Finally the Word is Out

BY RALPH BLUM

In the five years since writing our book, Invasion of the Prostate Snatchers, with the subtitle “No More Unnecessary Biopsies, Radical Treatment or Loss of Sexual Potency,”  Mark and I have continued advocating for changes in the management of low-risk prostate cancer. It has been an uphill battle, mainly because most men find it hard to believe that anything called “cancer” can be safely monitored, probably for years, even—in my case, for example—for decades.

Now, at long last, it appears the word is out: Finally more men are opting for regular, close monitoring, while holding off on aggressive treatment unless the disease progresses.  Instead of yielding to an overwhelming desire to "cut the damn cancer out and be done with it," men are increasingly choosing "active surveillance" and by so doing, dodging the two bullets of erectile dysfunction and loss of urinary control.

In a study published in JAMA this month, Dr. Matthew Cooperberg and Dr. Peter Carroll of the University of California, San Francisco, drew on data from 10,472 men with localized prostate cancer, who were treated at 45 urology practices in 28 states, between 1990 and 2013. The use of active surveillance among men with low-risk cancer ranged from 7 to 14 percent from 1990 through 2009, then increased to 40 percent between 2010 and 2013. Among men age 75 or older, 76 percent opted for active surveillance.

Rates of active surveillance in the U.S. have historically been lower than in other countries. In Sweden, for instance, 2013 figures indicate that active surveillance was used to manage 78% of men with very low-risk disease, and 59% of men with low-risk disease. Unfortunately, men in this country have been motivated to submit to radical treatment for what is typically a non-life-threatening condition.

Not many years ago, a PSA reading of 4.0 was considered "abnormal," and triggered an immediate biopsy regardless of age or prostate size. More recent studies show that microscopic amounts of low-grade prostate cancer are so common, that even when the PSA is totally normal, one-fourth of men will have a positive biopsy.  So if the biopsy was positive, inevitably it led to radical treatment; treatment that, in most cases, was unnecessary. Fortunately this is changing.

Some men, however, are still frightened into unnecessary aggressive treatment. They don't want the stress of regular check-ups. They just want to be rid of the cancer. But fear is an untrustworthy advisor. What they don't take into account is that men who have chosen surgery also have to be monitored regularly to make sure their cancer stays in remission.

So if you are blessed with the low-risk, slow-growing form of this disease—the tortoise of prostate cancers— wait and go slow. Your three most important considerations are quality of life, quality of life, quality of life. With active surveillance you avoid the toxic side-effects of radical treatment, without sacrificing the chance for a cure, even if the disease progresses.

Scare Tactics about the “Symptoms” of Prostate Cancer

MARK SCHOLZ, MD

In this week’s blog I was supposed to finish out the “Helpful Medications” theme started at my last blog. Specifically I need to make a case for using statin drugs and metformin, a generic diabetes drug, to help suppress prostate cancer.  However, that blog has been temporarily postponed in place of the following:

When Ralph and I wrote Invasion of the Prostate Snatchers we knew our highest priority was to calm people down so they could begin to think rationally.  Obviously the word “cancer” freaks everyone out. People get so scared that all rational thought ceases.  They immediately jump into the arms of the nearest doctor who is willing to offer a quick fix.  With prostate cancer that just happens to be a surgeon.

Scare tactics are effective from a business point of view since in business “time is money.” Frightened people act quickly and decisively, thus saving everyone time.  The psychology of fear is also quite commonly used in advertising.  You have heard these mottos and mantras many times before: “Time is Running Out,” or, “Space is Limited.”  No one wants to miss a one-time opportunity.

The threat of losing a one-time chance for cure naturally drives newly-diagnosed prostate cancer patients to act quickly. And there is after all a certain type of logic to people unfamiliar with prostate cancer.  With almost any other type of cancer a delay in treatment will reduce cure rates. Surprisingly with prostate cancer this is only rarely the case. However, the idea of a “harmless cancer” is certainly foreign to us all. It will take some time for newly-diagnosed patients to absorb this unexpected fact.

That’s why it is critically important to encourage men to take time to gather their senses and calm down.  Given some space to reflect they will learn that with prostate cancer they need to weigh the potential for treatment-related side effects against the tiny amount of increased survival surgery or radiation offers in men with low-risk disease.

As noted above, the fears and confusion incurred by a recent prostate cancer diagnosis have a certain type of logic. But what is totally illogical is the proliferation of articles I keep coming across on the internet that purportedly describe the “Symptoms of Prostate Cancer.”  Invariably these articles present a long list of symptoms such as urinary frequency, nighttime urination, slow urination, and blood in the urine as possible indications of prostate cancer.

These articles are completely false! EARLY PROSTATE CANCER ALMOST NEVER HAS SYMPTOMS.  This is why the PSA blood test has been so revolutionary.  PSA can detect prostate cancer before symptoms of advanced disease occur. The most common symptom of prostate cancer—bone pain—only occurs after the disease has spread to the bones. Prostate-related symptoms, when they are present, signal another diagnosis such as prostatitis or prostate enlargement. These prostate problems have nothing to do with prostate cancer. Symptoms such as these may need evaluation and treatment but there is no reason to scare people with the suggestion of cancer.

Competition on the internet has become so fierce that just about any scare tactic is considered acceptable, up to and including bald-faced lying.  But let’s put this falsehood to rest.  The myth that early-stage prostate cancer causes urinary or sexually related symptoms is an exploitative tactic that can lead to all kinds of harm, creating anxiety and fear that results in unnecessary diagnostic testing such as random needle biopsies that lead to the over-diagnosis of low-risk prostate cancer.