BY MARK SCHOLZ, MD
Yesterday I sat down with a new patient, Sam, a
charming man who, unfortunately, was just found to have a prostate nodule
and a PSA of 50. When I asked Sam why he had not visited a doctor for over 10
years or undergone any PSA testing, he responded, “I have always enjoyed
perfect health. Why see a doctor?” Sounds sort of like a stupid response, but
judging by his healthy appearance, (looking more like a 70 year old than an 80
year old), one would have to say that until now his policy has been pretty
However, if Sam was going to participate intelligently
in further discussions about the selection of optimal treatment, his prostate
cancer knowledge would need a major upgrade. Since my instruction had to begin
at a very elementary level, I thought I would use this blog to share the main
themes of our almost two-hour meeting together.
Focusing on the basic first steps seems an appropriate theme for this,
my first blog of the New Year.
Not All Cancers Are the Same
Many patients introduced into the cancer world fail to
understand that lung cancer, breast cancer, brain cancer and prostate cancer
are each a distinct illness, each with more differences than similarities.
These different cancers are as different as kidney stone disease is different
from pneumonia. Therefore, preconceived notions coming from personal
experiences with one type of cancer occurring in family members or friends are
Prostate Cancers are a Mixed Bag
It’s fairly easy to see why dissimilar cancer types,
such as bladder cancer and skin cancer for example, behave differently; it may
be harder to understand that prostate cancer itself comes in many different and
distinct subtypes. Part of this varied behavior can be explained by the disease
stage: No one is surprised by the fact that cancer diagnosed at an early stage
has a different outlook compared to cancer diagnosed after it has metastasized.
However, beyond the issue of variable stage, when
comparing two different prostate cancers of exactly the same stage, what we
call “prostate cancer” can be extremely variable. Consider the following: In
2014, 70,000 men were diagnosed with a type of prostate cancer considered to be
so harmless that experts universally agree it is best managed with active
surveillance only. However, at the other extreme, also in 2014, a very
different type of prostate cancer led directly to 28,000 deaths.
Prostate Cancer in the Bone is Not Bone Cancer
A common misconception that needs to be rectified is
that cancer that originates in the bone, i.e bone cancer, is a totally
different entity than prostate cancer that has spread to the bone. Primary bone
cancer grows quickly, often spreads to the lungs and does not respond to
hormones. Prostate cancer that spreads to the bone tends to grow much more
slowly, only rarely spreads to the lung and usually regresses radically with
hormone therapy. Prostate cancer in the bone and primary bone cancer are two
separate and distinct illnesses that should not be confused with each other.
Doctors and Patients, the Human Factor
The human factor further complicates the selection of
optimal treatment. Doctors who treat prostate cancer come from different
schools of thought. Not only are urologists, who are surgeons, trained differently
from radiation specialists, the true cancer specialists, the medical
oncologists, are practically never involved with early-stage prostate cancer.
Differences among patients—age, fitness, prostate size for example—can also
radically influence treatment selection.
With a PSA of 50, Sam is going to need a bone scan. He
may have already developed metastases. His initial color Doppler ultrasound
shows a rather vascular tumor (about an inch and a half long) with some early
extra-capsular spread. A targeted biopsy, a single core of the tumor, is
scheduled for next week and will let us know the Gleason score.
If the scans turn out to be clear, and if Sam was ten
years younger, radiation and hormone therapy would give him the best chance for
cure. But in an 80-year-old, the possible side effects that can result are more
problematic. Also, we don’t know anything yet about the pace of his disease. Might
it be feasible for Sam monitor to the situation for a while? Alternatively, radiation
alone or mild hormonal therapy alone (with Casodex) could be considered. Sam
and his wife left our meeting with a copy of Invasion of the Prostate Snatchers promising to read it in
preparation for our next meeting.