Active Surveillance: Follow-Up Essential

BY RALPH BLUM

 

A recent UCLA study found that a significant percentage of men diagnosed with low-risk prostate cancer who chose "active surveillance," rather than aggressive treatment in order to avoid the debilitating side effects of surgery or radiation, don't follow up with the required tests and office visits.

 

This is an alarming finding, because not being monitored appropriately puts them in danger of the cancer progressing or metastasizing without their knowledge. Before patients decide on active surveillance as a management option for prostate cancer they should agree with their physician on a strict follow-up schedule to closely monitor the cancer.

 

There is no doubt in my mind that active surveillance is the smart treatment option for low-risk prostate cancer.  With other cancers, or if the prostate cancer is aggressive, the main issue is survival. But with low-risk prostate cancer, since long survival is the norm, the most important consideration is quality of life. Having said that, with active surveillance regular check-ups are essential, because when men are watched closely, treatment can be started at the first sign of cancer progression.

 

So what does active surveillance require? How exactly is it carried out?

 

Different centers have different requirements. At a 2007 Active Surveillance Conference, attended by over 200 of the world's leading prostate cancer experts, the attendees recommended a biopsy after one year, subsequently repeating it every two to three years. But as I have often said, I am not a fan of biopsies. So I prefer to recommend doing a repeat targeted biopsy only on the basis of a PSA and prostate imaging with either color Doppler ultrasound or 3T multi-parametric MRI.

 

Here is an Active Surveillance Protocol that Dr. Mark Scholz recommends:

 

• PSA every three months
• Rectal examination every 12 months
• Color Doppler ultrasound annually
• Multi-parametric MRI annually

Whatever protocol your urologist recommends you need to be committed to following it. It may be inconvenient or uncomfortable but the alternative is aggressive treatment that has the potential to leave you with erectile and urinary dysfunction.

 

There is always the consideration to just treat the cancer and be rid of it. But having lived with this disease for over two decades, with my prostate intact, I am a firm believer in avoiding radical treatment and preserving quality of life as long as possible. And if you have low-risk prostate cancer, bear in mind that the longer you can wait before you submit to radical treatment, the better the odds are that research in the field will have advanced, and treatment will have become more effective and less toxic.                                                                

How to Cope with a Prostate Cancer Diagnosis

BY RALPH BLUM

There is no easy way to receive the news that you have cancer of any kind, but—and I cannot say this too often‑—it is important to realize that prostate cancer is typically not a death sentence. The majority of men diagnosed with prostate cancer have Low-Risk disease and will live a normal life span. And even more aggressive High-Risk type is now being successfully treated with a combination of therapies.

Having said that, a diagnosis of prostate cancer is daunting, and once you join the ranks of the newly diagnosed, you enter into what Mark calls “a medical minefield.”  While you are still reeling from shock you are required to make treatment decisions that can permanently affect your quality of life, and there are no easy answers. There are, however, a few basic things to bear in mind while you navigate the prostate cancer minefield.

1)    Don’t waste energy asking yourself, “How did this happen? Did I bring this on myself?” Because regardless of your lifestyle—eating habits, exercise regime, or anything else that might contribute to getting this disease—you did not cause it. Prostate cancer is incredibly common. Like diminished sight and hearing, it comes with advancing age.  In the words of one prostate oncologist, “If you are over seventy, and you don’t have prostate cancer, chances are you’re a woman.”

2)    Stay as calm as possible. The very process of gathering the information necessary to make an informed decision can be scary. But do not be panicked by all the numerical tables, statistics and graphs. Statistics measure populations. You are not a statistic. You’re a person. And statistics and pathology reports do not take into account all the variables and intangibles that make you an individual.

3)    Be proactive. The days of the passive patient with a “Whatever-you-say-Doc” attitude are over. The single most influential decision maker when it comes to obtaining the best care and treatment is you. Do your own research, and become actively involved with your doctor in the decision-making process. Ask your doctor about all your treatment options, and make sure you understand their short-term and long-term side effects.

4)    Recognize and resist your natural desire to rush into radical treatment. Be aware that a combination of the urologist’s preference for surgery and most men’s “just get it out” attitude, leads to tens of thousands of unnecessary radical prostatectomies every year. These men would have lived just as long without surgery, without the risk of losing both potency and normal urinary function and greatly compromising their quality of life.

5)    Even if you are satisfied with your urologist, it is critically important to get a second opinion, preferably from an independent board-certified medical oncologist—a cancer specialist—and if possible, an oncologist with a specialty in prostate cancer. Obtaining a second opinion doesn’t imply that you don’t trust your doctor. On a decision this important, you owe yourself the benefit of more than one person’s thinking.  Be prepared for conflicting opinions, and remember to trust your instincts about which doctor is right for you. Finding the right doctor may require traveling to a major cancer center to talk with a leading edge specialist.

Above all remember: if you are diagnosed with Low-Risk disease you do not require any immediate radical treatment. You can be safely monitored with “Active Surveillance.” When you are watched closely, treatment can be safely delayed until there is some sign of progression.

Even then, the cancer will still be manageable. Multiple studies clearly show that survival rates of men on Active Surveillance match those of men getting immediate surgery. Also, be particularly careful if you are in your 70s or 80s.  Men in this age group are rarely at risk of disease that will be clinically significant in their lifetime, and these men have the highest incidence of overtreatment. As you start out on your prostate cancer journey, be very aware that overtreatment of this disease is rampant, and do not become a needless victim of unnecessary treatment.

Active Surveillance: Knowing the Players, Betting the Odds

BY RALPH BLUM

Prostate cancer screening has led to the diagnosis and treatment of many cancers that would not have become life threatening during a man’s lifetime. Since Mark and I published our book, Invasion of the Prostate Snatchers, stressing the over-treatment of prostate cancer, the ascent of Active Surveillance has become the most game-changing factor in the management of this disease. And yet with the popularity of robotic surgery both doctors and patients are still opting for cutting out prostate with low-grade cancer unnecessarily.

Johns Hopkins was way ahead of the curve with their Active Surveillance program. In 2011, Hopkins published the results of a study involving 769 patients with low-risk prostate cancer who had been deemed eligible for the program. After seven years, only about 50 percent of the men had been treated with surgery or radiation. This meant some 385 men got a pass on one or another of life’s more risky and unpleasant procedures. Furthermore, it must be noted that not a single patient enrolled in the Hopkins’ Active Surveillance program died of prostate cancer.

The best prostate surgeons operate on an extremely small percentage of men over the age of 70, even though they meet the criteria for low risk disease. In fact, Hopkins only intervenes surgically in about 1 percent of those men. On the other hand, nationally, more like 80 percent are undergoing surgery or radiation. More than 90 percent of men over 65 with low to intermediate risk disease undergo treatment even though it is unlikely to extend their lifespan.

Active Surveillance reduces this radical over-treatment of low-risk, indolent cancers while allowing for curative intervention if and when the cancer progresses. Yet despite the obvious virtues of Active Surveillance, the dominant view in prostate care is that everyone who gets diagnosed gets treated in a one-size-fits-all approach regardless of their age, or the grade and stage of their cancer. Which means prostates are continuing to come out at a record pace, even though there is no benefit from the procedure. Senior urologists at top academic medical centers blame a host of reasons, not the least being the pressures on for-profit private hospitals to boost the volume of procedures in order to maintain their annual profit margins. Unfortunately, there are always financial issues involved.

While evidence is mounting that for men with low-risk disease Active Surveillance is both sensible and safe, the challenge is to further refine the protocols for separating out low-risk men from the men facing uncommonly aggressive tumors. In this regard there are some new genetic tests called Prolaris and Oncotype that help detect prostate cancer’s bad actors.

Meanwhile, if your prostate cancer has been diagnosed as low-risk (which has been defined as a Gleason Grade less than 7, a PSA less than 10), and your doctor is recommending immediate radical treatment, my advice to you is to get a second opinion from a doctor who has experience in treating patients with an Active Surveillance protocol. And if the time comes when you do trade Active Surveillance for surgery, never—repeat never—hesitate to ask the surgeon you are considering employing how many radical prostaectomies he performed this year. And last year. And the year before. I have been astonished to learn that hundreds of well-regarded urologists have performed fewer than ten a year. Last time I heard, between 150 and 200 procedures qualified you as “expert.” At that pace, you’d need to be a medically trained vampire to qualify. As for robotic surgery, it makes no great difference: I still want you closing in on 200 procedures, of whatever kind, before you get access to the prostate of any of my friends!

A Few Words About Prostate Biopsy by Someone Who Will Go a Long Way to Avoid Having One

BY RALPH BLUM

The large majority of men I meet are not aware that by agreeing to a prostate biopsy they are starting down a slippery slope. The biopsy is a pivotal step—not because it is painful— when expertly performed there should be minimal pain—but because, more often than not, if any of the tissue samples or “cores” taken from different sections of the prostate prove positive for cancer, the whole radical treatment process is set in motion.

Very few men understand that in most cases, prostate cancer is the more common Low-Risk type that is not life threatening and does not require immediate treatment.

So what can be done to prevent this rush to over treatment? Especially the panic to “just cut it out?”

First of all, family doctors need to refrain from recommending a biopsy at the first sign of an elevated PSA. You’d be surprised to learn how often this happens. But a slight increase in PSA does not justify an immediate biopsy. Instead, it should merely result in a risk assessment process to determine what is really going on in the prostate.

 

For instance, an enlarged prostate, the result of Benign Prostatic Hyperplasia (BPH), common in aging men, is often the cause of an artificially elevated PSA reading. Similarly, a random laboratory error, an underlying chronic prostate infection or even recent sexual activity, can cause a rise in PSA. I remember once, about ten years ago, my PSA was unaccountably elevated. Then I remembered I had helped a friend move some heavy carpets from his house to his truck the day before the test. We repeated the test a week later, and my PSA had dropped back again to its previous level. Could it have come from my vigorous exertion?

 

So an obvious first step, when there is an unexplained shift upward, is to make certain that all the above reasons are ruled out and have your doctor repeat the PSA. If on retesting your PSA is still elevated, additional testing with PCA-3, color Doppler ultrasound or mulitparametric MRI should be considered before resorting to a biopsy and starting down that slippery slope to unnecessary radical treatment—treatment that all too often leads to incontinence and loss of sexual potency.

 

If further testing indicates that you should to go ahead with a biopsy, remember that some margin of error is always present. Biopsies fail to spot cancer about 20% of the time, especially in men with enlarged prostates. So even when an initial biopsy comes up free of cancer, you are not off the hook.  Naturally doctors are concerned about missing cancer in their patients, so chances are they will recommend a second or even a third biopsy, and one of these follow-up biopsies is likely to show something that was missed in the first go-around.

 

A better approach is to consider an image-guided, targeted biopsy with MRI or Color Doppler Ultrasound. Not only is high grade disease located more frequently, low-grade disease can be overlooked.

 

However, if this should happen, don’t panic. As Mark pointed out in our book, Low-Risk prostate cancer is so common that the likelihood of the average man harboring some degree of microscopic disease can be estimated by putting a percentage sign after his age. Low-grade disease is a normal part of aging, not something to be frightened of.

 

So if your PSA is only slightly elevated, my advice to you—depending on your age, your life expectancy, your overall health and your family history—is to think very carefully about the risks inherent in radical treatment, and don’t allow yourself to be rushed into getting a biopsy before less invasive diagnostic methods have been explored.

 

In the meantime, put that percentage sign after your age, and know you are in good company. Just remember: The odds are on your side. Time is on your side. For my part, I am doing my best to live up to the sub-title of our book: “No more unnecessary biopsies, radical treatmentor loss of sexual potency.”

Too Many Prostate Biopsies

BY MARK SCHOLZ, MD

Every year in the United States one million men undergo a prostate biopsy.  Biopsy has a number of potential complications including serious infections requiring hospitalization and bleeding severe enough to require transfusions. One-percent of urologists have had a patient die from a biopsy-induced infection.

Despite these daunting risks, the real danger men face is the diagnosis of cancer.  In the United States, ninety percent of men who are diagnosed with prostate cancer undergo radical treatment, even when they have the Low-Risk variety of the disease that can be safely watched.  Treatment for prostate cancer is hardly innocuous, commonly causing impotence and urinary incontinence.

Misguided but well-intentioned experts have cogently argued that the rampant overuse of unnecessary biopsies and radical treatment have become so egregious that PSA screening should be discontinued. However, evidence is strong that PSA screening does reduce prostate cancer mortality.

So how can this dilemma be resolved? Is there a way to spare the men with Low-Risk disease while still detecting High-Risk prostate cancer while it is still curable?

Historically, biopsy has been the only accurate method for detecting prostate cancer.  However, for every case of High-Risk cancer detected, four or five men get the unpleasant news that they have Low-Risk disease, a diagnosis that usually leads to unnecessary treatment.

Two reports at this year’s American Urology Associate meeting indicate that modern multi-parametric MRI detects High-Risk prostate cancer very accurately.

In Abstract #2051 Dr. Noboru reported his findings in 320 men with PSA levels less than 10. They compared MRI with a standard 14-core biopsy. Only one man with very low volume disease in the Gleason 8-10 category was missed by MRI.

In Abstract # 1444 Dr. Emberton found that MRI accurately predicted the absence of any High-Grade cancer (Gleason score of 3 + 4 = 7 or above) with 95% accuracy.  Both Dr. Emberton and Dr. Noboru used a standard 1.5 Tesla MRI.  Enhanced, more accurate three Tesla MRI is available select centers.

High-quality prostate imaging is the only potential solution to the PSA screening conundrum.  Imaging detects High-Risk cancer that needs treatment. Men with Low-Risk disease can use the same technology for ongoing monitoring.

PSA screening is not the culprit for overtreatment in the U.S.   The policy of performing an immediate random, multi-core biopsy on every man with a PSA above 4.0 is the real problem. Fortunately, MRI imaging offers a viable alternative.

What is a Mindless Biopsy?

MARK SCHOLZ, MD

The recent recommendations by the U.S Preventative Services Task Force to stop PSA screening are articulated as follows:

1.  The magnitude of harms from screening (e.g., falsely high PSA, psychological effects, unnecessary biopsies, over diagnosis of indolent tumors) is “at least small.”

2.  The magnitude of treatment-associated harms (i.e., adverse effects of surgery, radiation and hormonal therapy) is “at least moderate”—particularly because of over treatment among men with low-grade disease.

3.  The 10-year mortality benefit of PSA-based screening is “small to none.”

4.       The overall balance of benefits and harms results in “moderate certainty that PSA-based screening … has no net benefit.”

In the United States a diagnosis of prostate cancer leads to radical treatment 90% of the time, even when men are diagnosed with the Low-Risk form, the type that experts agree can be safely monitored. In fact, since the definitive consensus conference of 2007 in San Francisco stipulated that active surveillance is a reasonable treatment methodology, the use of surgery has increased.  In 2005 approximately 56,000 men had radical prostate surgery.  This number ballooned to 88,000 in 2008.

Surgery is overused because of ignorance about the innocuous nature of Low-Risk prostate cancer and ignorance about the devastating consequences of surgery, which include impotence, incontinence, Peyronie’s disease (crooked penis disease), climactauria (ejaculating urine), urethral scaring and penile shrinkage.

Superstar surgeons are only successful in making 50% of 58-year-old men and 25% of 65 year old men “happy” when happy is defined as staying cured, not leaking urine and having a modicum of erectile function.

A prostate cancer diagnosis is dangerous, even if the terrible risks of over treatment are ignored.  This year the New England Journal of Medicine reported that in first 3 months after a diagnosis of prostate cancer, the rate of heart attack and suicides both increase by about 200%.

Even though the Task Force is entirely correct about the dangers of over treatment, PSA is an inexpensive test that’s proven to saves lives; it is here to stay. In reality, the essence of the problem is not PSA.  The problem resides in the mindsets of the doctors and patients. The doctors doing the biopsies, the urologists who are surgeons, are intensively trained to be action oriented.

The general populace is just as much to blame because the average person knows next to nothing about prostate cancer. When confronted with the shock of a cancer diagnosis, patients naturally assume prostate cancer just as deadly as other cancers.  Surgical removal seems like the most logical way to proceed.

No one has any idea what they are getting into before they are diagnosed. Yet more than a million men rush into a prostate biopsy every year wondering, “Do I have prostate cancer?”  But what are they wondering about?  It is a medical fact that more than half of elderly men harbor some form of prostate cancer. Even men with normal PSA levels will have a positive prostate biopsy 20% of the time.

If you are going to have a biopsy, prepare yourself to have prostate cancer.

So if PSA is abnormal, say between 2 and 10, what should a man do?  First, an individual’s risk of having cancer can accurately be estimated prior to biopsy using a calculator which is available on the web.  The calculator can be accessed by googling “PCPT Risk Calculator.” The real value in this calculator is its capacity to predict the risk of having high-grade prostate cancer, the type of prostate cancer that does require treatment.

In addition, men should consider measuring the size of their prostate gland with MRI or ultrasound. Men with a prostate gland that is in the 30-60 cc range are only one-fourth as likely to have prostate cancer as a man with a prostate that is less than 30 cc. Men with a prostate volume more than 60 cc are only one-tenth as likely to have prostate cancer as a man with a prostate less than 30 cc. High quality imaging with color Doppler ultrasound or 3T MRI can also “see” cancers, especially the larger more malignant types that need treatment.

It’s understandable that people are uninterested in these mundane issues prior to a diagnosis. They think they don’t have it.  The sad fact is that the majority of elderly men do have it.  All it takes is a biopsy to open Pandora’s Box.

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.

Biopsy, Biopsy Everywhere

BY MARK SCHOLZ

A month ago I promised to expound more concerning our national passion for prostate biopsy. A million men are biopsied every year. Two hundred thousand will be diagnosed, the majority with Low-Risk disease, a condition that can be safely monitored without immediate treatment. Even so, most will undergo prompt radical treatment. Irrational fears drive most men into taking immediate action.

Since diagnosis overwhelmingly portends overtreatment, some experts have suggested that we put a stop to PSA testing. Practically speaking this will never happen. Patients and doctors alike are unwilling to forgo the information that PSA provides, imperfect as it may be.

  

Realistically speaking, PSA testing per se is not the real problem.  The problem is doctors and patients overreacting to the information PSA supplies. The solution is not less frequent PSA testing, but rather convincing physicians to slow down the rush to immediately biopsy men with slight PSA increases. Diagnosing every single case of prostate cancer is of highly questionable value. Many men would rather be spared the unnecessary knowledge that they have a non-threatening Low-Risk prostate cancer.

Rushing into an immediate biopsy only makes sense when aggressive cancer is present and that is much less common.

So where is the middle ground between immediate biopsy of every PSA elevation and forgoing PSA testing and biopsy altogether?

Before deciding to do a biopsy, the prostate gland should be measured with an ultrasound scan to determine whether it is abnormally enlarged.  If the amount of PSA elevation is proportionate to the degree of prostate enlargement, then the PSA elevation is due to benign cause. Rather than proceeding with an immediate biopsy, additional PSA monitoring and a urine test called PCA-3 may be helpful. 

PCA-3 is a relatively new test that measures ribonucleic acid (RNA) secreted by the cancer cells into the urine following manual massage of the prostate. Studies show that the amount of PCA-3 in the urine increases in proportion to both the size and aggressiveness of a man’s prostate cancer. Unlike PSA, PCA-3 is unaffected by the size of the prostate. Low amounts of PCA-3 in the urine, say less than 40, indicate that the presence of an underlying aggressive cancer is less likely.

If the PCA-3 and PSA density are favorable, further monitoring with some form of imaging offers additional insurance against missing the diagnosis of aggressive cancer.  Modern 3-Tesla endorectal MRI and high-resolution color Doppler ultrasound, while not perfect, are reasonably accurate methods for detecting aggressive cancers. 

So in summary, biopsy should be reserved for men with elevated PSA levels that can’t be explained by a prostate infection, laboratory error or recent sexual activity. Here are some signs that a biopsy may be needed:

1.                  A PSA elevation out of proportion to the size of their gland or

2.                  Abnormally elevated PCA-3 levels or

3.                  An abnormality felt on digital rectal examination or

4.                  Imaging studies suggestive of underlying aggressive cancer.

PSA is a remarkable tool that has transformed the management of prostate cancer over the last 20 years. Rather than triggering an immediate biopsy, an elevated PSA should lead to further investigation. Rushing to a biopsy simply because PSA is elevated frequently leads to unnecessary radical treatment with detrimental lifelong consequences.

The More Things Change the More They … Stay the Same

BY MARK SCHOLZ

Everyone knows there is overuse of surgery and radiation in the United States for men with Low-Risk prostate cancer. But do not assume increased awareness means things are getting better.  Actually, they are getting worse. 

A study in the February issue of this year’s Archives of Internal Medicine reports that in 1999, 38% of men with Low-Risk prostate cancer received unnecessary treatment.  By 2007 that percentage was up to 52%.  Another study published in this year’s February issue of the Journal of General Internal Medicine reports that one-third of men queried after radical prostatectomy could not even remember being offered any other option than surgery.

Monitoring rather than treating Low-Risk prostate cancer became a mainstream approach in 2007, when Dr. Peter Carroll at University of California at San Francisco convened a conference of more than 200 experts who unanimously validated active surveillance for men with Low-Risk prostate cancer.

So what was the result?

Over the next year, surgery increased 10% from 80,000 annually in 2007 up to 88,000 in 2008 (New England Journal of Medicine, August 2010).

How can this be? Don’t doctors put their patient’s best interests first? 

The average patient fails to realize that surgeons are a unique sub-classification of doctors.  If an average doctor is likened to army infantry, then surgeons are the Navy Seals. Highly-trained, talented and very mission orientated. (For more insight on Navy Seals, check out Act of Valor which is playing in theatres now.)

Surgeons experience the satisfaction of eradicating disease by cutting it out. However, they don’t come by this privilege without intense training involving great personal sacrifice.  Once they get their wings, they are part of an elite fraternity that rightly or wrongly considers itself the best of the best. Who is to tell them otherwise?

These surgeons, known in the prostate world as urologists, stand at the entry hall welcoming the 200,000 newly-diagnosed men every year who have a positive biopsy. Urologists do all the biopsies. Cutting the disease out is at its core exactly what the whole life of a urologist is about.  As the old saying goes, when you’re a hammer, everything looks like a nail.

If urologists won’t spread the word about active surveillance then who will?

There is no easy answer because men with newly-diagnosed cancer are frightened.  Naturally, they want a quick fix.  The option of surgery, enticingly presented by the urologist, fits that bill.

The best hope for change lies in the more than two million prostate cancer survivors.  Entreaties from close friends or families can slow the charge to surgery.  Most men, if given time to really examine their options, discover that other treatment options including monitoring leads to better results than surgery.

 

My personal frustration regarding this over-treatment motivated me, a journalistic amateur, to sit down and write a book. “Invasion of the Prostate Snatchers” is designed to give prostate cancer survivors a tool they can give their friends and family to explain why active surveillance is safe and to help open the eyes of men who wrongly think that prostate cancer is a death sentence.