When “No Action” Can Be “Right Action”

BY RALPH BLUM

Back in 1990, when a suspicious lump was discovered on my prostate, my ignorance of the prostate gland and the possibility of prostate cancer was monumental. No one in my family or even among my close friends had ever had prostate cancer, and it never occurred to me that I might one day have the disease.

Now, 25years later I am still alive, the average man over 50 is more aware of prostate cancer, and also many less toxic and more effective treatment options are available. And yet one thing has not changed: just hearing the doctor say, “I’m afraid it’s cancer,” can leave even the most pragmatic man planning the music for his funeral.

Truth is there is still a lot of misinformation and misunderstanding out there about this disease. So here are some facts that I hope will alleviate some of your fears, and also clarify why I still contend that if you have to have cancer, prostate cancer is the best deal in town.

Prostate cancer is unique among cancers because the mortality rate is so low. According to the American Cancer Society, more than 2 million men who have been diagnosed at some point are living with the disease in the U.S. It’s difficult to determine actual prostate cancer survival rates because most men are around 70 years old when diagnosed, and many of them will die from medical problems unrelated to the disease. But if you check out the “relative” 5-year survival rate of all stages of prostate cancer, you will find it is almost 100%. And that almost 100% of men with low-risk or  intermediate-risk disease live more than 10 years after diagnosis.

Why is it that the statistics for prostate cancer are so much less frightening than for other cancers?
 
1)    The PSA test is an early warning system that other cancers don’t have.
2)    It can easily be diagnosed at an early stage.
3)    In most cases it has an exceptionally slow growth rate.
4)    Extremely effective monitoring and treatment is now available.
5)    It has a pattern of spread that spares critical organs like the brain, lungs and liver.
6)    There is a safety net like no other called “hormone blockade” that induces remissions lasting more than 10 years in men with relapsed disease after surgery or radiation.

So instead of thinking about your funeral, what you really want to be focusing on is not rushing into some form of radical treatment that will virtually guarantee  some degree of impotence or incontinence.

It appears that patients and doctors alike struggle with the idea of “watching” anything called cancer. But unless you have the less common high-risk form of the disease, my advice to you is to consider “Active Surveillance” really carefully, especially if you are over 70. Because bottom line—and it bears repeating—out of over 200,000 men in the U.S. diagnosed annually with prostate cancer, the overwhelming majority will die with the disease, and not from it.

The Art of Being a Patient

BY RALPH BLUM

In an essay entitled Complications: Surgeon’s Notes on an Imperfect Science, Atul Gawande, surgeon, writer and professor at Harvard Medical School wrote: “Just as there is an art to being a doctor, there is an art to being a patient. You must choose wisely when to submit and when to assert yourself.”

 

This advice is especially important if you have just been diagnosed with prostate cancer. Because prostate cancer is so common, and in most cases so slow growing, that to submit to any form of radical treatment could be a huge mistake, and hugely detrimental to your quality of life. Yet most doctors you consult will advocate some form of radical treatment. It’s what they know, what they do. And it goes against the grain for both doctors and patients alike not to treat cancer.

 

But prostate cancer is unique among cancers because the mortality rate is so low. Autopsies reveal that more than 50% of older men have the disease, live with it, and die from something else—sometimes without ever knowing they had a life threatening condition. Furthermore, the life expectancy of men with recurrent prostate cancer stretches out well past a decade. And yet the radical prostatectomy, one of the most complex and challenging surgeries because the prostate is located in absolutely the wrong place for a simple surgical solution, is still the most widely recommended treatment option. It is also the most unnecessary, and the one most likely to leave you incontinent and/or impotent.

 

My own experience with urologists has not been a happy one. Twenty years ago, a doctor who wanted nothing but patient compliance, told me that if I did not agree to immediate surgery I would be dead in two years. His recommendation and prognosis were not only wrong, but in my opinion violated the ancient medical precept incorporated in the Hippocratic Oath: “First do no harm.”  Fortunately I was not the kind of patient to be easily intimidated.

 

A significant part of any doctor’s job is to create a relationship based on trust, confidence and hope. And as patients, our job is to put ourselves in charge of our recovery. It is our job to do the research, and give ourselves permission to say “No” if we feel the recommended treatment—for what ever reason, or simply instinct— is not right for us.  My decision not to be intimidated by what, in effect, was a death threat, but to monitor the cancer and take the time to educate myself, has given me many years of quality time with my wife that almost certainly would have been lost or diminished if I had committed to immediate surgery.

 

Doctors have busy lives. They believe in what they do. But often they tend to treat the disease and not the patient. Traditionally we’re encouraged to go along with whatever they recommend, and asking questions, or refusing to follow advice is unpopular.  But this passive attitude does not serve us well. The feisty, “difficult,” assertive patient, the one who challenges the doctor, is the one who has the best outcome.