Gerald Chodak, MD, 72, who created the intellectual framework for the active surveillance (AS) approach followed by hundreds of thousands of men with low-risk prostate cancer and an opponent of routine prostate specific antigen (PSA) testing, died Sept. 28 at his home in Michigan City, Indiana. The cause was reported to be an aortic aneurysm.
He was a lightning rod for controversy who often took on the medical establishment, resulting in professional isolation.
University of Toronto researcher Laurence Klotz, MD, considered the "father of active surveillance," said Chodak was his role model and was the first in the field to propose conservative management of prostate cancer. He said Chodak's concepts led in 1997 to Klotz developing the concept of AS with close monitoring of patients with low-risk prostate cancer.
"His argument was that we were over-treating patients. And he was, I would say, the first to really make that argument in a compelling way. And he really took on the establishment," Klotz said.
Chaz Brendler, MD, Chodak's former chief at the University of Chicago, said Chodak was "a maverick in urology who bucked the urological community ... We didn't always agree, but I always respected his intelligence and commitment to do the right thing for patients. ... He founded Us TOO [the large prostate cancer support network] so that men and their families would receive much needed support and balanced information in order to deal with their disease."
Chodak was born March 13, 1947 in Garden City South, New York, and received his MD at the University of Buffalo. He spent most of his career at the University of Chicago.
I first met Chodak almost 40 years ago. He was an up-and-coming urologist and researcher at the U of C. I was a young medical reporter on the Chicago Sun-Times, whose job depended on knowing researchers like Chodak. He was always a great interview, in part because he was often embroiled in controversy.
Chodak was intense. He always stood out. He was fashion-forward, decked out in designer suits; he was well-coiffed with a jet-black mane combed back.
But he was also a man on a mission, a physician focused on science and, above all, his patients.
He never shunned controversy; he seemed to thrive on it. He always brought a sharp scalpel and sharper mind and tongue to whatever fights he got into. And there were many.
Most prominent was the PSA issue, which followed him throughout most of his career. PSA testing was taking off in the 1980s. Leaders in urology and powerful financial forces wanted the "simple blood test" to be used for mass screening.
In the late 1980s and early 1990s, Chodak campaigned for cautious use of PSA: testing men diagnosed with prostate cancer but holding off on it for mass screening until a benefit was proven.
It did not unfold that way. Instead, widespread testing, as he predicted, quickly led to a doubling in the number of diagnosed cases of prostate cancer and rampant overtreatment. Men with low-risk, non-life-threatening cancer often underwent radiation and surgery, which came with side effects including incontinence, impotence, and sometimes, death.
Klotz said Chodak's criticism of PSA screening "was part of the reason why he earned the ire of the establishment. He argued basically what the in 2012, but he was saying this 15 years earlier, that there was too much overdiagnosis and overtreatment." Chodak was ostracized and attacked.
Chodak nearly stood alone in trying to stop this unnecessary, aggressive slaughter. He wanted scientific evidence and the most conservative therapy.
Klotz said, "He didn't suffer fools gladly. So he was very assertive about his ideas. People thought he was a bit of a loose cannon, and yet basically everything he said turned out to be completely true and was validated and ultimately accepted."
"And the idea that we were over-treating, which he really promoted in the United States, was the inspiration for me and my group in Canada to start this active surveillance program, which was to say, well, we don't want to not treat people at all. We want to just treat them selectively, and that was really what took off."
Chodak saw how many men and their spouses had inadequate support in making decisions about dealing with prostate cancer. He observed the success of support groups for women with breast cancer, such as the Why Me? Breast Cancer Group in Chicago. So in 1989 he launched a support group with five of his patients.
A year later, it blossomed into , now a large national support network. James Schraidt, board chairman of Us TOO, said, "Gerry was a visionary leader in the face of strong opposition from the urological community. Gerry's untimely death is a tragedy for the prostate cancer patient community."
The years passed. Robotic surgery arrived in the 2000s. Chodak the skeptic stood up again, asking for proof that it was any better than open surgery. There wasn't any, in his mind. He felt that marketing for a high-tech robot had captured the imagination of the public and many surgeons.
He told me in an interview that in his view a well-done study had not been conducted that proved an advantage for robotic surgery. "Without a randomized study comparing results of different surgeons on a variable group of patients, valid comparisons are impossible," he said.
He told me that the robotic juggernaut was partly responsible for his decision to quit performing prostatectomies in 2007 and to close his private practice, Midwest Prostate and Urology Health Center, the next year. "I stopped doing prostate cancer removals because I didn't want to have to make a sales pitch for doing it my way. People want new in the U.S. They think new is always better. And the hype for robotic prostatectomy was that way," he said.
He didn't fully retire from medicine, though. He wrote the book . He taught about prostate issues online.
Klotz said, "He was an amusing, multi-talented guy who thought outside the box, who had diverse interests. I think he was the best dancer I have ever seen in my life, and I remember seeing him at some club and I mean it was just unbelievable. The guy was phenomenal."
Chodak was a competitive tango dancer. He also with glass blowing and painting. He also played chess and tennis and golfed.
Nine years ago, when I was diagnosed with low-risk prostate cancer, I turned to my old friend and source, Gerry Chodak. He gave me an unofficial second opinion.
He told me I was the perfect candidate for AS -- even as one of his former students was trying to rush me into an OR. (Chodak asked me if the former student had used an anesthetic when he performed a biopsy on me. I said he did. "Good student," he said.)
He reassured me: "When I get my prostate cancer, I want what you have."
When I had my first muli-parametric MRI, it showed two possible lesions. One matched my tiny biopsy core. But then, the MRI suggested a lesion on the other side of the capsule. Gerry gave me his opinion. "You can choose to believe it is cancer, or not. My suspicion is that it is an artifact," he told me. That cancer was not found on a subsequent biopsy. Chodak was right. Again.
When I helped organize Active Surveillance Patients International, I recruited Gerry to serve on the planning team for what would have been the first international meeting of men on AS. He immediately saw the need for an organization and worked closely with me and Gene Slattery, ASPI's president, on the program committee. He identified and invited some of the leading figures in the field. I suspect his name persuaded them to agree to speak. Unfortunately, the meeting in Iceland had to be cancelled for financial reasons.
Mark Lichty, board chairman of ASPI, said of Chodak: "He was a giant in AS, a man ahead of his time."
Chodak influenced my life and those of many other men diagnosed with prostate cancer. Donations in his memory are being made to Us TOO.
Klotz said Chodak "was really a lone voice in the wilderness. And he paid the price. He should have been one of the top people in the field and he was not. I guess this is what happens. There's a long history of that in the medical profession."