The Power of a Word

BY MARK SCHOLZ, MD

At an Active Surveillance Consensus Conference in 2007, it was openly bemoaned that the word “cancer” profoundly overstates the significance of low risk prostate cancer.  The pathology experts who were present, however, shot down the idea of a name change saying, “Under the microscope it looks like a cancer, so it’s cancer.” At that time no one had a rebuttal, so the subject was dropped. Now studies confirm that Gleason grade six prostate cancer never metastasizes.

In retrospect, I wish the conference attendees had been able to rise up to the name-change challenge. Back when the makers of 7-Up wanted to emphasize the distinctness of their product compared to other soft drinks, they came up with the name “Un-Cola,” a stroke of marketing genius. Since the pathology experts insist that low-risk disease is a cancer—we should undo the negativity of this word by renaming it: “The Un-Cancer.” Alternatively, the SHADES of Blue classification system calls this harmless type of prostate cancer SKY BLUE.

Misinterpreting the significance of the word cancer leads everyone to think, “I had better be safe and remove the gland.”  The biggest challenge of educating people about prostate cancer is overcoming their preconceived notions, what they already think they know about cancer.  Random biopsies are detecting cancers that are so small that even if they grow while under observation, they will still be curable.  And for the minority of men on active surveillance who develop progressive disease, at least they have real proof that their cancer truly needs intervention, for this minority, it’s not a paper tiger and undergoing treatment is justified.

Defining the Un-Cancer—The Basic Components of SKY

	Favorable	Ambiguous Zone	Unfavorable
Color Doppler or Multiparametric-MRI	< 10 mm  in maximum tumor dimension	11-17 mm  maximum tumor dimension	> 18 mm max tumor dimension
Highest Gleason Grade	Grade 3 + 3 = 6	3 + 4 = 7	4 + 3 = 7 or higher
PSA Density	Under 0.13	0.14 to 0.17	Over 0.18

Further In-depth Testing for SKY
New technology is also providing new insight into how favorable cancer can be distinguished from unfavorable cancer. The biggest advance is better imaging of the prostate. Other new blood and genetic tests such as Prolaris, Oncotype, MDx, OPKO 4K and Mitomics, can also ferret out the cancers that are prone to behave more aggressively or have been missed on the initial random biopsy.

The Drawbacks for Active Surveillance
The main concern is that the initial random biopsy missed a higher grade tumor somewhere else in the prostate. Most centers address this problem by doing random biopsies over and over. Repeated random biopsies are unpleasant and they can cause serious infections.  Multiple biopsies have also been associated with higher impotence rates and worse urinary symptoms. A better way is to rely on modern imaging with color Doppler ultrasound or multiparametric MRI (MP-MRI). Also, because with active surveillance prostate gland is left intact, there is the possibility of a new, higher grade cancer developing. The privilege of keeping the prostate intact entails the responsibility of close monitoring. Then, if a new higher grade cancer subsequently develops, it can be detected and treated at an early stage.

Anxiety and uncertainty about living with untreated cancer is also a problem, one that is often magnified by the treating physicians, surgeons or radiation doctors who often send an ambivalent and lukewarm message about active surveillance to their patients.  This half-hearted attitude is probably rooted in the doctor’s own uncertainties about untreated cancer. Despite all these very real issues, however, studies show that men on an active surveillance program are no more anxious than men who have had surgery or radiation and are being monitored after therapy to make sure their cancer stays in remission.

It’s Hard to Teach an Old Dog New Tricks
It’s easier to teach a proper golf swing to a true beginner than to someone who has previously developed bad habits.  The mind of a child learns a new language much more easily than the cluttered mind of the adult.  Good first impressions are valued so highly because we all know how hard it is to undo a bad first impression.  Changing the mindset of doctors and patients about how to treat something called CANCER is going to be a slow process.

Men need to realize that survival rates with low-risk prostate cancer managed with observation are extremely favorable.  Studies show that survival with active surveillance matches the survival of men getting immediate surgery. Men need to guard themselves from being rushed into unnecessary treatments that have irreversible side effects.