think the mammograms have shown we can do the same thing with prostate if we get a little accent to the research. my mind is fairly creative. i did book coming out next month and i take a train and a bus and promote my foundation to level the playing field for the next generation. if we do not plant negatives in the next generation they will grow up free of certain prejudices we might not know we have so i think this generation is of the inside of making sure we don't add to the problem but add to the solution how we can

be one nation under god and divisible with liberty and justice for all. prostate cancer is one of those subjects. i can't imagine this great country being fourth in pro and con eloquently about the fact somebody in this country who cannot afford their health. of all the countries in this world i believe that we should be the ones extempore if everyone in this country should be able to go to a doctor. i have a child who like took. i found him home listen st. louis and at that time we felt every child in america should have free medicine, free education, free shelter, free food, free clothing and free love and i believe america is

the foundation of that. if there are african-americans -- i get e-mails of those who cannot afford to go to the doctor and they know they might have prostate cancer they feel like stepchildren. we have to get rid of the stepped children and educate them to be three-dimensional, responsible americans give them the feelings they are as equally and loved as anyone else who the children of the stepchildren are gangbangers because they are planting the seed. they look at their fathers and see they are not getting anything and they say i'm going to go this way. sign in the trenches trying to get these kids to be responsible my idea is to take this bus the president is talking about putting in the bus and train systems, amtrak, propelled by book, my foundation and tell them they also are three-dimensional americans and will their sleeves and be

prepared to be responsible. and out of that will come a thought of going into clinics to advance the study of prostate cancer and other things so that we can realize in our mind we are equal and have access to be cured. i find myself special but those who are not special will not get this treatment unless we are sensitive to their problem. that's basically it. today is the subject of prostate cancer, tomorrow the subject will be something else but we are losing people should be responsible and makes the subject order. >> thank you for a much, mr. gosset. mrs. gallo. >> i want to thank do, chairman towns and the committee for holding this hearing. i appreciate the opportunity to speak to you today on a topic that has had a significant impact on my life and the lives of thousands of other men, women

and families. one of the areas i felt that we were lacking was the women and according to a lot of men and the field of the women are much more verbalized and talk about issues. so what we have decided to create the women against prostate cancer which and the co-founder of and what our mission is is to make the voice and provide support for the millions of women affected by prostate cancer and today i am speaking on behalf of all women, widows and care givers whose lives have been changed by prostate cancer. i should remember my husband, congressman dean gallo, was diagnosed with prostate cancer in 1992 and unfortunately he had a lot of pain in his back and when he went to the orthopedist dated a bone scan and he basically the up like a christmas tree. it was already in his own. normal psas four or less, his

was 882. due to the fact that he was in congress and was a little bit more familiar with what was going on as far as clinical trials he did go to the nih and was enrolled in a clinical trial and his psa dropped from the debris of 92 down to 3.5 the following march. at that point he had done other treatment options and when he was first laid dustin was alisa postulate three to six months and he survived two and a half years and in that time we still remained in conagra's working with constituents because he felt that is where his heart was there's other stories i've found that people, younger people, this woman, jenny and her husband were both positions. he was 45 he had a psa donner and as a result the psa testing found that cancer had spread for 70% of his prostate. they couldn't remove the prostate because the prostate was spread to other means and is

now in remission and during their time together again it's in remission for the time being and how long that is one doesn't know. there are a lot of stories i've heard about people going through this and now i'm finding they are younger men. it's not older men. we men truly have a big concern and it is being a caregiver to men that is so important and there's so many issues that come along with prostate cancer that sometimes it can create a lot of terrific defeat could have it because people don't understand how to deal with the side effects. more support and education is one of the things i think is needed for partners and caregivers and the entire family. we've really have not done a good job in that area. a lot of people don't know what to expect or how to deal with

issues and this is one thing in the 15 years i've been doing this i found we need to be doing more in. one of the areas i found in clinical trials we don't have any outreach for money to be able to use that to go out and talk to people about prostate cancer to let the community understand what clinical trials are and how we can help them. many people are afraid of being guinea pigs and that is not what we want them -- we want them to understand we have something that could help. early detection and appropriate treatment of prostate cancer remains a critical priority. especially among the men at high risk because of family history, ethnicity or other factors the define such risks. physicians and male patients should be encouraged to discuss the personal risk of prostate cancer and the individual prostate cancer dustin dittman at higher levels of prostate cancer including african-american men and men with a family history should be encouraged to undergo appropriate tests at the early

age. additional funding is needed to increase the promotion of the clinical trials are discussed before. psas isn't a perfect test but it's all we have right now i have gone through a mammography and through this have found out that in this -- 75% of the -- i'm sorry, the head of the biopsies 75% benign so you have the same issue in breast cancer as in the prostate but at least the prostate cancer at this point we do have -- this is the best we have and one of the issues that concerns me is like an new jersey we have the center for disease control, we have prostate and breast and cervical cancer they pay for detection and treatment of prostate cancer they only pay for early

detection so in other words if they have prostate cancer there's no way to treat them at this point so is almost a crazy kind of way to do things and this is something that needs to be corrected in that respect. screening should be provided in any health reform legislation. in new jersey we pay for the psa because we find it's important for men to have it done with their insurance company. there is a lot of confusion today about prostate screening and i think with the release of yesterday's prostate cancer screening guidelines from the american cancer society there are three sets of complex differing screening guidelines including those in the national cancer network and the american urological association. one clear set of guidelines would be for men to know what steps to take and to safeguard the health.

for the past 15 years i've been involved it has left me through the process of the grieving process knowing how to deal to help other men and their families. as men and women in congress we are aware what prostate cancer dustin families and how to experience the loss of several colleagues to this disease. increase education and awareness are the most critical issues. chairman towns and members of the committee i would like to see three u. for addressing the crisis and more needs to be done to help the thousands of men and women and their families across the country suffering because of prostate cancer and we need to allow them to have a better quality-of-life. thank you. >> thank you. let me thank all of you for your testimony. at this time i will yield to the ranking member for questions he might have. >> thank you, mr. chairman. the next panel we are going to have will be physicians and specialists, researchers but i think we were very fortunate

that dr. deweese was able to speak first and in looking through his testimony and some of the things he provided in written material interesting fact came out and one that i think has survivors and in fact a victim of somebody who i appreciate he survived for two years but in many ways the loss is just as great no matter how much time you have to@@@@@@@@@ r

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in other countries the fact that we can't measure or predicted but no court could be more demonstrative of the people who would most likely about does it agree -- i would like utilities dollars, the federal dollars where would you have to spend more dollars if we only had a very limited amount? what we put in three, four, 500 million more into trying to get these better tests first? >> well mai? >> of course. it's the leading question that knowing -- >> i've educated and i'm the lucky one who survived. i'm one of the lucky ones finding that cancer and prostate. for those who have doctors and access to the best it's still like winning the lottery. on the other side when men have mammograms and make the science

much more successful we need to catch up to them and to do that we need to concentrate our dollars, your dollars, or dollars to the specialists who know how to sophisticated equal to the mammogram to the prostate suffer because of the ones who fail because inadequacy of pinpointing what it is and i think we have the ability and the knowledge to be better than that and save lives. >> mrs. gallo, would you concur with that? >> honestly, in the beginning when this happened with the and the first thing i wanted to do is scheduled of these guys out that didn't have a psa because i lost a wonderful man and its been a difficult to understand why and again when we talk about breast cancer have all sorts of testing, you start with a mammography then go to another

if there's a problem and there's an ultrasound and a biopsy with prostitute can't see the prostate so everything is kind of a guessing game and i think even if they say it takes ten years for prostate cancer to get to the point where you are going to see it sometimes even during a baseline at an earlier age might be the way to go. at least you can to keep track of it that way. i agree we need to put more money into getting a better testing for prostate cancer and nothing is free to be 100% and it's the same thing in a lot of the cancers. but at the moment i feel that is something that we have and it at least has saved some people's lives and i think no matter what cancer there will be people the will buy from cancer and others will live. unfortunately because we've always thought of prostate cancer is an older man's disease we don't look how it's affecting the younger population. so i agree we need to put more

money to be will to find a better way to detect it. but also i personally feel what we have is better than nothing at this point. >> yes i think there is an abundant amount of data that exists that shows what we do now that saves lives, if you look at the decline in deaths since the psa was widely used we've seen over 30% decline. that is real, that isn't the recall that israel. >> i think the second panel spending a lot of time basically saying it's like the hubble telescope. it does give you a picture of the stars and unfortunately it is insufficiently clear to be meaningful to have only those people who have a treatable disease or at least close to only those people versus having 30 times as many people go

through extensive treatment as received benefits. i'm not disagreeing. i think universally the early detection and improving early detection and we think is important but then that second degree and i think mrs. gallo said it very well are the tools today for prostate as good as they are for breast cancer once you think you might have something the answer is no. if we were removing doing radical mastectomies as we did in the 50's on everyone who had a lump practically we would be horrified at the results but that is what we used to do in breast cancer. we have come a long way. i guess the question as a survivor as if i only have -- if the japanese would only loan us another $1 billion this year for something related to prostate cancer where would you put those dollars first to receive the testimony that we are seeing and i ask you because we are the

hardest people making the decision put it into research or better detection or better differentiation versus treatment and mr. gosset, use it very well there are so many people who don't have access but it's tens of billions of dollars to incrementally improve the access to the underserved and it's one of our challenges here and one of the things i've worked on with the chairman here is prioritizing at least some dollars to the area that could in the long run because 30 out of 31 people not to suffer needlessly and the bonn to treat early. >> you asked on two areas. let me respond, sir. bonn, in terms of research -- and i do think we have to focus much of our research -- i think we know there's genetic factors related to prostate cancer risk and i think their needs to be more research in the area of genetics and by zero markers

detection. i would put money there. the other area is education and awareness. a lot of them really do not understand the risk level for prostate cancer. and when they are diagnosed with prostate cancer they do not understand their options and they don't know whether they should be treated were not treated. today people are not educated on the factors, so they will many times move quickly to treatment when they should not be treated. so i will look at education and awareness and research into genetics and by zero markers and we talked about images today. so i think those are critical areas. -- before. i yield back. >> thank you free much. the -- first i want to thank you all for your testimony, and i just you know, when we have constantly addressed the issue

as we are doing in a fee health care debate we are having in the congress exactly how we take the resources we have and spend them most effectively and efficiently , and then there comes a time when you are trying to figure that out and you say what is a life worth? in other words, do you make a decision not to go forward in the direction which might yield a diagnosis or do you say we don't have enough money and let people suffer and die, and that is a question that i think the congress wrestles with right now

and i fall on the side of life. but i was just wondering when you hear all of this, mr. farrington, i guess your family history caused you to take extra precautions; is that right? i mean, in other words you see a history like that -- might offer had prostate cancer and i had many friends. center banks about a year ago and i was amazed standing there one person comes up and he's talking about he just got out of the hospital and then two or three more show up and then come to find out there were seven of us standing around and out of the seven of us, four of us had gone through prostate cancer. of course we were all around the same age level. but i was just wondering what --

when you -- what advice are you getting man? what are you saying to them? >> number one, my family history should have put me on the list brinkley my doctor never had a conversation with me about prostate cancer which is one of the problems with the guidelines that are dependent upon the discussion between doctors and patients. a lot of doctors do not have that discussion and they do not have it with black men at an early enough age to make a difference. i didn't have the discussion with my doctor which required me when i was diagnosed to leave boston to get specialized treatment. but what i am advising them to do is to know their prostate health to be the only way you can know your prostate health today is through psa testing and a digital rectal exam and once you know your prostate health, if you find that you have cancer than to understand your options. and the options may be to treat

and they may be to not treat. we have been being treated for prostate cancer and active surveillance. those are the things that need to be done and what it does require some action on the part of the patient. you cannot stand back and gamble with your prostate. you cannot stand back and not be knowledgeable because that is a high risk of death. that happened in my family last year, and so those are the things we are trying to foster higher level of understanding and education that saves lives. i would also which is like to add one other point to mr. issa's question about where we are on the right research. i feel to point out one of the key areas is the research to be able to distinguish between cancer that will kill and cancer that will not kill. that is the major question we

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that nih and others have to listen to it, and how do you see us raising this issue to the level of breast cancer when one out of every six families in the united states is affected by this, and i am just wondering. speak to be honest with you congressman i know a lot of it is the fact that we haven't taken the ability to really move, get out there-- ended my 15 years of working with men, it is very difficult for them to make a difference. i have explained to them, i have been out there fighting this for 15 years. sometimes it is difficult to implement that we really need to bring it to the forefront in part of the problem with prostate prostate cancers we don't work directly with what the

researchers, where the press coalition cancers do. we are lacking in a lot of areas and i hate to say sometimes it is he does. it is whatever but the bottom line is, as a woman, you bring the passion to the disease and you say, explaining to them and that is why a lot of prostate survivors have said to me and other women that they feel we are the ones that are going to make it happen and that is why we started the women against prostate cancer because we thought we as women, women that have lost their husbands or survivors or whatever are planning to come down to the hill, talk to congress and tell them the importance of losing them the importance of losing our hukbas@# @ @ rr@ @ @ @ @ rr

he would walk to the capital in excruciating pain and there was nothing we could do to make it better for him. that is a concern we have that we want to make sure we don't get to that point workout i just want to give you another note here. prostrate screening is not included in the provided health care reform and legislation in the problem we deal with would wipe out the prostate screening available to over 30 million men and 37 states so that is one thing i think when we go into the house, the bill needs to be looked at, that we don't overlook the prostate screening and the importance of doing that like mr. farrington said if you look at the numbers, it has been used as a tool. you have seen the death rate go down in the incident rate go up. even though more people are getting tight as there is not as many people dying from it. that is a good thing so again i think we need to get congress behind us to really be there, so we need to put our money into

outreach. we need to put more money into finding better tools to diagnose prostate cancer and just be able to do the best we can because i don't want to see men lost to this disease. >> thank you very much. >> thank you very much. my first question is to mr. goss it. first of all, when i was a teenager i was a big fan of yours, and one of the movies that i watched and still remember was iron eagle. whether or not you remember it. but it was one of my favorite movies during my teens. i represent the city of new orleans, which comprises of 60% african-americans. prostate cancer disproportionately affects african-american males. my question to you, knowing what you know now, what advice would

you give to my constituents as to one, how to prevent prostate cancer and two, what would they do if they were to have it, to fight prostate cancer, since you are a survivor. >> the way they have to be examined is a surefire way to-- [inaudible] >> i am sorry, can you turn on. >> the examination and certainly places like louisiana and detroit with the african-american man, it turns them off. you know what you have to do in order to examine the prostate. it literally makes them put it aside. they forget about it and as a

result of more deaths happen because people don't want to go through the experience. you know the experience i am talking about, with a rubber glove. that is exactly the reason why most african-american men did not go through that. they need to get that examination. they need to put it aside and go for it. i had a little bit of that because-- that it is over because i know how important it is. once you know you have it, then they talk about, and this is what i get in e-mails, a diaper, incontinence. that is the world that the african-american macho man does not want to let his mind, he puts it in the drawer and the next thing you know it is incurable. we need to educate them. we have to do deeper research to show it is more like a mammogram , to get them off that high horse. there is a fear of not being able to make love to your woman again and i'm speaking in real

terms. that is why the african-american man has more incidences of prostate cancer because he does not want to hear about it. he does not want to hear about not being able to make love, wearing diapers and having incontinence. those are real things especially for the poor. that is the last place he can express himself. he puts it in his back pocket until there is a problem. >> mr. farrington, do you believe we have done enough to inform the african-american community, the african-american male of the dangers of prostate cancer and the preventive measures in connection with prostate cancer? >> absolutely not. i don't think we have done enough to inform the high-risk community. >> what would you recommend? >> african-american men, men with a family history and some vietnam veterans, inform them

about the risk and you can prevention to death in knowledge. i am not sure there is a prevention to the disease itself but certainly the prevention of death is knowledge and early detection. what i would, because i learned in my testimony, i am a strong advocate of education. i've found are the prostate health education network and what we are doing is we are now reaching across the country through a number of means, to the public. we are outreaching through television, through on line and we have created a survival network of african-american men that can work on the ground in their community to talk with other men as mr. gosset pointed out. there is a fear about this disease but if prostate cancer survivor can touch another man and talk with him about his experiences and say i am here

and i have survived in your hole and you can do the same that you have got to begin the process of knowing your prostate. those are some of the things we are doing and in speaking with mr. gosset, we are starting this year a nationwide-- churches and we did that of massachusetts and in los angeles it just so happened the first book i wrote was unveiled in his church in los angeles, so we are going to work together. some of these things are a higher level of public education. >> be my last question to mrs. gallo, what would be your recommendation to women? how can they encourage their husbands to i guess to be more open to the procedure of prostate cancer detection? how can you encourage your

husband to take those preventative measures in order to stop suffering from this disease? >> nagging is always the first thing to do. sometimes it is making the doctor appointment for them and the other part is saying to them look honey, i want you around for a while and this is a deadly disease that is out there and we want to make sure you don't end up with that. i think women nowadays even the younger women are beginning, are really learning more about prostate cancer and need to get their husbands there. i know that there are a lot of women that have basically dragged their husbands to the doctor. some may be or a little more nice about it but that is why again we talk about education. my feeling is educating the women to go back and get their husbands, because most of the time the women are the ones who drive their husbands to the

doctor or are a little more persistent about it and also i say look, the women go through exams every year. look what we go through. yours is nothing compared to what we have to do. again, it is saving your life. i will give you a friend sent. at one point he said if it doesn't work, shoot me. when it came to prostate cancer in his possibility of dying that whole thing went out the window because the concert was he wanted to live. i think people have to understand that i don't think we have educated men and women enough to understand the importance of getting early detection and being able to treated at an earlier stage. 10 or 12 years ago or 15 years ago there wasn't much out there and i have seen such a difference in this 15 year time, that there are different ways to be able to help with the side effects and what not. what people have to understand, and if they don't tell them that they are more upset when they

find out afterwards because nobody talk to them. we can't just read around the bush and i'm talking about louis gosset talking about the side effects. we don't want to talk about it but it has to be talked about because when people find out-- that it creates another problem so i think it is more or less just getting women to really, if they care about their husbands they are going to get them there one way or another. >> thank you very much. >> thank you very much. we are going to, first of all thank you all very much for your testimony. we are going to turn for a half an hour to both send and this panelist dismissed. then we will come back and hear the second panel but your testimony has been very helpful. thank you very very much. >> mr. chairman? just unanimous consent, i would ask unanimous consent that my

full statement be entered into the record. >> without objection. >> thank you. >> thank you very much. [inaudible conversations] 's be if you would stand, we swear all of our witnesses and. stand and raise your right hand. do you solemnly swear to tell the truth and nothing but the truth? if so, answer in the affirmative. thank you. let the record reflect all the witnesses answered in the affirmative. so why don't we just go right down the line and start with you and come right down the line. thank you all for being here. >> thank you mr. chairman for giving me the opportunity to speak and i also want to thank you for the accommodating of my

schedule. i am the clinical director of the national cancer institute. i'm particularly research focuses on the development of strategies for the treatment of prostate cancer. prostate cancer is a second highest cause of cancer deaths in the united states. the good news is the overall death rates from prostate cancer are on the decline. most think this improvement is due to a combination of improved treatments and possibly detection. however it is important to remember that there is not just one prostate cancer. some patients respond to treatment while other lives are cut short by the aggressive disease. the clinical course of the disease reflects the interplay between the biology of the tumor, genetics of the patient among factors in the environment and available treatments. their huge challenges in the field right now. we are struggling to differentiate lethal or deadly prostate cancer from nonlethal prostate cancer, a form to ever

cause symptoms early to death. another unfortunate reality is the burden of rustic cancer is disproportionately borne by african-american men who have the 60% higher incidence compared to white men and are twice as likely to die from the disease. many men will die with prostate cancer but not from prostate cancer. or never have cancer related symptoms. the potential for overtreatment is a real problem in this disease. nevertheless nearly 28,000 men die yearly from this disease while many others have cancer related pain. the single biggest challenge of research is to identify a means to distinguish legal from nonlethal prostate cancer. without this information we are likely to under traitor overtreated our patients.

even within these broad categories, prostate tumors may have very different characteristics which may ultimately guide treatment decisions. all prostate tumors are like other prostate tumors and they do not respond to therapy in the same way. inside the biology may turn out to be much more like a tumor that i prostate tumor. nci is moving aggressively toward the goal of@@@@

as-- which targets blood vessel growth. results in a large clinical trial. [inaudible] we have continued to press forward in our effort to develop the knowledge to allow the prostate cancer based on

specific molecular characteristics of tumors that talk about the way the genes interact. in order for this to be successful we need to understand the relevant target of the tumor and develop drugs effective against this target. although this targeted approach is not successful for infectious disease for nearly a century unfortunately metastatic prostate cancer remains trial and error. that is drugs are not targeted or personalize for individual specific type of prostate cancer. we are aggressively pursuing research to enable personalized cancer therapies. we are optimistic that through the specific genetic abnormalities in a prostate tumor that we will not only be able to identify the aggressive form of the disease but also develop specific treatment appropriate for the patient's cancer ultimately reducing death thank you for the opportunity to testify. >> thank you very much dr. dahut. dr. brawley. >> thank you mr. chairman.

good afternoon. mr. chairman and distinguished members, i am otis brawley, a practicing oncologist. and the chief medical officer of the american cancer society and i am also a professor of hematology, oncology medicine and epidemiology at emory university. on behalf of the american cancer society and the millions of cancer patients and survivors, thank you for holding this hearing and for your continued leadership in the fight against cancer. as you know the society yesterday released updated guidelines on prostate screening. when new evidence or other information emerges. in the case of prostate cancer screening results in two randomized trials were reported early in 2009. the finding of the studies combined with other advances in knowledge related to prostate cancers grinning prompted this review. the review recommended no major changes in our position with respect to prostate cancer

screening. the society continues to recommend asymptomatic men who have at least a 10 year life expectancy should discuss with their doctor the uncertainties, the possible benefits and the known risks of screening for prostate cancer before deciding whether to be tested. there are uncertainties. there are non-proven risks and there are at this time possible benefits. we also provide additional guidance about testing for african-american men and those at high risk or go the bottom line is made me to have substantive discussions with their doctors in order to make meaningful decisions about which preventive services and early detection choice is the best choice for them. other organizations in the u.s., canada europe and australia that issue prostate cancer screening guidelines have also issued statements calling for this informed shared decision-making, realizing that prostate cancer

screening is not yet proven to save lives. i want to make sure my testimony is very clear about the society's position on prostate cancer screening as it has sometimes been misunderstood or mischaracterize. the society is not against testing for early prostate cancer detection of a man has been given the true facts about what we know and what we don't know about the uncertainties of rustic cancer screening. what we do know about the proven harms and the benefits and the possible benefits of screening. the society, along with many other health organizations as well, are against screening when the doctor-patient conversation is-- ascribes the benefit, to describe the benefits and harms does not take place in a meaningful way. where only gets prostate cancer screening when there is no informed decision-making. as an oncologist i have counseled and treated hundreds

of prostate cancer patients in my career. i've observed first-hand the dramatic impact this disease has on men and their families. i firmly understand the emotion involved when someone says they are life has been saved by a psa test, but in their friends since we need to better explain the limitations of the test and make sure we don't overstate the benefits. there is a legitimate argument based on scientific evidence as to whether prostate cancer screening saves lives. clear evidence has emerged from several trials indicating prostate cancer screening leads to unnecessary treatment or go for example, many men who do not have prostate cancer will screen positive and require unnecessary biopsy for diagnosis. in addition even if this biopsy finds cancer, prostate cancers grow so slowly that they may not pose a threat to the patient's life for his continued quality of life. this is an important point because treatment of prostate

cancers associated with side effects that can interfere significantly with quality of life such as and incontinence. the key problem is that we don't have, and we have yet to discover, definitive tests that tell us the cancers that kill and require treatment versus the cancers that don't kill and need to be watched. one can reasonably ask how do we get into this quandary of not knowing whether prostate cancer screening saves lives? the truth is the promotion of the psa test has delayed our medical progress because we have come to rely on what is really an imperfect test instead of doing the clinical trials to evaluate psa and actually defining the scientific questions and actually going out and answering those scientific questions. the plain fact is the psa test is not good enough. we need to invest in something and develop something that is better. we also need to invest in a way to determine the deadly tumors versus the tumors which are not

threatening life. in closing, increase funding for nih and the national cancer institute would do much to enhance current discovery efforts and also enable us to design better tests and better treatments for prostate cancer. thank you sir. >> thank you very much dr. brawley. >> chairman towns and distinguished members of the committee, thank you for this opportunity to convey the important efforts being supported by congress through the department of prostate cancer research program also known as the pcr p.. my name is dr. carolyn test and i'm currently program manager for the pcr p.. which has received over $1 billion in funding since the beginning of the program in fiscal year 1997. here with me today as captain lissa king, my supervisor and director of the congressionally directed medical research program under which the pcr p.

is one of the largest of 19 programs. the pcr p. is the second largest nationwide funder of prostate cancer research after the nih. the program division is nothing less than to conquer prostate cancer. which translates into her mission to fund research that will eliminate deaths and suffering from this disease. we fund highly innovative science to stimulate advancein research and clinical care. all pcr p. funds are openly competitive with contracts of leading prostate cancer scientists, clinicians and survivors of the highest scientific merit and best that the objectives of the program. with a $1 billion in funding this program has received, it has provided 2200 grants that support cancer research in almost every state and the district of columbia. our grantees are studying better

prevention, diagnosis, treatment and treatment decision-making, identifying aggressive disease and discovering the underlying environmental and genetic factors that contribute to prostate cancer. our grantees are striving to answer the most critical questions in prostate cancer research and clinical care what several of these witnesses have brought up today. does prostate cancer screening lead to more harm than good and eschew how can this be corrected? which men with prostate cancer need to be treated and which do not? how can we develop more effective treatments for preventing or hearing the advanced forms of the disease that are responsible for prostate cancer deaths? to briefly highlights two of our grants, since fiscal year 2005 the pcr p. together with prostate cancer foundation has supported a prostate cancer clinical trial consortium which is brought together 13 major cancer centers across the nation to conduct faster, more precise and more cost-effective clinical

teaching and treatment. another four years the consortium has conducted more than 60 early phase studies investigating over 30 drugs and has moved five potential therapies into the final phases of testing before the new drugs can be approved. another key research effort is the prostate cancer project or pcap. pcap is a collaboration among institutions and louisiana north carolina and new york that seeks to identify the factors that contribute to the highly disproportionate impact prostate cancer on african-american men as others have noted who are more than twice as likely to suffer and die from prostate cancer than caucasian men. over 2000 have participated in the landmark study which make finally help us understand and address the factors that cause health disparity. the effectiveness of the pcr p. relies on a strong partnership between the u.s. government and prostate cancer survivors, scientists and clinicians. these groups were closely together to determine the program priorities at tapping

them every year to ensure that we are continually addressing the most important needs. for example, for fiscal year 2010 the program is focused on two major challenges. first, to develop effective treatment for dan's prostate cancer so fewer men will be lost from there families and society due to this disease and secondly to distinguish legal from nonlethal disease so a great deal fewer been diagnosed with prostate cancer will undergo treatment that is actually unnecessary that causes them intense personal suffering and has an immense financial impact on our health care system. to conclude, the pcr p. provides direct and undiluted support for prostate cancer research funding innovative projects and researchers that might not otherwise be supported in the battle against this disease. i thank you once again for your interest in hearing about this program and we look forward to any questions. >> thank you very much dr. best.

dr. kaminsky. >> chairman towns thank you for the opportunity to address you. the uniformed services university, your university and i'm here to talk about one of the programs that congress set up at the university, the center for prostate disease research and it was the inside of congress that actually put this program on the map within the military, and i think the thing that is most important about what it put on the map is the fact that within the military health care system we have access to health care. with this particular center which is set up in three different aspects, the critical research center, a basic science research center in the database and repository the center is actually made enormous inroads into understanding the disease and equal access medical care system. the center was the first to

actually demonstrate that african-american males in the system actually needed to be screened earlier and more often with the testing that is available today. the challenge for the center is everything that doctor brawley talked about and that is how do we really come up with better screening tools. that is really what the center is all about from the standpoint of trying to really look at the aggressive forms of the disease and how to actually get there quicker, faster, better. today we are working on new genetic tools to try to do that and actually have some products that are hopefully going to be, make transitions. but one of the key pieces of the center is actually the database which is following over 28,000 patients in a longitudinal study with over 102,000 tissue and blood samples so that we can actually look at and analyzed

the disease across time. so, to keep us flowing, i am going to hold my comments and hopefully questions at at the end about this particular center and about essentially congress's wisdom in setting up a center like this at the university within the military treatment facilities which allow us to do things that maybe others can't because of the kind of help their system the military has. again thanks for the opportunity to talk. >> thank you very much dr. kaminsky. dr. shtern. is that correct? >> chairman towns, thank you for the opportunity to testify today and for your continued support of the foundation. there are many members of this committee who are supporting our work. as you know there is no family, no community in this country

that is not impacted by prostate cancer. when my father's prostate cancer was-- leading national hospital, a very powerful.was brought home. in spite of the-- of prostate cancer epidemic, men do not have accurate diagnostics for early detection which is critical to cure cancer and to save lives. the new guidelines by the american cancer society, there is no diagnostic tools for screening and early detection and american men die every 90 minutes because even though prostate cancer can be cured when diagnosed early. echoed sentiments.

prostate cancer and its treatment lead to anger and confusion among the men who have it and those who love them. mr. jennings, age 49, was diagnosed with aggressive prostate cancer only recently. he underwent surgery and hormonal treatments and medical. according to a recent study, men aged 50 and younger have had seven fold increase in the incidence of prostate cancer since 1986 when it was invented. my father's story is a genuine story that reflects our prostate cancer crisis. many other speakers pointed out the first aspect of the prostate

cancer crisis, the sheer multitude. many more millions face the threat of prostate cancer each year. african-american men have pointed out repeatedly are disproportionately affected unfortunately for millions of men. there is another aspect of prostate cancer crisis. current diagnostic tools are unreliable and has been pointed out to a staggering extent unnecessary biopsy, unnecessary treatment and failed patient care. this reduces the quality of life in men and billions of dollars in health care costs. in my written testimony, my estimate is over 5 billion each year wasted and health care

costs. our core mission is to end our prostate cancer-- accurate imaging tools for early detection and treatment. i would like to issue a disclaimer. imaging will not-- screening prevention but imaging will be critical for early detection and minimally invasive treatment and here is why. on the left of the slide you can see digital mammography in 1991 when i was the head of diagnostic imaging at the national cancer institute or go at that time you are likely to see a larger cancer. on the right you can see digital mammography done today. there is a striking difference in the quality.

you can see a tiny breast cancer. precise imaging has made it possible to guide needle biopsies to detect breast cancer very early and to save lives. just as importantly, to replace -- with imaging guidance, minimally invasive lumpectomy's are more common in breast cancer. men do not have accurate imaging. this congressional support and federal investment can create similar opportunities for men. on the left you see data from new york. it shows advanced prostate cancer missed in every imaginable diagnostic including blind biopsy.

there are reports from all over the world the show mri guided biopsies can detect at least 60% of prostate cancers that were missed by the blind biopsies at least twice. there are growing reports i am happy to report that imaging technologies molecular imaging mri can determine what is aggressive and what needs to be treated and what is nonlethal they cannot be treated. this report creates great hope for the future of prostate cancer care and is extremely preliminary for the expense of research needed. on the right-hand side you see a three-dimensional mri. it shows early prostate cancer. when we have this kind of three-dimensional data, we can see that image guided minimally

invasive treatment to eradicate cancer while saving normal tissue to avoid complication. these procedures can be performed in outpatient screening with minimal cost, complication and discomfort to the patient. that is how we end of prostate cancer crisis, with advance imaging. in order to save lives, improve quality of life and save billions of dollars. i was just told that the representative-- just introduced h.r. 4766 that calls for national investment of 500 million dollars over five years in medical imaging. it is only 10% of the annual waste in health care costs.

this also calls for increased $100 million for improved diagnostics over five years. it is only 2% of the annual waste. the success at the end of the five years, we will have accurate imaging technology for improved early detection and treatment and reliable in vitro testing for screening and prevention. i hope this committee will empower and support nih in making research diagnostics including imaging and much higher priority than it has been. [inaudible] it will be an important step in that action. thank you or your leadership.

>> thank you so much for your testimony. dr. mohler. >> my name is jim mueller and i in the chair of the department of urology at roswell park cancer institute in buffalo, new york. boswell park discovered psa that has been taking it eating here today. also, i chair the national comprehensive cancer network, commonly called nccn prostate cancer treatment panel. the nccn consists of 21 of the 40 nci designated comprehensive cancer centers. finally, i am the principle investigator for pcap, the north carolina louisiana cancer project that are best mentioned earlier which is the largest population-based study of prostate cancer ever undertaken and half of our patients in the study are african-american.

i would like to discuss just four points that warrant our attention and then make three recommendations. the first is that, prior to the development of psa, only 4% of men diagnosed with prostate cancer could be cured. most men were diagnosed with prostate cancer by congressman gallo, when it has spread to their bones and has caused pain. the standard treatment was androgen deprivation therapy and that survival was three years. now less than 10% of men are diagnosed with incurable prostate cancer and five-year survival. treatment is essentially 100%. however the age adjusted incidence of prostate cancer has increased 30% since 1994 to produce this 36% reduction in deaths. if we had achieved a 36% reduction in mortality in any

other solid cancer in america there would be cause for jubilation. so why is there so much controversy about psa? that controversy stems from my second , and that is a term that has been discussed here, autopsy prostate cancer, also called nonlethal prostate cancer earlier. the problem is that the incidence of prostate cancer is approximately the age of the man in other words, 20% of 20-year-olds already have prostate cancer in their prostate and 80% of 80-year-olds already have prostate cancer. prostate via seas will find about half of these autopsy cancers. because psa has been mentioned here today can be elevated for many reasons, many and may undergo prostate biopsy and have a non-toxic type of prostate cancer found.

this cancer poses no threat to their life expectancy. the "new england journal of medicine" published back-to-back papers in their march 26, 2009 issue that is reignited this controversy about early detection of prostate cancer, which has been increased by the acs guideline change issued yesterday. the american study shows no apparent benefit from psa early detection although many men were ineligible for the study because they probably had already have their potentially fatal prostate cancer is diagnosed and treated in the majority of the men in the army-- that were not subjected to screening received psa's anyway from their personal physicians. finally the follow-up of the study is so short that any benefit from psa early detection would not yet be apparent. the european study shows the benefits of early detection using psa which is actually

surprising to me because it's follow-up also a short. the psa screening frequency was only once every four years. the press has focused upon the fact that 1400 men needed to be screened and 49 men needed to be treated in order to prevent one death from prostate cancer in a european study. over treatment of prostate cancer would not be an issue of the treatment had no side effects and was free. this brings me to .3, over treatment of prostate cancer. the nccn guidelines have responded by changing their guidelines last month to focus on more careful depiction of aggressive prostate cancer in younger men while urging a more conservative approach to early detection of prostate cancer in older men. the nccn 2010 guidelines also recommend active surveillance of men who have been found to have low-risk prostate cancer when life expectancy is less than 10

years. in addition the nccn has created a new prostate cancer risk category, very low-risk prostate cancer. active surveillance is the only recommended treatment in this group of men when life expectancy is less than 20 years. let me emphasize that here is a cancer treatment guideline panel recommending active surveillance instead of treatment. these changes allow appropriate aggressive treatment of men who are at high risk of death from prostate cancer while avoiding over treatment of men at low risk of prostate cancer death. my last point is, how psa and treatment can actually perform better than it does today. african-american men and men with a family history of prostate cancer especially in their brother or father represented group of men that we all agree are at higher risk of death from prostate cancer. psa and treatment will perform better if efforts in early

distinction of prostate cancer are focused on these higher risk groups. this leads me to my three recommendations. the first hasn't been made by anyone yet. we needed blood or test that can be combined with psa to indicate who doesn't need a biopsy. this is critically important because then men with autopsy type of prostate cancer can be spared biopsy and the anxiety attached to the diagnosis of an autopsy prostate cancer. i agree with the other panels that once diagnosed with to the

consequences of over treatment. a tank of the committee for their wisdom in addressing these very complex issues posed by prostate cancer. >> thank you very much and let me thank you all for your testimony. the way i want to start out, i generally ask the witnesses, are there any statements that you have heard that you would like to sort of clarify, give your input to them either from the first panel or from this panel. the reason i do that is because i was at the airport one day in the person said to me, i did not agree with anything that person said and you didn't allow me to

respond. so i don't want to be guilty of not allowing you to respond. dr. brawley. >> if i may, sir. in the first panel i heard the mortality has gone down so it must be because of screening. i think it is important to realize that if you go to various countries in europe which have had the policy not to adopt screening, mortality has been going down in those countries as well so it is hard for me to attribute all of the decline in mortality in the united states to screening and there are several other countries, britain, france and so forth that have a decline in mortality without having screening. secondly, dr. mohler talk about, my good friend dr. mohler by the way. we worked together on a number of things, talk about five-year survival. when i'm teaching epidemiology and teaching screening, we don't use five-year survival is a good

use of outcome. it is not an evaluation about, especially in prostate cancer where many of the people with screening would have never died if they had those autopsies. they actually artificially pushed the five-year survival rate up. this is best seen in the old studies of lung cancer. lung cancer screening with chest x-ray. by the way we have been here before. lung cancer screening was advocated in the united states from 1960 to about 1975. the otis brawley's of 1960 did a study. many people said no. it increases five-year survival rate. when those studies were done my favorite is the mayo clinic study. the death rate on the screened arm of the mayo clinic randomized chest x-ray study was 3.2 per thousand per year on the screen and 2.8 per thousand per year on the unscreened.

keep in mind, survival was increased on the screened arm but risk of death was increased as well. so, when we teach epidemiology and we are doing screening we don't look at five-year survival rates. we look at decrease in mortality rates. that is what we want to find. >> thank you very much. anyone else? guest dr. mohler. >> i cannot let the statements by otis go under it-- on address. >> are you guys really friends? [laughter] >> i always like to say that two people can be looking at a horse and if one is standing at the head of the other standing at the tail they describe something that looks very different. many aspects of this debate are about where you are standing. the decrease in mortality in great britain which has been argued to counteract the 36%

decline in age-adjusted prostate cancer mortality in america has been thoroughly investigated. great read written change the way that their national registry recorded deaths at autopsy and when this was accounted for, the decline in prostate cancer mortality in great britain basically went away. i think our country is unique in having had objective evidence of declining prostate cancer mortality. this occurs at the same time the worldwide incidence of prostate cancer is increasing 1.1% per year. the reasons for this are unknown the best evidence suggests that this may be from westernization of the diet. but we do not know much more than we do know about prostate cancer, and so otis has very

appropriately challenge the five-year 100% survival teeing inadequate to study -- not to say the treatment is effective. we know that we follow these men longer, many of these will work her but this is the data reported to the american cancer society and why i can conform to the five-year number. >> thank you. there was a statement made at the previous panel that only 25% of women undergoing biopsies have breast cancer. what i would like to refocus, if you look at the number of breast cancer is close. let's say around 2000 per year. the average yield, the percentage of men who have cancer and are undergoing-- according to the data is 12%.

so if we look at that we know from actual numbers that 1 million men or 1 million humans undergo biopsy every year. however 2 million men undergo biopsy every year. these are the imaging tools that will eliminate-- and will eliminate freelance biopsies then. there is the possibility to save over $2 billion. >> thank you very much. we will go to you dr. brawley. i understand of course you are perhaps an expert on cancer screening and i respect that and really appreciate that you were here and your work over the years. before i get to that focus i wanted to ask your opinion.

any correlation between education and diet and why african-americans are significantly more disproportionately impacted by the lethal form of prostate cancer. i lost a brother to it. >> yes sir. thank you. we have been working long and hard for probably now 30 years to try to start addressing the question, why do blacks have a higher rate around 1980 and by the way it is blacks in the western hemisphere for sure. blacks and resell rozelle and jamaica have a higher rate as duplexing canada. don't know about blacks in africa because there is no good registry and the national cancer institute of the united states actually try to establish a registry to try to figure it out and just couldn't. what they-- data that we do have indicates a large number of the black prostate cancer problem can be due to diet. it can be due to differences in

diet over time, differences in rotting mass index. there are some studies that have been done primarily in animals that indicate that animals that are fed a high-fat diet when they are pregnant, their children will have a differing sensitivity in terms of and androgen tours when the children are born. so there are people who have speculated that it is so social economic status of the fetus and the mother and a the diet of the mother went in you that actually affects risk of both prostate and breast cancer 40, 50, 60 years after birth. for example many people talk about the breast cancer problem and blood women with triple negatives. if you go to scotland one of the best studies has been done in scotland where it they have no blood women.

they figured out women in scotland who have a lifelong history of poverty and you can't look at social economic status at the time of diagnosis. you have to look at social economic status over of the entire lifetime beginning in utero. women who are born and have a lifetime of poverty have cancers that are more likely to be triple negative, more likely to present at an earlier age just as black women in the united states so social economic status, diet and a number of other environmental factors actually can change the genetics of the breast cancer. reception negative as cancer, that is a genetic difference that white women in scotland who are poor tend to have more of that than white women in scotland who are not poor. >> dr. mohler. >> the north carolina louisiana prostate cancer study is seeking to look at many of these dietary

and lifestyle differences that may be contributing. i think it is very important to recognize that there is fundamental differences between the african-american prostate and the caucasian american prostate and dr. brawley is exactly correct, that we don't know where these come from. but, one of the fundamental questions that pcap will address is whether the african-american prostate seems to have a raft of androgen access. the circulating androgens are the same between the two races, but the african-american prostate for unknown reasons has more of the protein that testosterone binds to to turn on growth than does the caucasian american prostate. that level of protein is 21% higher in the benign prostate and once african-american men develop prostate cancer, the cancers have 81% more of this

protein. it is completely unclear why that is and whether this is a consequence of diet and lifestyle has something to do with genetics, environmental interaction, but much of pcap is devoted to figuring out whether this is actually true in a large number of men from a population-based series. i still think that most of the racial differences in prostate cancer mortality stem from social economic disadvantage and not race per se. in fact, when we look at our treatment results in north carolina and louisiana, once you correct for socioeconomic status, race is no longer a factor in treatment received or outcome of that treatment. >> you are also saying that education plays a part? >> i think that is the greatest contributor to the racial disparity, yes sir.

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the. >> when we talk about prostate cancer or really talking about the flu that i use the term broadly vs. h1n1 of the prostate and some other group of various things we use a broad brush statement when it is in the prostate but not prostate cancer? >> what we are talking about is actually the prostrated self that becomes malignant and start growing. >> but there malignant due

to different forms of cancer that they reacted differently and differently treated and if you could isolate various strains and treat them are pretty you could have better results? >> that i would agree with but the cancer itself originates from cells in the prostate and there are a variety of different more aggressive in less aggressive@@@@@@@ watched buy mr. jones you have prostate cancer read to treated aggressively because if we don't it will bother you.

>> the american cancer society has put out figures in both breast cancer and prostate cancer and they're relatively interesting in the sense of the similarity. breast cancer 192,370 cases of invasive breast cancer. in hundred 90,280 new cases of prostate cancer i noticed there is a word missing half the deaths today after all of the work from breast cancer 40,170 from prostate cancer 27,000. to understand the statistics and balance, if i understand correctly 192,000 prostate cases if you took out the bonds that were likely not to kill you in hindsight, you're probably not talking about 192,000 or

19,000 but 10,000 cases new cases and then use a way 22nd have a right end up with 27,000 deaths? a one to understand what that figure is. >> when the doctor talks about 30 or 50 people treated for one my saved those of who are screened and dejected. >> screen and found to have cancers fam i remember screaming will find the disease would not have found if there was no screaming pro a man in the united states to choose is to be screened doubles but chance to be found from one out of ted into one out of five. >> if you don't look you don't find. >> exactly. by the way come on the other hand if we take european steady to 20 percent

relative risk and increase of death, and that is 3% going down 2.4% by risk of death. the answer to your question is 30 or 50 /1 is of a screen population. >> but when you get at that are 192,000 for the two types of cancer and more people die of breast cancer, a cancer that we can look at with mammography and a better feel to be able to see it and feel it and eliminated but you have a higher number. to me that begs the question when we use the #1 hundred 92,003 basically saying here is a cancer we're not very good at curing but we're also not very good at putting a number up there that kills you? this is the number of people with live 20 more years? >> yes.

192 vs 192 that says invasive breast cancer will kill the men and 192 prostate not so much. >> that's right. but if you will bear with me. >> i don't want to interrupt you excess of the bible like to know after the fact if you could we estimate the 192,000 to give me your best guess of invasive cancer so we can look at the cases bursts days versus the death because it makes it look like breast cancer is more likely to kill women but it looks like there is less cases but we don't do so good with prostate cancer senate that is the reason i like to look at a mortality rates than the absolute numbers. we have nine randomized trials of breast cancer that consistently show mammography screening decreases the mortality rate. two out of the nine have the

focus of women in their forties by the way. we have four random negative chiles a prostate cancer that have never been attempted one was not psa three at a four actually show a slight increase risk of mortality versus the yen screened are but one of the european segments show that the 26% increase in in mortality. we have three studies that say this screening could be like lung cancer screening in the '60s we have one study that says no. it does save lives. >> i will concentrate on two questions. the europeans rather the day lower mortality they spend less is that right? they basically decided whether because of the cost they did not see a benefit they decided to prescribe

less action both in testing and treatment? >> yes. govett relates directly to the health care debate going on right now. if you go out and do it i can name 12 things you mentioned the mastectomy earlier agreed did that for 75 years because the doctor said it was a good thing and we criticize all the people who wanted to do any violation for more than 75 years finally may get around to do the evaluation and we find out that lumpectomy with radiation is equal to the domestic to me we did the wrong cling 75 years. psa came out late 80's and restarted encouraging people to get it rather than doing the adequate evaluation the europeans decided to do the adequate vibration the contamination rate on the

european study is so low the number of them control who did not get it because you can i get the psa unless you are in the study. >> i realize the indulgence but very quickly because you are someone who is talking about the alternative to anybody who talks about where we should invest in research for alternatives including if you talk about the next generation psa that is not such a shotgun approach to diagnosing specific cases of invasive cancer? >> thank you very much. >> i would like to refers to a couple of numbers i think to be put into a slightly different perspective and slightly different statistics. that the frame prostate

cancer in spite of the numbers. if you look at the number of men who fail prostate cancer treatment every year it is 70,000 men. what this means in practical terms 50% of men the treatment fails sam prostie -- prostate cancer persist and becomes life-threatening. this is 70,000 men. if you look at another number if they said there was a steady over 76,000 men and they demonstrated the necessary treatment, a 54% of men have unnecessary treatment. that is why with the procedures alone the could

never get the hospitalization costs. the bottom line is essentially a under treatment bailing on the other hand, we have failed treatment and retail we do not have diagnostic information. or four indigene to have appropriate treatment that is why the investment is that critical. >> thank you, mr. chairman chairman and i think the day after you eulogized jack murtha of it shows we don't want procedures unless a yields the right result life.e it can they do of >> i yield to the gentlemen

of california the. >> dr. brawley dinky for being here. i would like to address that you argue that prostate screening came before adequate studies were conducting an the such studies are still needed. in the meantime, who should be screened and when should they be screened should black man first and then at one age than white men at to another? and how should screening be utilized in the treatment? >> you may have given answers before i came in. >> a very important question. of the most important thing is the truth because a lot

of what i am hearing by advertisements and other places sometimes from hospitals that make money sometimes from survivor groups that want to do the right to saying it they are frequently supported by industries that take the test. but frequently but not always. they need to know the right to information but they don't know if this test saves lives there are people who think that it does provide i think it does save lives but i know we have to treat a large number of people in order to save each life. some men may want to take the option of getting screened and we should support those men some men may want to not get screened and we should support and not criticize those men for

that decision. i really do believe we need to have informed decision making the american cancer society says they have done that since 1997 but people would read what we said then said the acs men says men should get screened they say men should be informed and make a decision. that is why we changed our guidelines. it is within the physician and patient relationship none of the freeze greening 10 to generate income. within the relationship the position and the patient should have a conversation to talk about the uncertainties and unknown risks and the possible benefits and make a decision to what is right for the patient part of that is what we need to be doing. >> years ago when it was in the senate in california i

also was very involved in a state wide organization with black women with breast cancer a few months ago the question, not the question women ought to wait later until they are 40 before they do the screening i am talking about breast cancer in this instance the women part of our study was directed at ucla under dr. love time when our two years past all of them were dead. i was struck that there is something in good dna among african-americans that causes cancer at an earlier age and i am recognizing that because i carried the bill for the first screening on prostate cancer among

black males. i think you might have answered this it may have to be individual but i do see african americans more prone to prostate and breast cancer than other groups what will we have to do and how much time will it take us to come up with some decisions? >> unfortunately we have lost a lot of time because we started to advocate screening in the early 90's in the towel we lose time is saying everybody should get screened to figure out a screening works and things like the steady just reported was five years late because of the slow accrual why would you go into the steady when all of these advertisements say screening saves lives? that is how we slowed down.