Let’s Hear Those Treatment Options Again

BY RALPH BLUM

Some things not only bear repeating, they require it. Every year, in spite of all the progress made in the past half century, approxiametly another quarter of a million men are diagnosed with prostate cancer and face the daunting challenge: What treatment, if any, would be best for me? What treatment would be the least likely to put me at risk for side effects more serious than the disease itself?

Choosing a treatment plan that you can live with is an essential part of coping with prostate cancer, it is a tough decision to make.  All too often, there is no clear-cut “best” treatment, and you will get differing opinions from specialists. Your urologist will have a natural bias toward surgery (that is, after all, his specialty), a radiation oncologist’s bias will be toward radiation. Then too, friends and family will have different stories to tell that will further confuse you. Complicating the complex decision making process is the fact that all prostate cancer treatments have significant side effects. One thing is certain: the decision you make significantly alter the quality of the rest of your life.

After your doctor has evaluated the test results and you know the grade and stage of your cancer, there are other factors to consider. The first is your life expectancy, and this, of course, depends on your general health. If you have no other serious health problems and you are likely to live at least ten or more years, chances are your doctor will recommend more aggressive treatment. However, age is also a major factor, and doctors are often reluctant to pursue aggressive treatments with men older than 70 or 75, especially if the cancer is not fast growing. All the more reason to consider possible negative side effects of any treatment you choose.

Unless your PSA is rising fast, or “doubling,” I cannot repeat too often that there is no reason to rush into treatment that you might live to regret. You have to navigate a complex diagnosis, and you need to gather as much information as you can and consider all possible options before deciding which treatment is  the right one for you.

 And here’s something I learned early on: No matter how much you trust your doctor, you should get a second opinion, preferably from a medical oncologist who specializes in prostate cancer. Someone who is familiar with all the available reatments, who isn’t pushing one treatment over others, and who will give you an unbiased opinion.

If you have a low-risk or intermediate-risk cancer, the main treatment options to consider are watchful waiting (also termed “Active Surveillance”), surgery, radiation, and hormone therapy. Each has its risks and benefits and you need to investigate all of them-thoroughly. If, however, your cancer is high risk or more advanced, your treatment plan will be more complicated. Yourr options may well include a combination of these therapies, as well as chemotherapy, immune therapy, and gene therapy.

In a state of major shock after your diagnosis, you may be inclined to accept whatever treatment your doctor recommends. However keep in mind that it is very difficult for doctors who treat prostate cancer regularly not to have strong feelings that favor their own specialty. You are the one who has to live with the results if the treatment doesn’t work out well, and therefore it is you who must have the final say regarding which course to take. Never forget: if you have to get cancer, prostate cancer is the best kind to have because in the great majority of cases it is slow growing, and not only manageable but curable.

In my case, I was convinced that my prostate cancer was the tortoise and not the hare; that it was no more threatening than chronic asthma, and that I would die with it, not from it.  Now almost a quarter of a century has passed. Except for a year of hormone blockade a decade ago, I have stuck with the practice of Active Surveillance.

From everything I have seen and experienced, there are a few questions I would want answered if I were making a treatment decision today. Here they are:

What new drugs and/or treatments are on the horizon? What’s in the testing stage? How promising does it look? How long are we talking about before it comes on line?

Can I reasonably take the chance, given the degree of aggressiveness of my cancer, that waiting will result in my having a better quality of life?

Given the decision I finally make, what are the odds of my being cured?

And finally, if you are thinking about Active Surveillance, here is perhaps least discussed consideration: 

Have I got the temperament to live with even a small  amount of cancer in my body?
 

The answer to that last question is, for most men, the pivot upon which their decision must swing.  So face it. Answer it.  And then, depending on your answer, make your decision.

Without PSA, Prostate Cancer is a Silent Disease

BY MARK SCHOLZ, MD

Prostate cancer in the male population is like a vast subterranean reservoir of oil.  Unless you sink a well, you don’t know it’s down there.  The confusing thing is that prostate cancer rarely causes symptoms, even when the disease is advanced.

My career was just beginning when PSA testing first become popular in the early 1990s. Even back then the test was controversial, but for a different reason than today: No one could believe that a simple blood test detects cancer.

The medical practice I have today grew quickly because we embraced PSA testing early on when many other doctors were still skeptical. Our practice grew - patients self-referring themselves after having a shocking experience with their other doctor. Too often back then, worried men’s concerns were dismissed by their doctors in conversations that went like this:

“Hey doc, what about this new blood test called PSA?  I hear it helps detect prostate cancer.” 

 “PSA? You can forget that.  No blood test shows cancer.  You can’t trust it.  You are perfectly fine. You don’t have any urinary problems whatsoever.”

 

“But doc, I read about it in the paper.  It’s really supposed to work.”

“I can’t believe you are trying to tell me my job!  Do you think you can come in here and teach   me something by reading out of some damn column in the Los Angeles Times?   Trust me.  These new tests are unreliable.”

 “Aw come on doc, I don’t mean to make you angry.  It only costs thirty bucks.  And really, if we don’t do it my wife will be upset.  She’s afraid because my dad died of prostate cancer. I know you don’t believe in it but can we do it anyway?   I just want to humor her.”

So the doctor capitulates and sends the PSA test off to the lab.  A few days later he is dumbfounded when the report reads 467.  No, that is not a misprint four hundred and sixty-seven.   Totally humiliated, the doctor calls the patient and properly orders a bone scan.  When the scan confirms wide spread bone metastases, the patient, having lost all confidence in his doctor for not suggesting a PSA in the first place, fires him and starts asking around to find a doctor who embraces new technology.

Experiences like these quickly burned the need for PSA screening into doctor’s psyches.  Prior to FDA approval of PSA in 1987, 90,000 men a year were being diagnosed with prostate cancer.  In 1992, when PSA screening finally caught on, almost 400,000 men were diagnosed.  After the screening process unveiled the huge backlog of men who were walking around with silent advanced disease, the rate of new men being diagnosed settled down to a mere 200,000 a year, the rate that has been maintained to the present time.

No one with half a brain believes it is sensible to stop PSA testing.  Thankfully, due to almost universal PSA testing relatively few men are being diagnosed with advanced disease any more. However, the U.S. Preventative Services Task Force appropriately believes that the pendulum has swung way too far in the other direction. Thousands of men are getting unnecessary radical treatment for early-stage disease that is totally non-threatening.   We have pursued prostate cancer so vigorously with over aggressive biopsy tactics that many men are being diagnosed with an inconsequential disease Ralph and I christened, “The Uncancer.”

In my last blog, I promised to outline the pathway out of this conundrum, of throwing the baby out with the bathwater by nixing PSA testing altogether.  IHowever, in today’s blog I decided to postpone the fulfillment of that promise until my next blog.  I felt we first needed to be reminded  how the prostate cancer world looked at a time before PSA testing was widely adopted. 

The Tyranny of Statistics

BY RALPH BLUM

When you are first diagnosed with prostate cancer and you do your research into the various treatment options available, you are likely to come across a mountain of data, numerical tables, and graphs detailing your life expectancy. Do not let this statistical overload scare or dismay you! Remember: There is a biology of the individual as well as a biology of the disease. What is missing from statistics? A good many of the variables and intangibles that make you an individual.

In a magazine article on the subject of statistics, evolutionary theorist Stephen Jay Gould, who had been diagnosed with a rare form of cancer, quoted the Mark Twain quip about the three varieties of dishonesty, each worse than the one before: “Lies, damned lies and statistics.” The truth is that statistics measure populations, and they can be interpreted in a great many ways. What they do not determine are the distinctive features of any individual case—including yours. But if you allow them to frighten and depress you, statistics can become the stuff of self-fulfilling prophecy.

At the time of his prostate cancer diagnosis, one man I knew was told there was a 23% chance the cancer was contained in the gland, a 57% chance it had penetrated the prostate wall, a 10% chance of seminal vesicle involvement and a 9% chance that the cancer had spread to the lymph nodes.  “Well,” he said, “try sorting out that lot! And besides, I’m not a statistic, I’m a person!” That’s the healthy response to statistics.

Among the many things I learned in the support groups I have attended, is that every man’s prostate cancer is different, as is his general health, his diet, his lifestyle and—at least as important—his mindset and his attitude. There is a growing acceptance of the idea that what you believe, what you think and what you feel, can make all the difference on your prostate cancer journey. A belief in your chosen treatment, a positive attitude, an irreverent sense of humor, an independent and contrary spirit, large doses of hope and a strong will to live can all work together to overcome even the most dismal prognosis.

Cellular biologist Bruce Lipton, author of The Biology of Belief, claims that it is the “micro-environment”—things like your emotional state, your level of anxiety, the effect of stress hormones and all those other intangible factors that make you an individual—that either strengthens or suppresses your immune system. This is not a new idea. It was Hippocrates, the father of Western medicine, who declared that he would rather know what sort of person has a disease than what sort of disease a person has.

Statistics have their place. Be mindful of that, and keep them there. In the long run, it’s a matter of perspective. You’re not a statistic. You’re a person.

Over-Treating Prostate Cancer

BY MARK SCHOLZ, MD

Prostate cancer treatment is out of control, and the U.S. Preventive Services Task Force* has stepped up with the recommendation to stop PSA screening. The recommendation to ban PSA testing surprises patients and doctors alike. After all, in a trial published in the New England Journal of Medicine PSA screening was shown to lower prostate cancer mortality in a trial published in the New England Journal of Medicine in 180,000 men.

Some have questioned the expertise of the Task Force panel because there was no representation by urologists, radiation therapists or medical oncologists, the types of doctors usually responsible for treating prostate cancer.  Actually, the credentials of the panel members appear entirely appropriate to comment on screening, an area of medicine usually handled by primary care doctors.  The panel members consisted of 12 MD’s and four PhD’s trained in primary care, public health and statistics.

The Task Force has been taking massive criticism for recommending the end of PSA screening.  While conceding that PSA screening may save lives, their judgment was that too few lives are saved to justify the thousands of men getting radical treatment they don’t need. They also point out that at least a hundred thousand men annually are burdened with a diagnosis of CANCER when this particular type of cancer is very rarely life-threatening.  The sad thing is that even though most prostate cancers are harmless, a robust surgical and radiation industry can’t seem to stop treating ill-informed patients who assume that anything called cancer needs immediate treatment.

Invasion of the Prostate Snatchers was written to counter this dangerous ignorance. Throughout the entire book, Ralph Blum and I explained why something termed CANCER, as long as it is preceded by the work PROSTATE, in many cases should be totally harmless.  Ralph himself is a living example, diagnosed more than 20 years ago and still in possession of his prostate. Of course, confusion inevitably arises because certain types of prostate cancer can indeed be dangerous. Not dangerous like lung or pancreas cancer which can kill within months of diagnosis. But, over a decade or two, prostate cancer does indeed kill a minority of men. Demise from cancer certainly qualifies as “dangerous,” even if the death is much postponed.

Because there is so much confusion about the different types of prostate cancer our book pays special attention to the modern methods for distinguishing between the good and bad types.  Suffice to say in this brief blog, as long as there is a modicum of attention to detail, telling the difference between the good and the bad types is usually pretty simple.  Far more difficult is getting the uninitiated to slow down and study the situation before taking irreversible action. In the rushed process leading up to treatment, many fail in their struggle to believe that something termed CANCER really represents no threat at all.  Others, even more sadly, never hear their over-enthusiastic doctors marshal a single argument against immediate treatment.

So the Task Force is shooting PSA, the messenger, when doctors and patients are the real culprits. PSA is not the problem. The real problem is rushing to immediate biopsy at the very first sign of a PSA elevation.  A million men have mindless biopsies every year. I call them mindless because most men undergo biopsy before they have any idea of what they are getting into.  They are not pre-informed that most men over 50 have cancer cells in their prostate, and that a biopsy will be positive 20% of the time.  So when bad news comes, usually via a phone call, emotional hell breaks loose.  After all, isn’t CANCER a call to action?   Unfortunately, the urologists the doctors designated to treat prostate cancer are surgeons, who are by definition, men of action.

The Task Force is correct in their view that too many men are being frightened in unnecessary radical treatment.  The problem is a million men undergoing mindless biopsy, not PSA screening.  PSA elevation should precipitate further testing, prostate imaging and most of all, education.  My next Blog will outline the process of how to handle an elevated PSA.

*Previous blog written about this topic can be found here:  http://prostatesnatchers.blogspot.com/2011/10/discontinue-psa-screening.html