I find it very interesting how very, very little time the NYT spends on reporting the very real, very horrible, and very certain effects of prostate cancer treatment on men's sexuality.
As the moderator of the New Prostate Cancer Infolink says so pithily, the only guaranteed outcome of prostate cancer treatment is that sex after prostate cancer treatment will be less than it was before treatment.
One should always bring a healthy level of skepticism - perhaps even cynicism - to a field of medical practice that both sells the damage (as a 'side effect' of course) and then will again sell you the treatment for the damage they caused.
Too many Da Vinci machines to pay off to quit overtreating men with prostate 'cancer'...
As the moderator of the New Prostate Cancer Infolink says so pithily, the only guaranteed outcome of prostate cancer treatment is that sex after prostate cancer treatment will be less than it was before treatment.
One should always bring a healthy level of skepticism - perhaps even cynicism - to a field of medical practice that both sells the damage (as a 'side effect' of course) and then will again sell you the treatment for the damage they caused.
Too many Da Vinci machines to pay off to quit overtreating men with prostate 'cancer'...
9
I find the notion of a biopsy every year to be macabre. Behind the euphemisms, I did some simple calculations: A "biopsy" involves sticking 12 to 16 hollow 18 gauge needles throughout the prostate. These needles are 1.27 mm outside diameter. It's the outside diameter that's relevant to prostate damage, not the inside core. A typical "plug" is 12 mm long. Some go to 17 or 18 mm, but let's stay conservative.
So if you picture each needle as a cylinder 1.27 x 12, you get a volume of prostate tissue destroyed or displaced by each needle to be a touch over 14.1 cu mm. A typical biopsy involves 12 to 16 needles; the tendency is for more needles (another approach uses up to 60 in a template). 16 needles of 14 cu mm each = 224 cu mm or .224 cu cm. Yes?
Now a typical prostate of a middle aged man (40-19 years) is about 28 cu cm, according to the literature. So that means that each and every biopsy is boring out roughly 0.8% of the prostate. If a man with elevated PSA is expected to have a biopsy every year for say 20 years, from 45 to 65, that's nearly 16% of his prostate that's been destroyed, not to mention ancillary damage to nerves and blood vessels, the discomfort after a biopsy including bloody urine and semen, or the accumulating probability of a hospital acquired infection from penetrating the colon each time a biopsy is done.
Put another way, "watchful waiting" is anything but the calm, non-invasive approach it's pictured to be. It's time urologists faced this.
So if you picture each needle as a cylinder 1.27 x 12, you get a volume of prostate tissue destroyed or displaced by each needle to be a touch over 14.1 cu mm. A typical biopsy involves 12 to 16 needles; the tendency is for more needles (another approach uses up to 60 in a template). 16 needles of 14 cu mm each = 224 cu mm or .224 cu cm. Yes?
Now a typical prostate of a middle aged man (40-19 years) is about 28 cu cm, according to the literature. So that means that each and every biopsy is boring out roughly 0.8% of the prostate. If a man with elevated PSA is expected to have a biopsy every year for say 20 years, from 45 to 65, that's nearly 16% of his prostate that's been destroyed, not to mention ancillary damage to nerves and blood vessels, the discomfort after a biopsy including bloody urine and semen, or the accumulating probability of a hospital acquired infection from penetrating the colon each time a biopsy is done.
Put another way, "watchful waiting" is anything but the calm, non-invasive approach it's pictured to be. It's time urologists faced this.
11
Another layer of debate is race--studies conflict on whether African American men with the same grade prostate cancer should be treated more aggressively than Caucasian men. Some institutions will disqualify African-American men from active surveillance, while others such as UC San Francisco are more inclusive based on our own data.
It's important to note, that choosing active surveillance means choosing to comply with PSA labs, Digital Rectal Exams, office visits every 3-6 months, and a biopsy every 1-2 years. Patients (or as many like here have adopted, customers) often do not come back for checkups! The compliance rate after 1 year falls to 80%, and then 60% at 4 years. Therefore, it's imperative to convey the entire package.
-UCSF medical student doing research in prostate cancer active surveillance and biopsy techniques!
It's important to note, that choosing active surveillance means choosing to comply with PSA labs, Digital Rectal Exams, office visits every 3-6 months, and a biopsy every 1-2 years. Patients (or as many like here have adopted, customers) often do not come back for checkups! The compliance rate after 1 year falls to 80%, and then 60% at 4 years. Therefore, it's imperative to convey the entire package.
-UCSF medical student doing research in prostate cancer active surveillance and biopsy techniques!
8
It is already established that doing routine PSA tests is malpractice, for a number of reasons. I have been recommended and even directed without telling me via a paper form with a number of routine tests to have a PSA test by two general practitioners, and I told them, NO, it is not recommended. I do not wish to fall into "waiting and see" anything, that is the trap for the urologists to get more business. I can urinate and that's good enough. I do not wish to die of depression. If you know what I am talking about give this post a "like". We do have numbers about the carnage caused by PSA testings, it is not recommended.. Do not try...
10
Dr. Catalona is right. Active Surveillance can be a tragic mistake. It was for me. I had Gleason 6 at age 51 and elected surveillance. All calm for 3.5 years with PSA tests and MRI or repeat biopsy every 6 months. Still low-grade, low-volume, low-risk in mid-2015. Then, stage IV metastatic disease in Jan 2016 - just 6 months later. Active Surveillance failed to give me the opportunity for a surgical cure. Now I'm looking at a mean life expectancy of 5 more years, instead of 30+ had Active Surveillance given me a heads-up that things had changed. In my personal experience, Active Surveillance is being over-sold, without adequate disclosure that your cancer may change suddenly and aggressively between monitoring intervals. I would have gladly selected a low percentage risk of incontinence over a low percentage risk of dying so young from prostate cancer if I had known.
13
My father died of metastatic prostate cancer. Diagnosed in his early seventies, his doc said you'll die of something else before this gets you. He was not queried on family longevity. No surgery. The cancer became more aggressive and was treated with chemo. Remission lasted a few years, but the recurrence was chemo resistant and metastasis ensued and he died very uncomfortably at 90. Think carefully before selecting your options.
2
PSA levels started to go up after watching and waiting for 3 years then had a biopsy which determined that I had Gleason 6 cancer. It was caught early enough that I was eligible for brachytherapy which is probably the least invasive treatment and now it's back to watching and waiting. Que sera, sera.
1
"Choose"?
Nobody is choosing anything. Medicare and the Obamacare plans are restricting access to proper prostate cancer therapy. Trust me, no one in the corrupt political and ruling class is going to do any "active surveillance" for Gleason 6 prostate cancer.
Nobody is choosing anything. Medicare and the Obamacare plans are restricting access to proper prostate cancer therapy. Trust me, no one in the corrupt political and ruling class is going to do any "active surveillance" for Gleason 6 prostate cancer.
3
More men who can do this with respect to prostate cancer does not include black men. Black doctors like Arthur Burnett II at Johns Hopkins and Isaac Powell at Wayne State have done work showing that black men have more dire outcomes for all forms of prostrate cancer treatment including watchful waiting. See "The Meaning of Race in Prostrate Cancer Treatment" Otis Brawley JAMA Oncology January, 2016 Vol. 2 No.1 and JAMA Oncology October 22, 2015.
3
The elephant in the room, not mentioned, is whether the cancer has metastasized. If it hasn't, localized treatment (surgery, radiation) is likely to be successful. If I has metastasized, localized treatment will not be useful because the cancer is still present elsewhere. The problem is that, unless there are clinical symptoms, there is no sure way to know whether or not it has metastasized. The PSA score is an estimate not only of the aggressiveness of the cancer but also whether or not it has spread outside the prostate. I was diagnosed with PCa in 1998, PSA 7. Had brachytherapy (radioactive seeds) and external beam radiation. A year later, recurrence (rising PSA) said metastatic PCa was still present. A urologist recommended salvage prostatectomy, with a 50% chance of colon damage that would require a colostomy bag. With metastatic disease, that would have been futile. Fortunately, I found an oncologist who knew more than most, began treating me with anti-androgen meds and also meds to control osteoporosis (PCa usually metastasizes to bone). My PSA is less than one, no clinical symptoms so far. I also attended several prostate cancer medical conferences and learned much that has been helpful, and I have been able to give helpful advice to other men with PCa. I recommend Prostate Cancer Research Institute (PCRI.org) for useful information about Prostate Cancer.
1
Prostate Cancer: When will Black Men's Lives Start to Matter?
The New York Times is appropriately devoting extensive coverage to this very common cancer but missing a critical point: Black men die from prostate cancer at twice the rate of any other group.
Their problems in fact are under-testing and under-treatment when diagnosed, as often is the case with high-risk, aggressive prostate cancer. These facts are always lost in the controversy surrounding the PSA test, which is first and foremost about the over-treatment of low-risk, indolent disease.
The advent and increasing use of active surveillance avoids over-treatment, thus enabling targeted testing of this high-risk group. Patients, doctors and policy-makers all need to understand that those at highest risk should indeed be tested. If diagnosed, those at lowest risk need systematic monitoring, not surgery or radiation.
The New York Times is appropriately devoting extensive coverage to this very common cancer but missing a critical point: Black men die from prostate cancer at twice the rate of any other group.
Their problems in fact are under-testing and under-treatment when diagnosed, as often is the case with high-risk, aggressive prostate cancer. These facts are always lost in the controversy surrounding the PSA test, which is first and foremost about the over-treatment of low-risk, indolent disease.
The advent and increasing use of active surveillance avoids over-treatment, thus enabling targeted testing of this high-risk group. Patients, doctors and policy-makers all need to understand that those at highest risk should indeed be tested. If diagnosed, those at lowest risk need systematic monitoring, not surgery or radiation.
The article did not mention a formal earlier study which showed that men treated for prostate cancer in the USA actually did marginally worse than expected in terms of mortality at every interval following treatment up to about 10 years out. Apologists said, "Well wait for year 15." That year is approaching with no further word. Only in Europe was there a 1 in 50 chance of some benefit. Informal study groups set up by parties with a financial interest in the outcomes (such as urologists) are not to be trusted.
Not really new. My Dad was in surveillance for 30 years. Always said something else would get him first. He survived a lot along the way. Three different cancers unrelated. He lived to be 88. It got him after all.
3
I wish to clarify that this article relates to men diagnosed with early stage prostate cancer ie:Gleason score 6. Anyone with Gleason 7 and up is considered intermediate risk and almost everyone in the urology and oncology world would recommend intervention. I wonder how many men with a Gleason score of 7 or more would opt for active surveillance which would mean serial prostate biopsies (which can be far from innocuous). A patient of mine had a Gleason 6 and decided to operate and the pathology of the entire prostate showed Gleason 7 which had not been detected with a series of biopsies. The key is to individualize each patient.
27
There needs to be more examples like this one by Dr. Levy. It is easy for men in their 50s and 60s to skip PSA blood testing for fear of the results, thinking that they can only be led down a path to surgery or radiotherapy when it is not needed. If they are seeing competent doctors, unnecessary biopsies or treatments will not occur.
Well, my initial biopsy showed a Gleason 4+3=7; intermediate risk. Based on that score, on the recommendation of my urologist, and after a fair bit of research on my own, I chose to have a robotic assisted prostatectomy (while the original urologist who recommended treatment was gently goading me to have a regular prostatectomy, since he didn't do robotic surgery and thus would be aced out of the surgery income). Post surgery, a more thorough pathological examination of my prostate tissue yielded a Gleason 3+3=6; low risk. Not 3+4=7, 3+3=6. Where did the Grade 4 cancer cells which predominated in the pre-surgery biopsy go?! I'm now impotent and incontinent; two concurrent life sentences. I profoundly regret ever listening to my doctors. At the very most I should have chosen active surveillance.
4
Mephitis -
I am very sorry about the outcome of your journey with prostate cancer. I believe the answer to your question about where the clinically aggressive cancer cells went is that you may never have had them and that the finding was determined by a pathologist with substandard skills. The level of skill and experience required in diagnosing and treating prostate cancer is THE critical factor in avoiding your very unfortunate outcome. I wish you all the best.
I am very sorry about the outcome of your journey with prostate cancer. I believe the answer to your question about where the clinically aggressive cancer cells went is that you may never have had them and that the finding was determined by a pathologist with substandard skills. The level of skill and experience required in diagnosing and treating prostate cancer is THE critical factor in avoiding your very unfortunate outcome. I wish you all the best.
In a system that compels almost all medical (and dental) practitioners to be primarily business persons, patient often face the dilemma: "will the treatment benefit me or the revenue stream of the medical practice?". It’s not surprising that “research organizations have begun to recommend active surveillance … but not the urologists in private practice, who treat most men”. Medicine is a practice, not a science. When the doctor has to guess – and this happens much more frequently than we think – the rational decision is to treat and bill for the treatment. If you need a second opinion hop on a plane to France, Iceland, Ireland, Austria, Germany, Spain, Chile or Uruguay. Australia / NZ is also ok if you can put up with 15 hrs in the air. Avoid UK, Switzerland.
9
I'm surprised nobody mentioned androgen deprivation therapy (ADT). I had a Gleason 8 and an oligometastasis in one rib, the result of watchful waiting. I was not considered a candidate for surgery or radiation. I get a shot of Lupron every 3 months and take a bicalutamide pill every day. The former tells the brain to stop asking for testosterone, and the latter plugs up the testosterone receptors, with the result that the growth of the cancer stops abruptly. Supposedly it will remain effective for "two to twenty years," after which they have other tricks up their sleeves, and will have even more. The much-feared downside is the disappearance of sexual ability, but the desire also vanishes, so it's not the disaster it might sound like.
6
That is unless you're young, married, otherwise healthy and want to have a physical relationship with your woman!
4
A doctor's failure to thoroughly discuss active surveillance with a patient is nothing less than gross criminal medical malpractice.
7
Both my father and father-in-law have had prostate cancer diagnosis when in their 60's. My father chose traditional radiation treatment, my father-in-law chose brachytherapy for his.
Neither of the guys has had the best of results with their choices. My dad had considerable bleeding after treatment and my father-in-law has since had his prostate removed and an artificial sphincter installed. Both received treatment from some of the best hospitals in Southern California, Hogue Medical Center and City of Hope.
My dad is okay for the most part but there is considerable scaring in his bladder where my father-in-law has had multiple and severe infections due to the sphincter installation, prostate surgery and bladder scaring from the brachytherapy.
If there is an alternative to the treatment the guys received, I am in when it's my turn. And, prostate cancer eventually gets us all guys.
Neither of the guys has had the best of results with their choices. My dad had considerable bleeding after treatment and my father-in-law has since had his prostate removed and an artificial sphincter installed. Both received treatment from some of the best hospitals in Southern California, Hogue Medical Center and City of Hope.
My dad is okay for the most part but there is considerable scaring in his bladder where my father-in-law has had multiple and severe infections due to the sphincter installation, prostate surgery and bladder scaring from the brachytherapy.
If there is an alternative to the treatment the guys received, I am in when it's my turn. And, prostate cancer eventually gets us all guys.
6
After reading the article, I made a prediction about the type of comments I could expect to see submitted by readers. I was right: dozens (hundreds by now) of stories recounting each individual's personal experience, with no unifying trends or information that might lead to one course of action over another. It's all up to the individual to do his best toward becoming informed and then making a guess, which might or might not turn out to be right. We didn't hear from those who died after making the wrong choice, but we did hear from their loved ones. It's still an awful situation, but we can hope that someday we'll be able to know which cells will have a high likelihood of becoming aggressive and metastatic.
6
The article does not mention that biopsies result in about one third of men having problems such as incontinence, impotent after the biopsies according to the study of the US Preventive Services Task Force. Middle age and older men should read the USPSTF report and draw their own conclusion (do not depend on their urologist's recommendation) about PSA and prostate biopsies and treatment.
3
That seems to be similar or even a higher rate than the incidence of problems that arise from prostate surgery. I could not find anything that backed up your numbers, although I didn't do an in depth search. The primary risk of biopsy, as I understand it, is infection.
1
When will they do the same with DCIS for women?
10
PSA was .7 for years, escalated to a 3 over 18 months. Not particularly high, but something was clearly changing. Urologist did the biopsy, came back with a Gleason score of 8. Caught it early. I had surgery 4 years ago and I'm a poster boy for good outcomes. Thank goodness I had a 7 year history of PSA results and didn't change doctors on that last physical that came back with a 3. If I would have gone to another doctor for my physical, chances are a 3 would not have raised any flags. By the next year, I would have had big trouble.
In my opinion PSA tests should be required. But, I do understand that with Gleason's of 6 or so, a good plan is to watch and see. I have had a few conversations with guys in a panic over Gleason scores of 6. Relax, talk to your doctor and monitor. I can see how the PSA test results can lead to biopsies and unnecessary surgery. When you get the news you have cancer, its hard not to want to "fix it!"
I have a buddy with a PSA of 10, been thru the biopsy twice now, no cancer, he just has a high PSA.
In my opinion PSA tests should be required. But, I do understand that with Gleason's of 6 or so, a good plan is to watch and see. I have had a few conversations with guys in a panic over Gleason scores of 6. Relax, talk to your doctor and monitor. I can see how the PSA test results can lead to biopsies and unnecessary surgery. When you get the news you have cancer, its hard not to want to "fix it!"
I have a buddy with a PSA of 10, been thru the biopsy twice now, no cancer, he just has a high PSA.
8
I'm 70, and now my doctor does not want me to get PSA blood tests any longer. The last test, which I insisted upon, was 4.2, after years of an average of 2. I asked for the PCA3 test which is considered a good predictor of the necessity of biopsy, but I cannot find a doctor who will do that. It seems that they all want to do a biopsy right off. I plan to live to a ripe old age, not the 10 to 15 year survival that they talk about. What is a man to do?
9
bern- just for your information. I had 2 separate PCA3 tests performed that both came back negative even though my PSA was 23.4 I ran the 4K score and it came back at 75% so I figured a biopsy was in order. My Gleason came in at 4+4 with 9 of 12 cores positive. I emailed the company that developed the PCA3 test to see if they would like more information on my circumstances so they could possibly improve their testing. They were not interested though???
Do what I did in 2013. Contact the makers of the Liquid Biopsy test of your choice and ask them who is working with the test in or around your city. Most likely a large (university) hospital.
To start off, check the websites of these manufacturers or their support groups like pca3.org, that has dual separate information pages for Medical Professionals and Patients.
(I am in NO way connected with any manufacturer or what soever. I am just immensely happy that I was so stubborn, have an physician who supports me and that I was lucky to defy the urologist by going to the Internet for my information, while backing up whatever I found with discussions with my MD and friends in the medical field.)
To start off, check the websites of these manufacturers or their support groups like pca3.org, that has dual separate information pages for Medical Professionals and Patients.
(I am in NO way connected with any manufacturer or what soever. I am just immensely happy that I was so stubborn, have an physician who supports me and that I was lucky to defy the urologist by going to the Internet for my information, while backing up whatever I found with discussions with my MD and friends in the medical field.)
Have the biopsy.
I was diagnosed with PC in August 2009: Gleason 6. The following year I had a confirmatory biopsy and went into acute renal failure( from infection). I have continued Active Surveillance relying on annual MRI's, semi annual PSA blood tests, Digital Rectal Exams, and genetic testing. Though not perfect these methods give me enough evidence to make a reasonable decision on going forward. The Gene tests (Oncogene and Prolaris) give a sense of aggressivity of the tumor. Last month, had my first biopsy in 6 years and my cancer is still a Gleason 6. I feel lucky to live in New York with very good academic centers and very good Doctors. It's so important to have urologists and oncologists that keep up with the latest research and developments. Finally, I belong to an international support group ,Us Too, which meets monthly at Weill Cornell and offers excellent speakers and group support.
5
A few years ago, my PSA was found to be 8-10 times the normal. Understandably, my doctor recommended a biopsie. I did not do it because before taking the test which can have complications, I came to this excellent book by Dr. Richard Ablin, who DISCOVERED PSA about two decades ago, THE GREAT PSA HOAX. In the book he described how the urologists and their industry have hijacked the concept of PSA and encouraged many needless operations, thereby doubling their income in a few short years. But the worst part is that the men who underwent such needless surgery, now suffer from impotence and incontinence.
According to Dr. Ablin, the inventor of PSA, high levels of PSA can have a number of causes, and cancer is only one such cause. Those who just discovered high PSA, PLEASE get hold a copy of Dr. Ablin book!
PS. I am grateful for his book, but I have never met him, nor have any
commercial interest in his book.
According to Dr. Ablin, the inventor of PSA, high levels of PSA can have a number of causes, and cancer is only one such cause. Those who just discovered high PSA, PLEASE get hold a copy of Dr. Ablin book!
PS. I am grateful for his book, but I have never met him, nor have any
commercial interest in his book.
12
Gee, I wish I'd known that before I had a biopsy and they found cancer. i could have saved myself a whole bunch of grief....for a while.
You have an unprofessional opinion that Ablin's book is "excellent." My unprofessional opinion is that it is complete rubbish. One of us is right!
I highly suggest that everyone undertake due diligence when sourcing information from books, online forums, comment threads, etc.
PSA tests are a proven way to discover the possibility of prostate cancer. The test pose no danger, is not invasive and is not expensive. PSA tests gain value over time as a trend line develops.
When warranted, there are options for further investigation, including a needle biopsy. No invasive procedure is 100% guaranteed not to have complications. Everyone who has a biopsy will be informed of that fact. Decisions can be made accordingly. Further, there are other tests such as imaging that can be conducted prior to or in conjunction with a biopsy. My understanding is that a biopsy is the only test that can analyse types of cancer cells. Some cancer cells are far more aggressive and pose a far greater risk. You should verify this statement and any other statement I or anyone posits.
A cursory search will reveal that most professionals do not ascribe to Dr. Ablin's claims about PSA testing and that is views are unfounded. Do your own due diligence before reading this book!
I highly suggest that everyone undertake due diligence when sourcing information from books, online forums, comment threads, etc.
PSA tests are a proven way to discover the possibility of prostate cancer. The test pose no danger, is not invasive and is not expensive. PSA tests gain value over time as a trend line develops.
When warranted, there are options for further investigation, including a needle biopsy. No invasive procedure is 100% guaranteed not to have complications. Everyone who has a biopsy will be informed of that fact. Decisions can be made accordingly. Further, there are other tests such as imaging that can be conducted prior to or in conjunction with a biopsy. My understanding is that a biopsy is the only test that can analyse types of cancer cells. Some cancer cells are far more aggressive and pose a far greater risk. You should verify this statement and any other statement I or anyone posits.
A cursory search will reveal that most professionals do not ascribe to Dr. Ablin's claims about PSA testing and that is views are unfounded. Do your own due diligence before reading this book!
2
Six years ago I was biopsied and found to have a Gleason 6. Surgery or radiation was recommended. This prompted an online inquiry of national and international studies including my own 70 year age group which prompted me to get a second opinion. I've been on active surveillance ever since with quarterly and now semi annual PSA's. After multiple biopsies and the discomfort they produced, I felt that there had to be a better monitoring system. This is so because biopsies are essentially an imperfect guessing game that cannot possibly provide more than a snapshot of possibilities, while repeatedly perforating the prostate with risk of infection or other complications.
Rather than biopsies, I insisted on MRI monitoring once a year, since the new, Tesla 3 magnets combined with dynamic contrast can actually pinpoint the cancer and provide a chronology of data points to determine tumor growth. Five MRI's have shown no growth, with the last two showing improvement. I have no delusions or unreasonable expectations that I will never require aggressive treatment in the future. But active surveillance should be the go to course for my age cohort with Gleason 6 findings. I also believe that PSA readings are not at all conclusive and high readings, such as mine in the 20's, are not reliable given my diagnostics. I would hope that medicine finds a way out of the medieval, hit and miss biopsy practice through MRI guided biopsies.
Rather than biopsies, I insisted on MRI monitoring once a year, since the new, Tesla 3 magnets combined with dynamic contrast can actually pinpoint the cancer and provide a chronology of data points to determine tumor growth. Five MRI's have shown no growth, with the last two showing improvement. I have no delusions or unreasonable expectations that I will never require aggressive treatment in the future. But active surveillance should be the go to course for my age cohort with Gleason 6 findings. I also believe that PSA readings are not at all conclusive and high readings, such as mine in the 20's, are not reliable given my diagnostics. I would hope that medicine finds a way out of the medieval, hit and miss biopsy practice through MRI guided biopsies.
24
I could not agree more with this statement "I would hope that medicine finds a way out of the medieval, hit and miss biopsy practice through MRI guided biopsies." Traditional biopsies are random sampling and very hit and miss. My first one said I had "a typical cells" ??? When I had the MRI performed and subsequent MRI guided biopsy they found the Gleason 6 tumor.
Also why does this article not discuss PROTON treatment? This is a very effective and non invasive treatment.
Also why does this article not discuss PROTON treatment? This is a very effective and non invasive treatment.
8
Of course you should have MRI guided biopsies - you mean you did not have those? Just stabs in the dark?
2
Tongue in cheek? Why be definitive when you can repeat the billing process in an endless search for truth with hit or miss puncturing? Urologists have much to be modest about by persisting in outdated and discredited standards, such as PSA readings and biopsies without further substantiation before removal or radiation. Litigation avoidance and trading in cancer phobia cannot be ruled out as motives behind the facile practice of removal when the ethics of medicine demand "do no harm."
1
It is really important to get more than one PSA test before making a decision. A typical prostate exam puts finger pressure on the prostate and this causes the PSA to go up. I always wait a day or two after the exam before getting the PSA test. On one occasion where I didn't, the PSA was 6 but a retest a week later showed only 4.5. In this business that is a big change.
2
"A typical prostate exam puts finger pressure on the prostate and this causes the PSA to go up"
NO!
NO!
I had a slightly elevated PSA, had MRI done, found a few nodes. Upon biopsy one turned out to have a fragment with a borderline Gleason score. Upon consultation with the head oncologist underwent what is apparently the latest in radiation therapy, image guided radiation therapy, where you lie on a bed, get a low dosage CT scan, and the radiation source then turns around the high-risk area. Eight weeks, 15 minutes a day, no collateral damage to surrounding tissue, absolutely no side effects. PSA is down to 0.5, testosterone normal. Had it done in Toronto, covered by Ontario Health insurance. Happy as a clam.
8
I just want to thank everyone who has contributed to this comment section. As a 61 year old cancer free (so far) male, I read through every comment with acute interest.
10
DITTO My Friend ~ Thanks Again to the thoughtful - Insightful commentary !
4
The decision on whether to have a prostate cancer treated is a deeply personal one, with your age being the most important parameter.
I was diagnosed in my early fifties and I could not wait to have the whole thing extirpated.
This was fifteen years ago. I know that I made the right decision, although other people might differ.
It all boils down as to whether you want to spend the rest of your life wondering whether the cancer will catch up to you or not.
There is no right answer, you might have the operation and have no side effects, or have some serious incontinence problems.
On the other hand, you might decide to watch it, ponder whether things are going to be okay, which they might be or not.
I would not want to stand up here and tell other people what is best for them.
I was diagnosed in my early fifties and I could not wait to have the whole thing extirpated.
This was fifteen years ago. I know that I made the right decision, although other people might differ.
It all boils down as to whether you want to spend the rest of your life wondering whether the cancer will catch up to you or not.
There is no right answer, you might have the operation and have no side effects, or have some serious incontinence problems.
On the other hand, you might decide to watch it, ponder whether things are going to be okay, which they might be or not.
I would not want to stand up here and tell other people what is best for them.
10
NOW you tell me?!?!????
5
Risk of tumor cell seeding through biopsy and aspiration cytology
K. Shyamala, H. C. Girish, and Sanjay Murgod
Abstract
Cancer cells, besides reproducing uncontrollably, lose cohesiveness and orderliness of normal tissue, invade and get detached from the primary tumor to travel and set up colonies elsewhere. Dislodging neoplastically altered cells from a tumor during biopsy or surgical intervention or during simple procedure like needle aspiration is a possibility because they lack cohesiveness, and they attain the capacity to migrate and colonize. Considering the fact that, every tumor cell, is bathed in interstitial fluid, which drains into the lymphatic system and has an individualized arterial blood supply and venous drainage like any other normal cell in our body, inserting a needle or a knife into a tumor, there is a jeopardy of dislodging a loose tumor cell into either the circulation or into the tissue fluid. Tumor cells are easier to dislodge due to lower cell-to-cell adhesion. This theory with the possibility of seeding of tumor cells is supported by several case studies that have shown that after diagnostic biopsy of a tumor, many patients developed cancer at multiple sites and showed the presence of circulating cancer cells in the blood stream on examination. In this review, we evaluate the risk of exposure to seeding of tumor cells by biopsy and aspiration cytology and provide some suggested practices to prevent tumor cell seeding.
K. Shyamala, H. C. Girish, and Sanjay Murgod
Abstract
Cancer cells, besides reproducing uncontrollably, lose cohesiveness and orderliness of normal tissue, invade and get detached from the primary tumor to travel and set up colonies elsewhere. Dislodging neoplastically altered cells from a tumor during biopsy or surgical intervention or during simple procedure like needle aspiration is a possibility because they lack cohesiveness, and they attain the capacity to migrate and colonize. Considering the fact that, every tumor cell, is bathed in interstitial fluid, which drains into the lymphatic system and has an individualized arterial blood supply and venous drainage like any other normal cell in our body, inserting a needle or a knife into a tumor, there is a jeopardy of dislodging a loose tumor cell into either the circulation or into the tissue fluid. Tumor cells are easier to dislodge due to lower cell-to-cell adhesion. This theory with the possibility of seeding of tumor cells is supported by several case studies that have shown that after diagnostic biopsy of a tumor, many patients developed cancer at multiple sites and showed the presence of circulating cancer cells in the blood stream on examination. In this review, we evaluate the risk of exposure to seeding of tumor cells by biopsy and aspiration cytology and provide some suggested practices to prevent tumor cell seeding.
1
Article covering facts when it is too late.
The actual procedure ought to be: invite every man over 45 to visit his physician (with option to renegue) and every year after for a PSA test.
2005 to 2013 my PSA level went from 0.8 to 2.6. Doubling had occurred within last 2 years, went to urologist, he laughed in my face as age 67 his records showed PSA needed to be >4.
Insisted as PSA had doubled fast. He conceded but wanted a biopsy. Read up on biopsy and found >37% of unguided biopsies fail and have added risk of cancer cells escape through blood vessels or Lymph system, allowing metastases elsewhere like thyroid, lower back, bones, pelvis.
Then found: PROGENSA PCA3 ASSAY a prostate cancer genes nucleic acid amplification test system.
Prof. v. d. Poel of AvL Cancer Inst. Amsterdam tested and approved application for test on 11May13. The test needed a DRE, which was used to massage the prostate. Outcome was 111/125th on scale and definitely Prostate Cancer. 17th July MRI scan taken: cancer at 4 spots. Tough decision. Had to concede: 12 biopsies taken, guided by MRI results. PSA value 2.96.
Da Vinci Method extraction, as HOW SOON the Cancer is discovered AND eliminated counts!
Contacted Prof Dr. Stefan Siemer of UCS - Homburg/Saar - Germany, operation Aug23rd 2013, they keep patients in Hospital for a week - train them for continence and only send them home without catheter. Friday the 30th August I travelled back home by train - an 11 hour trip! No problem!
The actual procedure ought to be: invite every man over 45 to visit his physician (with option to renegue) and every year after for a PSA test.
2005 to 2013 my PSA level went from 0.8 to 2.6. Doubling had occurred within last 2 years, went to urologist, he laughed in my face as age 67 his records showed PSA needed to be >4.
Insisted as PSA had doubled fast. He conceded but wanted a biopsy. Read up on biopsy and found >37% of unguided biopsies fail and have added risk of cancer cells escape through blood vessels or Lymph system, allowing metastases elsewhere like thyroid, lower back, bones, pelvis.
Then found: PROGENSA PCA3 ASSAY a prostate cancer genes nucleic acid amplification test system.
Prof. v. d. Poel of AvL Cancer Inst. Amsterdam tested and approved application for test on 11May13. The test needed a DRE, which was used to massage the prostate. Outcome was 111/125th on scale and definitely Prostate Cancer. 17th July MRI scan taken: cancer at 4 spots. Tough decision. Had to concede: 12 biopsies taken, guided by MRI results. PSA value 2.96.
Da Vinci Method extraction, as HOW SOON the Cancer is discovered AND eliminated counts!
Contacted Prof Dr. Stefan Siemer of UCS - Homburg/Saar - Germany, operation Aug23rd 2013, they keep patients in Hospital for a week - train them for continence and only send them home without catheter. Friday the 30th August I travelled back home by train - an 11 hour trip! No problem!
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"have added risk of cancer cells escape through blood vessels or Lymph system, allowing metastases elsewhere like thyroid, lower back, bones, pelvis."
You are spreading misinformation.
You are spreading misinformation.
2
This is a short-list of the Mayo Clinic:
Risks associated with a prostate biopsy include:
- Bleeding at the biopsy site. Rectal bleeding is common after a prostate biopsy.
- Blood in your semen. It's common to notice red or rust coloring in your semen after a prostate biopsy. This indicates blood, and it's not a cause for concern. Blood in your semen may persist for a few weeks after the biopsy.
- Blood in your urine. This bleeding is usually minor.
- Difficulty urinating. In some men, prostate biopsy can cause difficulty urinating after the procedure. Rarely, a temporary urinary catheter must be inserted.
- Infection. Rarely, men who have a prostate biopsy develop an infection of the urinary tract or prostate that requires treatment with antibiotics.
+++
And this is just the information for the patients in their "procedure details"!
And you can assure me that with all that blood PC cells that have just been circumcised from the prostate will dutifully stay in that very same prostate?
Besides scientific studies have shown Biopsies do cause prostatitis in most cases.... (the percentage is very high - unfortunately I do not have the study results here right now as it sits on an older Laptop.
Risks associated with a prostate biopsy include:
- Bleeding at the biopsy site. Rectal bleeding is common after a prostate biopsy.
- Blood in your semen. It's common to notice red or rust coloring in your semen after a prostate biopsy. This indicates blood, and it's not a cause for concern. Blood in your semen may persist for a few weeks after the biopsy.
- Blood in your urine. This bleeding is usually minor.
- Difficulty urinating. In some men, prostate biopsy can cause difficulty urinating after the procedure. Rarely, a temporary urinary catheter must be inserted.
- Infection. Rarely, men who have a prostate biopsy develop an infection of the urinary tract or prostate that requires treatment with antibiotics.
+++
And this is just the information for the patients in their "procedure details"!
And you can assure me that with all that blood PC cells that have just been circumcised from the prostate will dutifully stay in that very same prostate?
Besides scientific studies have shown Biopsies do cause prostatitis in most cases.... (the percentage is very high - unfortunately I do not have the study results here right now as it sits on an older Laptop.
1
This part was not published below my 25thMay comment so here anew:
On 17thJul13 date of the biopsies - Gleason Score was 3+3=6 and the PSA value:2.96
On 23rdAug13 date of operation -malign tumors: 7 - the Gleason Score was 3+4=7a Grading GIIa with Extra Capsular Extensions and PSA value 2.44!. The pathology showed that cancer was eradicated, the ultimate distance between the cancer cells and the cut was LESS than 1millimeter (.03937 Inch)!
My only concern right now is what damage have the 12 biopsies caused elsewhere in my body. So far after nearly 4 years my PSA value has been less than 0.001 or < 1 promille.
THE ARGUMENT:
The lesson should however be:
1) Early PSA blood testing (+DRE) are a must!
2) Records to be kept and diligently maintained, there are some 22 different Prostate Cancers, 4 only are aggressive.
3) Ban unnecessary Biopsy taking (it's dangerous and 37% futile), go Liquid Biopsy tests,( like PCA3 test) and MRI scanning. After that and only then biopsies should be necessary because of (stupid?) laws. These Laws to be scrutinized.
4) Life for ALL men would be so much more pleasant, knowing that IF you will get Prostate Cancer, the irons are in the fire for a rapid early treatment (whichever one you decide upon, but SEARCH for answers first).
5) Remember if the PSA value doubles within 1 or 2 years there is a problem! Then immediately go for Liquid Biopsy
On 17thJul13 date of the biopsies - Gleason Score was 3+3=6 and the PSA value:2.96
On 23rdAug13 date of operation -malign tumors: 7 - the Gleason Score was 3+4=7a Grading GIIa with Extra Capsular Extensions and PSA value 2.44!. The pathology showed that cancer was eradicated, the ultimate distance between the cancer cells and the cut was LESS than 1millimeter (.03937 Inch)!
My only concern right now is what damage have the 12 biopsies caused elsewhere in my body. So far after nearly 4 years my PSA value has been less than 0.001 or < 1 promille.
THE ARGUMENT:
The lesson should however be:
1) Early PSA blood testing (+DRE) are a must!
2) Records to be kept and diligently maintained, there are some 22 different Prostate Cancers, 4 only are aggressive.
3) Ban unnecessary Biopsy taking (it's dangerous and 37% futile), go Liquid Biopsy tests,( like PCA3 test) and MRI scanning. After that and only then biopsies should be necessary because of (stupid?) laws. These Laws to be scrutinized.
4) Life for ALL men would be so much more pleasant, knowing that IF you will get Prostate Cancer, the irons are in the fire for a rapid early treatment (whichever one you decide upon, but SEARCH for answers first).
5) Remember if the PSA value doubles within 1 or 2 years there is a problem! Then immediately go for Liquid Biopsy
My cancerous prostate was removed in 1998 at age 54 by Dr. William Catalona. (Disclosure: I served as a national trustee on the Urological Research Foundation where Dr. Catalona is medical director.) The good news: I’ve survived 17 years. The bad news: last month, my younger brother died from metastasized prostate cancer that once discovered, was initially treated with four years of active monitoring. Perhaps sharing my experience can help others with this critical health decision. Regular DREs (Digital Rectal Exams) were negative. At 50, my first PSA was 4.0 and advanced for four years, reaching 12, which suggested a biopsy. No cancer was detected in biopsy samples. My local doc suggested the PSA uptick was likely from infection and recommended antibiotics, which failed to lower the PSA. The next action was a TURP, commonly known as a rotor-rooter job. The TURP provided many tissue samples. Result: half were cancerous with a Gleason 7. My cancer cells were sprinkled throughout the prostate and not lumped together. The biopsy missed them. They were not easily felt in DREs. The lesson learned is to encourage men to get tested! Unfortunately, this task often falls to the women who care about the men in their lives. Treatment options exist with varied degrees of success, but none are effective unless there is an opportunity for diagnosis. I am fortunate to have survived to take this message forward. My younger brother was not so fortunate. RIP Steve.
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The comment supports the view that Pca diagnosed at early age tend to be aggressive and, perhaps life threatening. However, pure reliance on PSA's without further confirmation is inadvisable. A high PSA reading can frequently be attributable to infection and inflammation, to BPH or even to having sex before the test. I have readings in the 20's for two years, with MRI's showing no growth or even a lessening of inflammation. Avoiding cancer phobia by study and comprehensive questioning of the alternatives given by the urologist is mandatory in providing peace of mind going forward.
1
Family history is an important consideration when evaluating treatment options. Having a father with prostate cancer, or other relatives with BRCA 2 cancers may suggest a more aggressive, genetic cancer that would make surgery more prudent, and then continue active surveillance for the other BRCA cancers if a genetic mutation is found. Most insurance will now cover genetic screening if at least 2 first degree relatives have had a BRCA cancer.
2
If you have been newly diagnosed with a Gleason 6 lesion (as I was 5 years ago) and are being rushed into surgery or radiation, GET A SECOND OPINION. Many now believe that Gleason 6 diagnoses constitute a separate, non-life-threatening disease (as the article implies), and a large European study indicates that it does not progress into more aggressive forms (although more serious disease may appear spontaneously later as an unrelated matter).
I am now on Active Surveillance, not with biopsies (I've only had one to classify the disease, and had an infection from that), but with quarterly PSA testing and annual MRIs to monitor the disease for progression, which has not happened.
Many prostates have been unnecessarily removed or irradiated with sometimes horrendous side effects, all based on an imperfect understanding of the disease(s). Fortunately, we're learning more now -- do your homework, and make sure your doctors do theirs.
I am now on Active Surveillance, not with biopsies (I've only had one to classify the disease, and had an infection from that), but with quarterly PSA testing and annual MRIs to monitor the disease for progression, which has not happened.
Many prostates have been unnecessarily removed or irradiated with sometimes horrendous side effects, all based on an imperfect understanding of the disease(s). Fortunately, we're learning more now -- do your homework, and make sure your doctors do theirs.
4
My father-in-law was diagnosed at 61 and chose radiation, Lupron injections and watchful waiting. He was symptom free and lived another 25 years, dying of heart failure. Sound like the right choice? Here's the rub, he felt as though he had a cancer diagnosis hanging over his head every single day. Prostate cancer dominated every holiday conversation, any discussion about vacations, major purchases, etc. and it drove his wife crazy. She begged him, to just get the surgery and be done with the anxiety.
13
His anxiety had little to do with real risk.
4
Ergo, he didn't need surgical treatment for his non-existent prostate cancer. He needed treatment for his chronic anxiety.
4
The lower the grade of cancer, the more agonizing the choice. I was 65 when diagnosed with Gleason 6 in 8 of 12 biopsy cores last year. I am otherwise healthy with some very long-lived ancestors and the thought of death by PC was more appalling than the prospect of long-term side effects. Still, the decision was extremely difficult. I read a lot and consulted a number of urologists, finally settling on robot-assisted protatectomy at Johns Hopkins. I looked for a skilled surgeon who has done thousands of procedures and who does not make extravagant promises. A Hopkins urologist, Patrick Walsh, discovered that nerves controlling erections could be spared and developed techniques now widely employed by the profession. The surgeon I chose works closely with him. Still, if the cancer involves the nerves, the nerves likely will be damaged and sexual function may be affected. In my case, the nerves were completely spared, the cancer was removed while it was still confined to the prostate and I am doing well on all fronts. The procedure was nowhere near the epic ordeal I was fearing. Pain was surprisingly minimal and the two weeks with a catheter, while uncomfortable, were far from the drama I was expecting. Four months after the procedure, I am almost completely continent and sexual function is "on the rise." Most importantly, my PSA is undetectable. I highly recommend Dr. Walsh's book "Guide to Surviving Prostate Cancer." To all facing this decision: God bless.
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Thanks for sharing this positive news. I am doing AS, and things are going well. Good luck and God Bless.
1
If the doctors knew which tumours will remain slow growing and which could suddenly become aggressive and spread to other tissues, it would be a much easier risk assessment to make. But they do not know. Also, complications are fewer and recovery is better from surgery when for younger men, but if complications do occur, a guy can be left with them for 20 or more years. Active surveillance vs active treatment is a risk judgement, but estimating the risk is far more complicated than this article makes it seem. Especially when the actual data on outcomes won't exist for another 20 years. And since my dad had prostate cancer 10 years ago, had radiation therapy and is doing fine now, I could easily be faced with making that decision any time now.
1
I agree there is a role for active surveillance in today's world and with the knowledge or lack of knowledge we currently have. However, I'm certain that as we dive more and more into personalized medicine and tumor genomics, there will come a day when we routinely test an otherwise low-grade low volume prostate cancer (Gleason 6) and determine if the tumor has the potential to be more aggressive based on its genetic profile. There are already some tests on the market that do this and I believe they will become the standard. We will therefore be able to triage patients into a category where treatment should be strongly considered and those where active surveillance is the best option.
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http://www.nytimes.com/2016/05/25/health/prostate-cancer-active-surveill...®ion=top-news&WT.nav=top-news&_r=0
This article fails to mention that cancers are often underestimated on biopsy, but pathology findings are sometimes higher by as much as 30% by some estimates. My biopsy showed Gleason 6. The pathology report from surgery showed 40% Gleason 7 and Stage 3 cancer. It would have gone undetected if I relied on the biopsy report.
This article fails to mention that cancers are often underestimated on biopsy, but pathology findings are sometimes higher by as much as 30% by some estimates. My biopsy showed Gleason 6. The pathology report from surgery showed 40% Gleason 7 and Stage 3 cancer. It would have gone undetected if I relied on the biopsy report.
2
The more aggressively I pursued my cancer, the worse it became. My PSA tests were just a bit high. The biopsy showed low Gleason. The surgical report showed 10 percent involvement. That was eleven years ago. I'm in my seventies, healthy and vigorous and doing great things without a prostate gland. The women I love still love me. My pants stay dry. Like some other commenters, I suspect this "active surveillance " fad has more to do with money than the docs and insurers will admit. My surgery (robotic) and hospital stay (overnight) cost about $20,000. "Active surveillance" sounds like it costs a lot less. If 50% of men get prostate cancer, that's a lot of money the insurance companies can use for CEO bonuses for coming up with such a bright idea.
5
The decision on whether to have a prostate cancer treated is a deeply personal one, with your age being the most important parameter.
I was diagnosed in my early fifties and I could not wait to have the whole thing extirpated.
This was fifteen years ago. I know that I made the right decision, although other people might differ.
It all boils down as to whether you want to spend the rest of your life wondering whether the cancer will catch up to you or not.
There is no right answer, you might have the operation and have no side effects, or have some serious incontinence problems.
On the other hand, you might decide to watch it, ponder whether things are going to be okay, which they might be or not.
I would not want to stand up here and tell other people what is best for them.
I was diagnosed in my early fifties and I could not wait to have the whole thing extirpated.
This was fifteen years ago. I know that I made the right decision, although other people might differ.
It all boils down as to whether you want to spend the rest of your life wondering whether the cancer will catch up to you or not.
There is no right answer, you might have the operation and have no side effects, or have some serious incontinence problems.
On the other hand, you might decide to watch it, ponder whether things are going to be okay, which they might be or not.
I would not want to stand up here and tell other people what is best for them.
1
Treatment options and choices are extremely personal and unique to each individual. While living in Seattle and 48 years old, I was diagnosed with Gleason Score 5 prostate cancer. My urologist, Dr. James Gottesman M.D. and I discussed different modes of treatment. When it was clear that the odds of having my cancer metastasize to my bones were high given my relative youth, I chose a procedure that Dr. Gottesman developed: Nerve Sparing Radical Prostatectomy. Prior to Dr. Gottesman's procedure, ALL men were left incontinent and impotent after prostate removal surgery because the nerves that served those two functions were cut. Dr. Gottesman's simply deduced that by excising the nerves from the surface of the prostate and leaving them in place meant that a very large percentage of those patients would be left with their normal functions intact. Almost 20 years after the surgery (I'm 67) I'm free of cancer, have my functions exactly as they should be and all accomplished without the need for chemo or radiation.
5
We don't know the natural histories of these cancers. I just discovered another patient of mine with prostate cancer, referred him to urology and after prostate biopsy his cancer was Gleason stage 6. This article is timely for him. I called him up and asked him to read it, because right now he is consulting various surgeons and didn't know surveillance is a choice--his urologist didn't tell him. Most urologists, in group or private practice do not want the burden of surveillance and are afraid of malpractice suits, in case the tumor takes off. Many cancers, including ductal carcinomas of the breast in situ and thyroid CA, follicular with papillary elements, recently have undergone reclassification, as relatively benign and non life threatening where wait and watch is reasonable. The trouble with this approach is that each patient is different and we don't have simple blood tests to tell us when these cancers are about to go distant. Prostate biopsies are not easy. They are painful and can result in infections, sometimes drastic. We also don't know how long patients need to be followed and if it is for a life time, young patients can get complacent and be lost to follow up. I would say people with insulin resistance or diabetes and the obese in whom cancers tend to be more aggressive, people with prostate cancer as a second cancer, people with a family history of prostate cancer, smokers, immoderate drinkers and the sedentary should not opt for surveillance.
7
As a prostate cancer survivor going on 8 years, I can tell you with some authority that there is a ton of information available to read, study and digest if you are so inclined. Some people choose to put all their trust and faith in their medical team and skip the research.
I've read this article and most of the comments, all I'm sure are well meaning, but with the exception of a handful of comments, most are misleading, incomplete and some are incorrect. I hope everyone understands that situations and diagnoses and treatments are not routine matters, not formulaic and in every instance fraught with some risk.
When my primary care physician and I began our relationship many years ago, I gave him my philosophy about health care. I told him that I'm proactive, and I err on the side of having as much understanding about my health care as possible, including tests that can rule in or rule out a diagnosis. I figure that it is better to treat something early than later when it is less treatable.
How this applies to prostate cancer is important because advanced prostate cancer can take a life in a few months. The only way that prostate cancer can do this is because the patient was not having routine exams including a digital rectal exam and a PSA.
I can see I'm going to run out of room finishing my comment. So, my recommendation is be proactive and do your own research, not to make a diagnoses or determine treatment, but to know your choices and to assess your medical team.
I've read this article and most of the comments, all I'm sure are well meaning, but with the exception of a handful of comments, most are misleading, incomplete and some are incorrect. I hope everyone understands that situations and diagnoses and treatments are not routine matters, not formulaic and in every instance fraught with some risk.
When my primary care physician and I began our relationship many years ago, I gave him my philosophy about health care. I told him that I'm proactive, and I err on the side of having as much understanding about my health care as possible, including tests that can rule in or rule out a diagnosis. I figure that it is better to treat something early than later when it is less treatable.
How this applies to prostate cancer is important because advanced prostate cancer can take a life in a few months. The only way that prostate cancer can do this is because the patient was not having routine exams including a digital rectal exam and a PSA.
I can see I'm going to run out of room finishing my comment. So, my recommendation is be proactive and do your own research, not to make a diagnoses or determine treatment, but to know your choices and to assess your medical team.
13
I'm 68 years old and had been watching my PSA rise over the past 15 years from 1.0 to 6.4. The DRE exam had been negative until 10/16. My 1st urologist retired and saw a younger urologist who suggested a 4K blood test which Medicare covers and is specific for "aggressive PC". The 4K results stated I had a 67% chance of having aggressive PC so I underwent a biopsy (under IV sedation-REQUEST IV sedation!!). My Worst Gleason score was a 4+3. I elected to have a robotic prostatectomy and am feeling a return of continence and partial return of erectile function. I am a physician who sees patients ONLY in Skilled Nursing Homes. I encounter men who are in hospice for metastatic Prostate Cancer...it's a very sad experience. Remember almost 30,000 men will die from prostate cancer. Watchful waiting can be appropriate but remember this is a cancer and it can kill.
12
The difference in opinion between academic urologists and those in private practice is that a surgeon is paid very little to watch & wait as opposed to performing surgery.
My father was hospitalized for bacteremia after a prostate biopsy a few years ago. The surgeon wanted to remove his prostate after the pathologist he worked with found 1 out of 12 samples to look a bit like cancer. I was in med school at the time & I recommended he get a second opinion at MD Anderson in Houston.
Long story short, my father doesnt have prostate cancer today & he likely never did. Most likely, he had an elevated PSA due to an infection of the prostate which led to the whole ordeal.
Most physicians are good, caring people, but they are human and the idea of providing a certain lifestyle for your family absolutely influences decisions that are in a grey "standard of care" area.
My father was hospitalized for bacteremia after a prostate biopsy a few years ago. The surgeon wanted to remove his prostate after the pathologist he worked with found 1 out of 12 samples to look a bit like cancer. I was in med school at the time & I recommended he get a second opinion at MD Anderson in Houston.
Long story short, my father doesnt have prostate cancer today & he likely never did. Most likely, he had an elevated PSA due to an infection of the prostate which led to the whole ordeal.
Most physicians are good, caring people, but they are human and the idea of providing a certain lifestyle for your family absolutely influences decisions that are in a grey "standard of care" area.
5
25,000 men in America and 300,000 men worldwide will die from prostate cancer each year.
3
With a U.S. population of 323,887,484 and a world population of 7,424,458,118, that indicates that 0.00404% of world population and 0.00772% of Americans will die from prostate cancer this year. (Numbers taken from www.geohive.com) All these numbers may be confusing, but what that is implying is that Americans will die at nearly twice the rate of the world at large from prostate cancer this year.
1
Ny PSA numbers went up fast...a biopsy (which scared me to even think about and turned out to be not that uncomfortable) said it was there. Had a good health plan and killed it with radiation only. At the same time a friend of mine died from prostate cancer mainly because he kept fending off his doctor's entreaties until it was too late
6
The difference in opinion between academic urologists and those in private practice is that a surgeon is paid very little to watch & wait as opposed to performing surgery.
My father was hospitalized for bacteremia after a prostate biopsy a few years ago. The surgeon wanted to remove his prostate after the pathologist he worked with found 1 out of 12 samples to look a bit like cancer. I was in med school at the time & I recommended he get a second opinion at MD Anderson in Houston.
Long story short, my father doesnt have prostate cancer today & he likely never did. Most likely, he had an elevated PSA due to an infection of the prostate which led to the whole ordeal.
Most physicians are good, caring people, but they are human and the idea of providing a certain lifestyle for your family absolutely influences decisions that are in a grey "standard of care" area.
My father was hospitalized for bacteremia after a prostate biopsy a few years ago. The surgeon wanted to remove his prostate after the pathologist he worked with found 1 out of 12 samples to look a bit like cancer. I was in med school at the time & I recommended he get a second opinion at MD Anderson in Houston.
Long story short, my father doesnt have prostate cancer today & he likely never did. Most likely, he had an elevated PSA due to an infection of the prostate which led to the whole ordeal.
Most physicians are good, caring people, but they are human and the idea of providing a certain lifestyle for your family absolutely influences decisions that are in a grey "standard of care" area.
5
Two years and three months ago, after years of slowly and erratically rising PSA's, I had a biopsy which resulted in a Gleason 8. There was no question - I had a Urologist who had done thousands of DaVinci Robotic Radical Prostatectomies, and was adept at nerve saving techniques. The procedure took a couple of hours, and the catheter was uncomfortable for a week, then recovery. I was never incontinent so no pads, etc. and potency returned slowly but steadily over the next two years, to nearly pre-procedure levels today.
But, after any prostatectomy there is the possibility of micro-metastatic activity. After two years of PSA's of 0.01 - 0.0.4, it went to 0.09 and then 0.10, which may, or may not, require further action. So we're back to watchful waiting, with focused radiation in the wings if necessary.
Bottom line: for me, the procedure was the right path, even if later radiation is needed to finish the job.
I hesitate to recommend watchful waiting to everyone before surgery, because we're all different, but for me, I think I'd be in big trouble today had I waited.
But, after any prostatectomy there is the possibility of micro-metastatic activity. After two years of PSA's of 0.01 - 0.0.4, it went to 0.09 and then 0.10, which may, or may not, require further action. So we're back to watchful waiting, with focused radiation in the wings if necessary.
Bottom line: for me, the procedure was the right path, even if later radiation is needed to finish the job.
I hesitate to recommend watchful waiting to everyone before surgery, because we're all different, but for me, I think I'd be in big trouble today had I waited.
7
In 2014 I had a diagnosis of prostatic adenocarcinoma with a Gleason score of 6 on the right and 7 on the left. There was some concern of extra capsular extension on palpation and the rapidity with which my PSA rose from a low level to just under 4 (still considered in the upper "normal" range). I chose to have a radical prostatectomy at Northwestern University in Chicago with no post surgical radiation and after all was said and done I was told I was very lucky to be aggressive in my treatment because I did have extra-capsular extension even with a PSA level of 4. Tissue examination during surgery showed no discernible lymph node involvement.
I tell men who inquire about my experience to question their doctors about the rate of onset (very important), how the Gleason score is calculated (so you understand what they are seeing on biopsy), an explanation of the Partin tables clinical stage value (this can be found online at John Hopkins) and a complete explanation of what the urologist is feeling on palpation. I also recommend going online to John Hopkins and requesting their current white paper on how to choose a treatment path and who to choose to do the procedure. It is an excellent source of information that will help them in their decision making during a very stressful period in their lives.
Should he choose a prostatectomy, it is imperative that he learns all about Kegel exercises for men and that he starts them ASAP (presurgically).
I tell men who inquire about my experience to question their doctors about the rate of onset (very important), how the Gleason score is calculated (so you understand what they are seeing on biopsy), an explanation of the Partin tables clinical stage value (this can be found online at John Hopkins) and a complete explanation of what the urologist is feeling on palpation. I also recommend going online to John Hopkins and requesting their current white paper on how to choose a treatment path and who to choose to do the procedure. It is an excellent source of information that will help them in their decision making during a very stressful period in their lives.
Should he choose a prostatectomy, it is imperative that he learns all about Kegel exercises for men and that he starts them ASAP (presurgically).
12
A little knowledge is a dangerous thing. I would suggest that any concerned male apply himself to studies by respected medical authorities both here and abroad before agreeing to surgery or radiation, given a Gleason 6 finding. I would insist on an MRI, immediately, preferable one with the most advanced magnets and contrast applications. It seems obtuse to rely on biopsies after the first finding, simply because they are purely random, when a more mass definitive diagnostic is available. At the very leasts, the needle can be directed at a defined target.....no hit or miss.
1
Had a high PSA test at age 52. That Dr. told me I had cancer. So, I changed Dr. and came up with a lower PSA score. Everything was fine. He instructed to enter into a "watchful waiting" program with him. He put me on three medications which I was on for five years. While on those medications I had constant chest pains, dizziness, BP spikes, and bad constipation. Reading the local newspaper one day and see my Dr. (him) in the headlines. He was fired by the local hospital in a sexual harassment suit. Turns out he liked giving and receiving rectal exams to nurses and co workers. Did I tell you he was a Boy Scout Leader?
Anyway. My new Dr. took me off the meds. My PSA was fine. The 10-15 year thing works great for me.
Anyway. My new Dr. took me off the meds. My PSA was fine. The 10-15 year thing works great for me.
6
For anyone with increasing PSA scores or high gleason scores be sure to consider Proton radiation treatment. Effective and not invasive. Some side effects but nothing like surgery. A growing number of major medical centers offer the treatment. But like others have mentioned, if your doctor or hospital doesn't offer Proton treatment then we will not even mention it as an option. Some insurance companies wont cover it as it is more expensive than traditional radiation. But look into it!!
7
It's also mostly used for low grade cancers according to my medical team, so it has it's limitations as well.
My dad lived for many years, nearly two decades with "watchful waiting" - though he was angry they did nothing but surveillance. He did not die of cancer, but a stroke.
My spouse had a Gleason 7. But warning! A 7 depends on 2 other numbers, based on types of cancer cells. A 4/3 is more worrisome as it means there are more of the 4's - which is not good.
He had the surgery, which left him without cancer. But also with a constant dripping of urine and finally "diaper rash". That led to 2 more surgeries for an artificial urinary sphincter. He still wears a pad as a precaution, but no longer gets the diaper rash. Other problems, due to the cancer surgery, as you can imagine, but he was already in his 70's so lack of libido is more tolerable.
If you can save yourself surgery, do it!
My spouse had a Gleason 7. But warning! A 7 depends on 2 other numbers, based on types of cancer cells. A 4/3 is more worrisome as it means there are more of the 4's - which is not good.
He had the surgery, which left him without cancer. But also with a constant dripping of urine and finally "diaper rash". That led to 2 more surgeries for an artificial urinary sphincter. He still wears a pad as a precaution, but no longer gets the diaper rash. Other problems, due to the cancer surgery, as you can imagine, but he was already in his 70's so lack of libido is more tolerable.
If you can save yourself surgery, do it!
3
An excellent article enhanced by the superb readers' comments.
To treat or not to treat has been a problem since 1934 when
Arnold Rice Rich described "the frequency of occult
caricinoma of the prostate". Readers are referred to the National
Cancer Comprehenisve Network site for guidance.
To treat or not to treat has been a problem since 1934 when
Arnold Rice Rich described "the frequency of occult
caricinoma of the prostate". Readers are referred to the National
Cancer Comprehenisve Network site for guidance.
1
Surveillance (with PSA's) saves one life out of 2000 surveilled. The number of men subjected to needless biopsies with pain and complications is legion. Many men who have elevated PSAs from benign or low grade tumors or inflammatory disease subsequently live in fear that their cancer was missed if the biopsy is negative. Many others fall in the 99%plus of the 2000 surveilled who would have lived end up with radical prostatectomies resulting in incontinence, impotence and fear. The major question therefore is whether to do routine surveillance in men at normal risk (white men without family history). This requires an honest, full discussion between doctor and patient before the PSA is done. Could the reason that academic doctors have this discussion more often be pecuniary?
3
What isn't said in the article is that active surveillance is indeed active. There are quarterly PSA tests and annual biopsies and Annual MRIs. Any one of these tests can indicate a shift to treatment instead of surveillance.
My concern is that the male fear of impotence carries more weight in the treatment decision than it perhaps should. I say this as a female but also a wife of someone dealing with the situation. When you consider the possibility of biopsy sampling error - for example, stick a pea inside an orange and then insert a needle into the orange several times trying to hit the pea- you might give more weight to a negative biopsy than is optimal. At some point, you may hit the pea and learn that you need treatment and you might wish you had treated earlier.
You so badly want to hear that the biopsy was normal that you undervalue the odds of the exercise. Doctors are learning more every day and we are fortunate to live in an area where there are docs doing outstanding work but everyone has to wear a thinking cap when they process their own situation.
My concern is that the male fear of impotence carries more weight in the treatment decision than it perhaps should. I say this as a female but also a wife of someone dealing with the situation. When you consider the possibility of biopsy sampling error - for example, stick a pea inside an orange and then insert a needle into the orange several times trying to hit the pea- you might give more weight to a negative biopsy than is optimal. At some point, you may hit the pea and learn that you need treatment and you might wish you had treated earlier.
You so badly want to hear that the biopsy was normal that you undervalue the odds of the exercise. Doctors are learning more every day and we are fortunate to live in an area where there are docs doing outstanding work but everyone has to wear a thinking cap when they process their own situation.
5
I was diagnosed with prostate cancer about three years ago, and went for radical prostatectomy two years and five months ago.
At the time of the diagnosis, I was 52, and I spent some time gathering opinions from experts. Dr. Epstein of Johns Hopkins, mentioned in the piece, also reviewed the slides from my biopsy and he recommended treatment.
I opted for radical prostatectomy because a specialist who does radiation therapy told me that I should get treatment, but it should be radical prostatectomy. My urologist agreed that I should opt for treatment and that radical prostatectomy would be the best option.
Six weeks after surgery I was back at work, and my PSA has been where it should be-- near zero. My functions are almost back to where they were pre-surgery (I stopped using pads within about five months after surgery), even though full recovery, if it will happen, may take up to three years.
At the time of the diagnosis, I was 52, and I spent some time gathering opinions from experts. Dr. Epstein of Johns Hopkins, mentioned in the piece, also reviewed the slides from my biopsy and he recommended treatment.
I opted for radical prostatectomy because a specialist who does radiation therapy told me that I should get treatment, but it should be radical prostatectomy. My urologist agreed that I should opt for treatment and that radical prostatectomy would be the best option.
Six weeks after surgery I was back at work, and my PSA has been where it should be-- near zero. My functions are almost back to where they were pre-surgery (I stopped using pads within about five months after surgery), even though full recovery, if it will happen, may take up to three years.
4
For me, it was a choice pushed by emotion and logic. Emotion won out and I had my prostate removed. Having had cancer before, I couldn't tolerate the idea of being host to it again even if logical evidence told me I would be fine to monitor my prostate cancer and act only if it changed.
4
It is good to see more options developing, but patients must be given all of the options and associated risks. While it is true that Gleason scores are not always definitive, they are very good indicators of potential problems, and should not be ignored. Age is also a critical factor. Someone diagnosed with stage 1 in the mid 70's presents a totally different situation than someone in their early 50's being presented with the same diagnosis.
2
Typical of the reversals in the medical profession , for we older men who lived for many many years with completely different guidelines , one doesn't envy all the contradictory new opinions, of the Medical profession. I found in my case, Urologist haven't moved away from constant PSA , DRE, and biopsies. Appears they treat real world cases everyday, while non Urologist so called task force's, are making decisions based on statistics. That in itself is in my opinion a major issue with the medical profession, the one size fits all equation.
I wish this article had gone into a comparison of the PSA numbers to the Gleason numbers. This seems to be a vital piece of information for men who have elevated PSA scores.
1
One issue not mentioned in the article is that, according to my urologist who has performed thousands of prostatectomies, repeated sampling of the prostate causes it to stick more tightly to the surrounding tissue, making it harder to remove without damage to important nerves. That fact helped convince me to go ahead with surgery when a biopsy indicated Gleason 7 cancer at the age of 52. (Post surgery analysis indicated Gleason 8.)
The article describes PSA, prostate specific antigen, as a "protein associated with prostate cancer" but that is wrong and exactly the confounding fact about PSA: It is associated with the prostate, period. It is NOT specific for prostate cancer. You can have high PSA from prostatitis, inflammation / infection of the prostate. You can have a high reading from having sex a day or two before the blood draw - possibly even from a lot of bike riding prior to the test.
Prostate cancer is never diagnosed by PSA. PSA is a red flag that needs to be double-checked and then followed with a biopsy. Biopsies are not perfect, but should become more predictive as they're beginning to be combined with gene testing of the samples.
Also biopsies are not as horrendous to experience as they would appear. The pain is like having a rubber band snapped on your skin - not pleasant but not excruciating, and brief - it's just coming from a place you're not used to feeling. If nervous about a first biopsy, have someone drive you to and from it and ask for an anti-anxiety drug (eg, Xanax) prior to the procedure.
Prostate cancer is never diagnosed by PSA. PSA is a red flag that needs to be double-checked and then followed with a biopsy. Biopsies are not perfect, but should become more predictive as they're beginning to be combined with gene testing of the samples.
Also biopsies are not as horrendous to experience as they would appear. The pain is like having a rubber band snapped on your skin - not pleasant but not excruciating, and brief - it's just coming from a place you're not used to feeling. If nervous about a first biopsy, have someone drive you to and from it and ask for an anti-anxiety drug (eg, Xanax) prior to the procedure.
8
Why is that people, perhaps some adviser doctor to the author of this article, try to sell PSA? Because it is the easiest way to get you hooked into some surgery and biopsy. PSA is not recommended nor as you say anyway to diagnose prostate cancer, but is way to put you into a false and vicious cycle of fear and then take your prostate and you potency and continence. They keep bombarding the public with these articles, misleading doctors are behind...Yes there is prostate cancer, and it will kill people 8 in 1000 thousand people in two rooms, one taking the PSA and the other not. And it is even worst than that, it seems that treatments do no give any longer life..If I am wrong please someone comment on this..
Prostate cancer has afflicted all of the men in my family, eventually. My father was the only one who chose impotency over wait and see. He is still alive, two are dead from prostate cancer, and one is in the early stages of waiting and seeing. My brother and son are also waiting, for their seemingly inevitable turn. I, too, am forced to wait and see, with no other option.
I have envied men many things, but the difficult question that must be answered with a prostate cancer diagnosis is not one. I pray for something better on the horizon, for those I love and those who are loved by others.
I have envied men many things, but the difficult question that must be answered with a prostate cancer diagnosis is not one. I pray for something better on the horizon, for those I love and those who are loved by others.
16
Excellent comment. I am currently on active surveillance (7 years). But I do my share of worrying that the cancer will bust out. Thanks you for understanding the challenges and tragedies Prostate cancer can mean for men.
1
I had Da Vinci surgery at 48. For me, a father with two middle schoolers at the time, the 2% chance of having a dangerous cancer combined with the effects of both biopsies and repeated prostate infections from other causes made the decision easy to risk impotence and incontinence. I'm not impotent or incontinent but frankly wouldn't be upset if I was. To each their own. I feel fortunate to have faced my decision when I did. I can't imagine yearly biopsies.
15
Most men wouldn't be so blase about becoming impotent at age 48, and nor would their life partners.
4
Is it possible that prostate cancer can be GOOD for you? It certainly has been for me!
I'm 74. In 2013, I was diagnosed with prostate cancer (Gleason 4+3), and had my prostate removed. I then said to myself: "If this cancer is as slow-growing as the experts say, what can I do to really prolong my life? If it isn't going to kill me, what will?"
The answer was most likely "heart disease", so I decided to do something about that. I now visit a gym daily to take "spin" (bicycle) classes or lift weights. Moreover, I cut way back on sugar and eliminated red meat from my diet. I eat tons of fresh fruits and veggies. I don't smoke or drink. I live in Hawaii, with lots of sunshine and, perhaps, the best air and water in the world. Best of all, my wife is super supportive, and has changed HER lifestyle, too.
The results? I feel fantastic! My blood pressure has fallen from 140/80 to 114/75. My cholesterol is way down. My PSA, at .26 has risen slowly, but is still very low. My BMI is perfect and I'm more muscular than when I was a teen. Indeed, I'm am more healthy now than I've been in many years!
So, in many ways, I'm GRATEFUL for having contracted prostate cancer! I needed the "shock" to change my lifestyle to something much more positive. Instead of dying of a heart attack in my 70's, I now have an excellent chance of extending my life for decades to come.
Yes, it hasn't been easy, but isn't living a long and healthy life well worth it?
I'm 74. In 2013, I was diagnosed with prostate cancer (Gleason 4+3), and had my prostate removed. I then said to myself: "If this cancer is as slow-growing as the experts say, what can I do to really prolong my life? If it isn't going to kill me, what will?"
The answer was most likely "heart disease", so I decided to do something about that. I now visit a gym daily to take "spin" (bicycle) classes or lift weights. Moreover, I cut way back on sugar and eliminated red meat from my diet. I eat tons of fresh fruits and veggies. I don't smoke or drink. I live in Hawaii, with lots of sunshine and, perhaps, the best air and water in the world. Best of all, my wife is super supportive, and has changed HER lifestyle, too.
The results? I feel fantastic! My blood pressure has fallen from 140/80 to 114/75. My cholesterol is way down. My PSA, at .26 has risen slowly, but is still very low. My BMI is perfect and I'm more muscular than when I was a teen. Indeed, I'm am more healthy now than I've been in many years!
So, in many ways, I'm GRATEFUL for having contracted prostate cancer! I needed the "shock" to change my lifestyle to something much more positive. Instead of dying of a heart attack in my 70's, I now have an excellent chance of extending my life for decades to come.
Yes, it hasn't been easy, but isn't living a long and healthy life well worth it?
6
Then there are guys like me who have lived nearly their whole lives this way (road, trail & marathon runner for 37 yrs, triathlete for 13) who still get bitten by prostate cancer.
I do believe it's possible to hold off or at least greatly slow cancer's growth by taking great care of yourself. Not sure how long I can continue to do this without some procedure, given a Gleason of 8 and PSA in the 20's, altho those numbers have been static for 2.5 yrs now & MRIs in that time have not shown any tumor growth. Those closest to me all urge some procedure. But they're not the ones who will be incontinent and lose libido, nor are any of the well trained and sincere doctors and assistants I am discussing this with.
I do believe it's possible to hold off or at least greatly slow cancer's growth by taking great care of yourself. Not sure how long I can continue to do this without some procedure, given a Gleason of 8 and PSA in the 20's, altho those numbers have been static for 2.5 yrs now & MRIs in that time have not shown any tumor growth. Those closest to me all urge some procedure. But they're not the ones who will be incontinent and lose libido, nor are any of the well trained and sincere doctors and assistants I am discussing this with.
1
The latest trend in those who don't treat prostate cancer: Dying.
6
Women, with our various female health troubles, have said that if a men's health issue was in the spotlight, much would be done, quickly, to find resolution and avoid disfigurement. Here it is!
2
Men and Women have equal annual mortality rates from Breast and Prostate cancer respectively. But the research dollars for Breast cancer are double that for PC. Hardly an advantage for men.
3
I was diagnosed seven years ago. My Urologist asked if I had a history of cancer in my family. I told him that of the seven people who lived in our house growing up, 6 had a diagnosis of some form of cancer. Three had died as a direct result of the disease. My father, the only one who didn't have cancer, died at an early age from something other than cancer. After listening to as much advice as I could stand, I chose radiation and I'm presently fine though some of the side affects described in the article are now part of my life. But, at least, I'm still above the ground.
You have to become your own doctor re America's de facto criminal health care system that puts the salaries of billionaire HMO and Drug barons above the health of Americans.
The worst of these barons should be prosecuted for malpractice for enriching themselves on needless tests and procedures re this affliction and others that resulted in not only wasted time and money but serious side effects.
The worst of these barons should be prosecuted for malpractice for enriching themselves on needless tests and procedures re this affliction and others that resulted in not only wasted time and money but serious side effects.
4
While it is good to see the major media outlets cover Active Surveillance, there are many other changes/improvements over the past 5+years in the diagnosis and treatment, like 3T-MRI and focal treatments (FLA [focal laser ablation] being one of the most promising).
Using 3T-MRI, interventional radiologists can now see tumors as small as 1mm and track the progress of any suspicious areas without repeated biopsies. When a biopsy is necessary, using the MRI they can target only the suspicous area(s) vs randomly poking holes in the blind.
Using 3T-MRI, interventional radiologists can now see tumors as small as 1mm and track the progress of any suspicious areas without repeated biopsies. When a biopsy is necessary, using the MRI they can target only the suspicous area(s) vs randomly poking holes in the blind.
2
The prostate is a small gland. If one opts for annual biopsies they might as well have it removed as after a few biopsies the prostate will no longer function. However, they add much to the surgeon's bank accounts and we must keep our priorities straight.
4
This saves health care costs by reducing medical services. It is just another example of the sinister plot by the private insurance companies and the government (the largest insurer in the US) with the cooperation of physicians who have grown a "social conscience" to replace their ethical obligation to give priority to the patient's welfare.
Women howled when it was recommended to reduce breast cancer testing. Of course, government immediately catering to them and backed down. But I guess it is OK to take advantage of men and jeopardize their health.
Women howled when it was recommended to reduce breast cancer testing. Of course, government immediately catering to them and backed down. But I guess it is OK to take advantage of men and jeopardize their health.
5
As is I write this, there are 128 comments, each one seemingly unique in describing that individual's approach to his prostate woes. Overall, I am struck by the predominance of the when in doubt do something method. Scans, seeds, biopsies, surgery.
Maybe it's me. Maybe it's my doctors. But I'm perfectly happy (well, relatively) with my annual PSA test and DRE and my doctor's reasonable, balanced, non-alarmist guidance, which generally consists of "see you in a year."
Maybe it's me. Maybe it's my doctors. But I'm perfectly happy (well, relatively) with my annual PSA test and DRE and my doctor's reasonable, balanced, non-alarmist guidance, which generally consists of "see you in a year."
2
My father was diagnosed in 1994 at the age of 55- Triggered by a PSA test, and confirmed by a biopsy, he elected for surgery, and after a fairly minimal recovery, went on about his life. Five years ago, his PSA began elevating, and they confirmed that the same cancer had metastasized into his bones, after living dormant somewhere for 17 years. He was treated with a variety of hormone injections, radiation, and finally chemo, and then a blessedly short miserable stint in hospice before passing last November.
On the flip side, my father-in-law had the same surgery in the late '80's, and is the healthiest 80-year-old you'll ever meet.
My physician once told me that once you get to a certain age, a positive diagnosis is fairly meaningless, as you'll die of old age before the cancer gets you. I'm not so sure. Basically, every case is different.
I have a PSA every six months (I'm 50 now) and so far, so good.
On the flip side, my father-in-law had the same surgery in the late '80's, and is the healthiest 80-year-old you'll ever meet.
My physician once told me that once you get to a certain age, a positive diagnosis is fairly meaningless, as you'll die of old age before the cancer gets you. I'm not so sure. Basically, every case is different.
I have a PSA every six months (I'm 50 now) and so far, so good.
2
First off, it is a mistake not to have regular PSA tests once you reach a certain age, that age depending on family history. Second, if you are diagnosed with prostate cancer, regardless of the PSA and Gleason score, YOU need to take charge and not rely on your primary care physician, urologist, or radiation oncologist to make the decision for you. Get second and third opinions. Research your options online. Talk to men who have been treated with the various options. Attend a support group meeting in your area and ask questions of those in attendance. And then decide what sounds like the best option for YOU in YOUR situation.
Urologists are going to want to operate on you. Radiation oncologists are going to want to irradiate you. There's often money, politics, and bias in their opinions. Consider that as you decide.
All of the treatments--surgery, radiation (seeds, IMRT, proton), appear to be equally effective in treating the cancer. However, the difference in side effects can be substantial. In my case, after extensive research I selected proton beam therapy. Six years out, my PSA is 0.2 and I have zero side effects. That appears to be the case with all of the men who were treated with protons at the time I was treated, and surveys by our support and advocacy group, Brotherhood of the Balloon, indicate very low levels of impotence and virtually zero cases of incontinence. Sadly, many insurers have stopped covering PBT because it is more expensive than the other treatments.
Urologists are going to want to operate on you. Radiation oncologists are going to want to irradiate you. There's often money, politics, and bias in their opinions. Consider that as you decide.
All of the treatments--surgery, radiation (seeds, IMRT, proton), appear to be equally effective in treating the cancer. However, the difference in side effects can be substantial. In my case, after extensive research I selected proton beam therapy. Six years out, my PSA is 0.2 and I have zero side effects. That appears to be the case with all of the men who were treated with protons at the time I was treated, and surveys by our support and advocacy group, Brotherhood of the Balloon, indicate very low levels of impotence and virtually zero cases of incontinence. Sadly, many insurers have stopped covering PBT because it is more expensive than the other treatments.
5
Too bad you will have to shell out through the nose for those second or third opinions because your insurance will consider them "frills." It's not a question of your health, it's all about how to access your money.
2
This 'life expectancy of 10-15 years' is a troubling thing. Years ago, someone my age (73) was considered old, almost aged.
The advances of medicine in my lifetime alone have extended the average lifespan by many years. I think I have a reasonable expectation of living the better part of 25 years based upon family history, and I had radiation and seed therapy about 8 years ago. With a Gleason score of 7 my PSA never went above 1.4. It happens. My PCP found a nodule on physical examination and referred me to a urologist. Although he is a skilled surgeon, my urologist recommended radiation.
Yes, there are some side effects, but only living people have them.
The advances of medicine in my lifetime alone have extended the average lifespan by many years. I think I have a reasonable expectation of living the better part of 25 years based upon family history, and I had radiation and seed therapy about 8 years ago. With a Gleason score of 7 my PSA never went above 1.4. It happens. My PCP found a nodule on physical examination and referred me to a urologist. Although he is a skilled surgeon, my urologist recommended radiation.
Yes, there are some side effects, but only living people have them.
3
I continue to have PSA tests 15 years after my radical prostatectomy (I'm 61). One thing I worried about was whether the process of doing the biopsies could cause the cancer to spread. My two sites of cancer were deep in the gland, but can the cancer spread when the gland is repeatedly pierced and cells are dislodged? My understanding is that once it spreads, it is incurable.
2
I'll start at my present. My last PSA - at age 78 - was 9.2. I have had no treatment and, at present, do not plan to have any.
My first alert was about 20 years ago (age 58 or so) when my PSA was above 4. I was then seen to have an enlarged prostate. I then had a 12-point prostate biopsy which was negative. The biopsy was quite uncomfortable - but I believe that the urologist did not wait long enough for the local anesthesia to take effect. On the other hand, while waiting for the biopsy procedure I saw three men stagger out of the room where the biopsies were being performed - in obvious "discomfort."
I continued to have annual PSA tests which rose almost every year to my present 9.2. But I decided to have no more biopsies. I continue to have PSAs done: "watchful waiting." My benign hypertrophic prostate gland continues to enlarge and interfere with urination. My doc prescribed generic Flomax for the BHP, which helps the urination problem fairly well. At my age (almost 80) sex relations are not a consideration (but it was on my mind when I decided to have no further biopsies which might lead to surgery).
My guess to engage in watchful waiting has paid off. I assume that I have some prostate cancer but have not wanted to know for certain for at least 20 years. If my BHP (hopefully it is benign) becomes a blockage and interferes significantly with urination I probably would undergo surgical removal.
Of course, my case is just one case.
My first alert was about 20 years ago (age 58 or so) when my PSA was above 4. I was then seen to have an enlarged prostate. I then had a 12-point prostate biopsy which was negative. The biopsy was quite uncomfortable - but I believe that the urologist did not wait long enough for the local anesthesia to take effect. On the other hand, while waiting for the biopsy procedure I saw three men stagger out of the room where the biopsies were being performed - in obvious "discomfort."
I continued to have annual PSA tests which rose almost every year to my present 9.2. But I decided to have no more biopsies. I continue to have PSAs done: "watchful waiting." My benign hypertrophic prostate gland continues to enlarge and interfere with urination. My doc prescribed generic Flomax for the BHP, which helps the urination problem fairly well. At my age (almost 80) sex relations are not a consideration (but it was on my mind when I decided to have no further biopsies which might lead to surgery).
My guess to engage in watchful waiting has paid off. I assume that I have some prostate cancer but have not wanted to know for certain for at least 20 years. If my BHP (hopefully it is benign) becomes a blockage and interferes significantly with urination I probably would undergo surgical removal.
Of course, my case is just one case.
3
So many men have been badly harmed by unnecessary prostate operations. It is a difficult operation that can result in many complications. Physicians eager to operate forget the first moral code of medicine. First, do no harm.
The procedure very often leaves the patient incontinent and impotent for the rest of their lives, no matter the assurances of the surgeon. My father had prostate cancer and his urologist advised the "wait and watch" approach. He died at age 89 of pneumonia. A prostate removal operation fifteen years earlier would have probably killed him.
The procedure very often leaves the patient incontinent and impotent for the rest of their lives, no matter the assurances of the surgeon. My father had prostate cancer and his urologist advised the "wait and watch" approach. He died at age 89 of pneumonia. A prostate removal operation fifteen years earlier would have probably killed him.
11
So sorry man, they did a carnage years ago..with the PSA thing, I ask myself, so many comments talking about "My gleason level", how did they get to a gleason level in the first palace? The massive PSA test of urologists and other doctors looking for costumers-victims..
1
I received a continuing string of indications of the onset of prostate cancer and then the nascent detection of it. My urologist suggested active surveillance after first referring me to specialists in radiation and surgical treatment. I was dismayed that my Gleason scores and PSA results continued to rise, and finally so was he. Although transrectal biopsies showed little affected areas, he did not feel that that was consistent with the velocity of rising PSA results and performed a transperineal biopsy, whcih showed where the cancer was growing and hiding.
I opted for da Vinci radical prostatectomy and found a great surgeon to do the procedure. Only in the hospital overnight, but the first week home was still a bit challenging with catheters and drain tubes. Four weeks later, though, I was fully continent and have in the few years since remained so with normal retention times. PSA has shown undetectable results.
Were it that I could have delayed surgery or avoided it altogether would have been great. But I am thankful for the forward-looking approach my urologist took with me, his advice on surgery vs. radiation, and his great jokes whenever I see him.
Maybe one day it will become popular for people to wear little blue ribbons to call attention to this far too common and often deadly - in the most unpleasant way I can imagine - male affliction. Until then keep the longitudinal studies going, make more men aware of what they need to do to monitor their prostate
I opted for da Vinci radical prostatectomy and found a great surgeon to do the procedure. Only in the hospital overnight, but the first week home was still a bit challenging with catheters and drain tubes. Four weeks later, though, I was fully continent and have in the few years since remained so with normal retention times. PSA has shown undetectable results.
Were it that I could have delayed surgery or avoided it altogether would have been great. But I am thankful for the forward-looking approach my urologist took with me, his advice on surgery vs. radiation, and his great jokes whenever I see him.
Maybe one day it will become popular for people to wear little blue ribbons to call attention to this far too common and often deadly - in the most unpleasant way I can imagine - male affliction. Until then keep the longitudinal studies going, make more men aware of what they need to do to monitor their prostate
14
Although it's outside the scope of this article, I think it's worth mentioning that the most aggressive prostate cancers are often detected by the velocity of their growth. In 2007, when he was 58, my husband noticed that his PSA, which had been 1.2 one year, had doubled to 2.4 the following year. His physician agreed that this rapid growth should be investigated. A biopsy revealed high-Gleason-score cancer in most cores. Even today, he would not have been a candidate for active surveillance. Plus, his experience with the biopsy was excruciating. I realize that's not true for everyone, but it's something that he would not have wanted to repeat regularly.
After researching his options, my husband opted for removal of his prostate by conventional surgery, rather than robotic, which was quite new at the time. The surgeon found cancer throughout the prostate, but it had not yet left the capsule. He was able to spare the nerves on one side, but not both.
My husband was more fearful of incontinence than impotence. He was fortunate in that his bladder control fully returned. However, despite the nerve sparing on one side, he never regained the ability to have a full erection. This sounds dire for a man still in his fifties. But the reality is that, while he lost the ability to have intercourse in the "normal" way, he didn't lose his testosterone. His sex drive is still alive and well, and we've found many ways to achieve sexual satisfaction. And most important, he's still alive.
After researching his options, my husband opted for removal of his prostate by conventional surgery, rather than robotic, which was quite new at the time. The surgeon found cancer throughout the prostate, but it had not yet left the capsule. He was able to spare the nerves on one side, but not both.
My husband was more fearful of incontinence than impotence. He was fortunate in that his bladder control fully returned. However, despite the nerve sparing on one side, he never regained the ability to have a full erection. This sounds dire for a man still in his fifties. But the reality is that, while he lost the ability to have intercourse in the "normal" way, he didn't lose his testosterone. His sex drive is still alive and well, and we've found many ways to achieve sexual satisfaction. And most important, he's still alive.
12
What this article does not consider is the statistical fact that many men have undiscovered cancer, if that is the right word, cells in their prostate. The study quoted in Gilbert Welch's excellent "Less Medicine, More Health" indicates that biopsies carried out on men who had died in accidents at age over 70 (i.e. asymptomatic for any medical condition that caused their death) 80 percent had identifiable cancer cells in their prostate. At 80 percent I would call it a normal condition, not a disease. If you look you will find. The question is; should you?
4
Is it too cynical to observe that "active surveillance" is not terribly profitable for urology practices?
5
A random PSA test four years ago came back with a borderline result of 4.5. In the next six months, two more psa tests with slightly increasing numbers. Next, a biopsy which confirmed cancer, Gleason 7. Surgery. PSA test after surgery had very low but detectable psa. Three more psa tests with a doubling in 2 years. Radiation plus hormone therapy. PSA subsequently drops to zero in two tests. Phew!
The PSA test saved my life because otherwise I had no idea I had borderline aggressive prostate cancer. Get a PSA test and start in your 40's. There is nothing wrong with active surveillance, it may be the best option for a large number of men. However, not an option in my case and that random psa test added years to my life.
The PSA test saved my life because otherwise I had no idea I had borderline aggressive prostate cancer. Get a PSA test and start in your 40's. There is nothing wrong with active surveillance, it may be the best option for a large number of men. However, not an option in my case and that random psa test added years to my life.
3
There is something in between "active surveillance" and one of the scary surgeries or radiation. My now 72 year-old husband had annual PSA tests for several years with results typically just under 3. When the PSA spiked to 5.7 I insisted he have a biopsy and it showed Gleason scores from 3 to 7 in half the samples. In the five years since he has had occasional acupuncture treatments, takes two Oriental medical preparations daily and does daily exercises specifically targeted by Oriental medicine for healthy prostate. His twice yearly PSA results have hovered between 4 and 5. The last one was 2.7. I would still like to talk him into another biopsy but our GP is supportive of this brand of "active surveillance."
This article is very misleading. I had a PSA of just 4.08 and the subsequent biopsy determined growths of Gleason four and 6, about evenly distributed. A subsequent MRI concluded that there was more Gleason 6 cancer than the biopsy indicated. After surgery the pathology showed mostly Gleason 6 with some Gleason 8 that was not picked up by either the biopsy or the MRI. What's more the pathology showed that the cancer was closer to the margin than either test indicated.
My takeaway: these non-invasive tests re extremely crude and misleading. A diagnosis of a modest tumor based on an elevated PSA and a biopsy could lead to a false sense of security when in fact you have more cancer than indicated, which is much more aggressive and closer to escaping the prostate capsule and entering your lymph nodes, or worse your bones.
I would never advise someone to let that crap fester inside you based on a crude PSA test and a small sample of your prostate.
My 2 cents.
My takeaway: these non-invasive tests re extremely crude and misleading. A diagnosis of a modest tumor based on an elevated PSA and a biopsy could lead to a false sense of security when in fact you have more cancer than indicated, which is much more aggressive and closer to escaping the prostate capsule and entering your lymph nodes, or worse your bones.
I would never advise someone to let that crap fester inside you based on a crude PSA test and a small sample of your prostate.
My 2 cents.
5
Regular PSA tests in my case provided valuable information. When the PSA jumps from a 2 up to a 6 in one year, then something is going on. The next question is find out what. Could be an infection, a prostate increasing in size, cancer, etc. My biopsy indicated a Gleason 8. My age was 62. The cancer was on the outside of the prostate and could be felt, so it was not hard to find in a biopsy.The Seattle prostate institute at the time used radiation, seed implants as an option, and their success rate was far over 90%. We did a few weeks of external beam radiation, followed by Brachy therapy (seeds). The PSA monitoring indicates less than a 1, 14 years later. Side effects include watching coffee or alcohol consumption, which causes a quick urgency so I need to be close to a bathroom. I can live with that.
5
The PSA test to patients on a routine base is malpractice. Last cancer authorities say do not do it. It can come high for many reasons, and it will damage you. This is for the readers of your post. It is possible that you saved your life..but many more will be damaged by the routine PSA test, seriously damaged..thinking that PSA test is good..
You are mixing up the PSA test (which is drawing a blood sample in a tube) and the follow-up procedures or biopsies. The PSA test itself is a simple blood draw, just like testing your cholesterol. The PSA test itself has no risk. Try not to confuse the biopsy with the blood test. Big difference. Biopsies can have secondary effects. I have never seen a secondary effect from the process of drawing a blood sample.
1
I was diagnosed with prostate cancer 11 years ago, and although my Gleason score was only six, the diagnosing urologist told me that my cancer was "aggressive" and that I needed immediate treatment. I then consulted with three additional urologists and a radiation oncologist, none of whom ever mentioned the option of active surveillance. Four months after diagnosis I had a robotic-assisted, minimally-invasive prostatectomy at a very well known and highly respected cancer treatment center - this was undoubtedly the worst decision I have ever made as my life has been an horrific nightmare for the last eleven years.
As a result, I strongly urge all men diagnosed with prostate cancer to thoroughly and carefully weigh their options, including specifically active surveillance, before choosing how to proceed.
As a result, I strongly urge all men diagnosed with prostate cancer to thoroughly and carefully weigh their options, including specifically active surveillance, before choosing how to proceed.
10
"... the worst decision I have ever made as my life ... " Ditto!!
1
I am a 23 year PC survivor, treated with radiation, The one thing that is consistently missing in these discussions is that the science of uro-pathology still does not have a good measure of the aggressiveness of the cancer. Lo aggressive would obviously fall into the surveillance category, while Hi aggressive would get treatment. We are not there yet.
my other advice is for men to get 2 or 3 different opinions before deciding on treatment options. My long experience with urologists who recommend active intervention confirms that when the only tool you have is a hammer, every problem looks like a nail.
my other advice is for men to get 2 or 3 different opinions before deciding on treatment options. My long experience with urologists who recommend active intervention confirms that when the only tool you have is a hammer, every problem looks like a nail.
4
I know a man who had prostate cancer and was advised to do nothing. That prostate cancer, a short time later, metastasized to a lung and he died of cancer of the lung.
If I ever receive a prostate cancer diagnosis I would want that cancer removed post haste.
If I ever receive a prostate cancer diagnosis I would want that cancer removed post haste.
3
The article misses this: Urologists are one of the very few specialists that do their own surgeries. Most other specialists refer to a surgeon. That means urologists are financially inclined to recommend surgery. Remember that when you get a surgery recommendation.
Who does it to you is as equally as important as what they do to you. The age of the stand offish doc "oh but he's really good" are over. Doctor knows best alright, for the doctor. If you don't feel totally confident in your doc, run. Not to say there aren't good docs out there, because there are.
Biopsies are primitive, a practice that should have been stopped long ago with the advent of new technology. Look for other tests before you submit to a biopsy.
Finally, even the "big" clinics are not foolproof. In spite of their reputation my friend had terrible experience at Cleveland Clinic. Fail.
Take matters into your own hands. Research, ask questions, get 2nd and 3rd opinions. Good luck.
Who does it to you is as equally as important as what they do to you. The age of the stand offish doc "oh but he's really good" are over. Doctor knows best alright, for the doctor. If you don't feel totally confident in your doc, run. Not to say there aren't good docs out there, because there are.
Biopsies are primitive, a practice that should have been stopped long ago with the advent of new technology. Look for other tests before you submit to a biopsy.
Finally, even the "big" clinics are not foolproof. In spite of their reputation my friend had terrible experience at Cleveland Clinic. Fail.
Take matters into your own hands. Research, ask questions, get 2nd and 3rd opinions. Good luck.
8
Medical treatment based largely on statistics? No thanks.
The decision requires informed intelligence. For starters this means a second opinion after in depth discussions with one's primary care team.
This saved me from a round of fairly aggressive chemo I did not need. That was fifteen years ago and the indolent N. H. Lymphoma is still moving very slowly. My every two year CT Scan will be in September.
My best friend adopted a watchful waiting attitude and lived less than four years after a small slow cancer was diagnosed. Each case has to be handled individually.
The decision requires informed intelligence. For starters this means a second opinion after in depth discussions with one's primary care team.
This saved me from a round of fairly aggressive chemo I did not need. That was fifteen years ago and the indolent N. H. Lymphoma is still moving very slowly. My every two year CT Scan will be in September.
My best friend adopted a watchful waiting attitude and lived less than four years after a small slow cancer was diagnosed. Each case has to be handled individually.
4
The accurate prostate cancer diagnosis and staging tests and procedures are changing rapidly and treatment options depend more and more on diagnosis and staging. Many consensus opinions about when and how to be tested are somewhat antiquated when they come out because they rely on data and guidelines written years ago.
Contrary to some comments and opinions, dealing with PCa, especially its diagnosis, should not be looked upon as largely a patient decision. What's missing for most men is the ability to speak with expert and up to date urologists as well as access to centers of excellence for treatment, if needed.
Contrary to some comments and opinions, dealing with PCa, especially its diagnosis, should not be looked upon as largely a patient decision. What's missing for most men is the ability to speak with expert and up to date urologists as well as access to centers of excellence for treatment, if needed.
1
the trouble is no one can actually see the cancer, so no one truly knows what you have. that's what confounded me when my time came. gleeson 6, i had a choice. biopsy, MRI, palpitate, it was hard to tell exactly what was there. so you guess. it's a bet, like it says in the story. a life gamble. in my case, i went for safety - removal. in pathology, it turned out it was in both lobes, not just the one initially diagnosed, and of a more aggressive type than the biopsy revealed. i don't really understand why anyone on the cusp would take a chance on something like this. i've always suspected the massive pr campaign against treatment was based on cost, and manifested by insurance corporations stealthily, as they do. too many surgeries they were paying for.
3
Several years ago, I had a hospital in WI that asked me to help them design new operating theaters - they wanted to make those theaters as ergonomic as possible to make their surgeons and their staff more efficient. This required that I "scrub in" and wear all the appropriate clothing and a mask. One of the procedures I watched was a prostatectomy. The surgeon to remove the prostate the surgeon must attach knives to his/her fingers and cut away the prostate.
I wondered how they kept from damaging surrounding tissue. Well they do and the result is incontinence and impotence in many men. There are other dangers also any time one has surgery. A close friend had a prostateectomy and the anesthesiologist took him down too far and he lost most of his memory and this was a brilliant research person.
I once also sold for a very short time a urodynamics system to determine why females were incontinent. I became uncomfortable because all of the women tested were to receive a wire mesh implant to stabilize their bladder and IMHO all they needed was to do Kegels exercises. Now of course this procedure is almost never done - lawsuits stopped it.
My friends in the same rep business as myself later told me they knew I would not last selling these systems. One even quipped that his urologists scheduled the surgery before seeing the test.
Urologists can be very dangerous to your health - beware.
I wondered how they kept from damaging surrounding tissue. Well they do and the result is incontinence and impotence in many men. There are other dangers also any time one has surgery. A close friend had a prostateectomy and the anesthesiologist took him down too far and he lost most of his memory and this was a brilliant research person.
I once also sold for a very short time a urodynamics system to determine why females were incontinent. I became uncomfortable because all of the women tested were to receive a wire mesh implant to stabilize their bladder and IMHO all they needed was to do Kegels exercises. Now of course this procedure is almost never done - lawsuits stopped it.
My friends in the same rep business as myself later told me they knew I would not last selling these systems. One even quipped that his urologists scheduled the surgery before seeing the test.
Urologists can be very dangerous to your health - beware.
9
I was 42 when a low, but rising PSA indicated prostate cancer. A biopsy confirmed prostate cancer was present, which was classified as Gleason 7. What I would not have known without having surgery was that the cancer was not just confined to my prostate, but actually was locally advanced having also entered the prostate bed. The surgery ultimately failed and I required salvage radiation treatment, considered a secondary curative approach. I've now been cancer free for over 2 years post radiation, but had I not been properly guided by my urologists I fear my life expectancy would have been shortened.
It's a very personal decision and the side effects are real. What I hope those with prostate cancer give thought to is that biopsies don't tell the whole story. I'm deeply sorry for anyone faced with this dilemma.
It's a very personal decision and the side effects are real. What I hope those with prostate cancer give thought to is that biopsies don't tell the whole story. I'm deeply sorry for anyone faced with this dilemma.
3
I was diagnosed with Prostate cancer in 2015 with a Gleason number of 6. My Doctor suggested keeping an eye on it and on my very next PSA test the number went from 4 to 8. That was just 3 months later. Not what we had expected but other cancers had been treated in 2013 that was attributed to Agent Orange exposure so just a precautionary note to those men in similar situations.
1
Readers need to keep in mind that observation and monitoring is just one approach. Having been through treatment for bladder cancer, radiation and chemo, I can attest to the fact that my whole groin, prostate, rectum area has been damaged. Sure I am a "survivor" but nothing is free and at 80 years of age, I will continue to be fighting damage done by the Cure.
All I would say to those who suffer prostate cancer is, "Be very careful!" There are many considerations.
All I would say to those who suffer prostate cancer is, "Be very careful!" There are many considerations.
17
Thank you for you comment. I agree with you advice to be careful and consider your options. However, bladder cancer is a very different animal compared to low grade prostate cancers. If invasive into the muscle it can metastasize and possibly lead to an early death if not treated. Not treatment is not advisable for muscle invasive bladder cancer for an otherwise healthy patient.
1
As usual with the prostate, it's always filled with uncertainty and dread. Definitive answers are hard to come by. The "cure" seems worse than the disease, but spreading cancer kills.
Educated guesses is really all we have.
A tangential point: Some men complain that they shouldn't be paying for the insurance of a woman's maternal health issues. Well guys, women pay for OUR prostate needs.
Educated guesses is really all we have.
A tangential point: Some men complain that they shouldn't be paying for the insurance of a woman's maternal health issues. Well guys, women pay for OUR prostate needs.
3
My son was diagnosed at 39 . He had witnessed his father pass away in agony at age 54, he opted for surgery - the choice depends on genetics , choices, type of prostate cancer rather than the numbers
7
Prostate cancer is a longterm disease. Therefore changes in treatments take time to evaluate. Optimally the patient should be given all the options and they should decide. Of course it needs to be an informed decision since it is their life.
1
Unfortunately the Gleason cannot determine if your cancer is fast growing or not.
So a "6" or a "7" Gleason is indeterminate.
The article skips over what the Gleason score really is: it is a visual inspection of cells by a human technician to see if any are cancerous cells. The inspection tries to pick a number that indicates how many cancer cells are there on the slide before her/him. If it sounds a bit subjective if you get a 6 or a 7, that is because it is.
So a "6" or a "7" Gleason is indeterminate.
The article skips over what the Gleason score really is: it is a visual inspection of cells by a human technician to see if any are cancerous cells. The inspection tries to pick a number that indicates how many cancer cells are there on the slide before her/him. If it sounds a bit subjective if you get a 6 or a 7, that is because it is.
3
Sorry- but your understanding of the Gleason System is a bit inaccurate. A physician (a pathologist such as myself) examines the slides from a prostate biopsy and determines if malignant cells are present and then determines the growth pattern of the malignant cells. The Gleason score is related to these growth patterns. I will agree that there is some subjectivity, but it is totally independent of the number of cancer cells present.
5
Gleason is based on a preponderance of certain cell characteristics -- Gleason 7 can be composed of cells 4+3 or cells 3+4. Those cells with a score of 4 (as in the first calculation) are considered more aggressive because of their population preponderance -- the reverse is the case with the 3+4 calculation.
So I Gleason score of 7 needs to be broken down and understood by the patient.
So I Gleason score of 7 needs to be broken down and understood by the patient.
4
It makes a person wonder how long we live with cancer, not only proostate cancer, if tests are not done in the first place, and survive.
1
Readers should research the OncotypeDx Test which currently is used to evaluate Breast Cancer treatment risk, and now is being studied to see if it can be applied to Prostate Cancer treatment risk.
1
We (and you) should not refer to early choice to apply interventions as "treatment". This misleads the reader and perpetuates the myth that these activities are "treating" something.
Applying activity to something that does not require treatment is simply a waste of funds and time and can create side effects and damage.
Applying activity to something that does not require treatment is simply a waste of funds and time and can create side effects and damage.
2
The random needle biopsy as a diagnostic tool for prostate cancer should be a thing of the past. As is noted in the article the test causes sometimes serious infections and it can miss aggressive cancer. The latest generation of MRI scanners, call 3 Tesla or 3T, can see all but the tiniest tumors. The ones they can't see almost certainly don't matter. Men with high PSA numbers nees to look for centers that are experienced with what are called multiparametric prostate scans. I'm on active surveillance and have a scan at the Cleveland Clinic every 12 to 18 months along with PSA tests every 6 months. A listing of centers offering these scans can be found at www.pcri.org.
8
This article fails to mention that the scientific basis for "following" newly diagnosed cases is as flimsy as the original rationale for surgery. There is no validated method for follow-up to decide when to intervene. The trend the article describes is a justifiable reaction to excessive surgical enthusiasm but doesn't replace it with a proven alternative. Once again expertise is oversold.
3
If you think getting prostate biopsies on a regular basis is not an issue, try again. It is one of the more painful procedures you can imagine - 8 snippets he said...count them, - I couldn't count past two. Ouch.
4
I am 69 years old. I have been on active surveillance for a number of years now. I have DRE and PSA test every 6 months or so and a biopsy about every 18 months. I have the greatest amount of trust in my doctor at the Cleveland Clinic. He is an expert. Biopsies are never fun and always uncomfortable. They never last more than about 5 minutes or so. But, as far as pain is concerned, I can tell you that the doctor's expertise is key. My doctor is very quick and gentle and I experience only a little pain. However, I have had less experienced residents give it a try for a few snips and it feels like they're taking big chunks rather than little snippets. I only let my doctor do them now. In any case, a little humor about it on both sides of the bottom are necessary and helpful.
1
Ask your doctor to presribe a sedative/anesthetic.
1
As a medical oncologist who specialized in the treatment of prostate cancer prior to retirement, I am a bit dismayed that the author did not interview any of the leading oncologists at the larger institutions who specialize in the treatment of prostate cancer. There would have been a fuller discussion of active surveillance. A Gleason score is the combination of two numbers based on the histology of the specimen. Gleason 6 is actually the lowest score prostate cancers receive these days. Nobody gets a lower score anymore and patients with a Gleason 6 are usually the best candidates for active surveillance. Consultation with a medical oncologist, especially one specializing in the treatment of prostate cancer is highly advisable.
32
My father was diagnosed with prostate cancer in his mid-70's. He was told it was slow-growing and they would watch it. They monitored him regularly, but it eventually metastasized and he died at 84. That isn't a young age to die, but I dearly wish I could have had my Dad for a few more years. His mother lived to nearly 100, so the genes for longevity were definitely there. Early treatment might have given him a chance to break her record.
3
It is all designed to save money for the government (the largest insurer) and the private insurance companies. Doctors have grown a social conscience and now prioritize saving medical resources for others rather than their ethical obligation to place their patient's interest first.
Women howled when it was encouraged to test less for breast cancer, and the effort was promptly killed. No one protests when medical resources are saved from men.
Women howled when it was encouraged to test less for breast cancer, and the effort was promptly killed. No one protests when medical resources are saved from men.
3
The most important aspect of this article is to fully consider your options if you get an indication that you might have prostate cancer. Too many of us rush to "get it out" without considering all of our options specific to our disease. As the article notes, not every diagnosis presents the same set of facts about what might be considered as options.
My father was diagnosed with his cancer in his mid-60s (early 1990s) and took the time to explore his options In the literature and the best cancer centers in the country. His research led him to Sloan Kettering to have the radioactive seed implants as his treatment. He never had any incontinence or impotence side effects and his cancer was not the cause of his eventual death 15 years later.
His experience with urologists at that time led him to the conclusion that too many of them were prone to recommend removal surgery, rather than watchful waiting or alternative treatments like the one he chose at the time. To help other men, he founded The Protate Forum in Southern California, which provided support for en faced with the decision of what to do about their cancers. The Forum also provides support for men who have cancers too late for most treatments. I don't know if there are Protate Forum groups elsewhere in the country, but he believed that taking the time to assess a man's options, with the support of others who are and have been dealing with their disease was critical to a good outcome for most men.
My father was diagnosed with his cancer in his mid-60s (early 1990s) and took the time to explore his options In the literature and the best cancer centers in the country. His research led him to Sloan Kettering to have the radioactive seed implants as his treatment. He never had any incontinence or impotence side effects and his cancer was not the cause of his eventual death 15 years later.
His experience with urologists at that time led him to the conclusion that too many of them were prone to recommend removal surgery, rather than watchful waiting or alternative treatments like the one he chose at the time. To help other men, he founded The Protate Forum in Southern California, which provided support for en faced with the decision of what to do about their cancers. The Forum also provides support for men who have cancers too late for most treatments. I don't know if there are Protate Forum groups elsewhere in the country, but he believed that taking the time to assess a man's options, with the support of others who are and have been dealing with their disease was critical to a good outcome for most men.
10
your dad had the right idea--the Longwood PC Support Group in Boston is one of many around the country--run by men for men, with great peer support to counter the too prevalent macho attitude of "cut it out , doc"..........
1
"urologists at that time led him to the conclusion that too many of them were prone to recommend removal surgery,"
Surgeons do surgery. Don't expect too many of them to recommend CyberKnife which has better results and far fewer side effects.
The writer should do a follow up article on CyberKnife .
Surgeons do surgery. Don't expect too many of them to recommend CyberKnife which has better results and far fewer side effects.
The writer should do a follow up article on CyberKnife .
2
It has long been known that prostate cancer is often a disease men die with rather than of. We all die -- sometime that seems to be forever forgotten...l
This is excellent news. Instead of dispensing unnecessary treatment, maybe the MDs can do something more impt with their time and training.
This is excellent news. Instead of dispensing unnecessary treatment, maybe the MDs can do something more impt with their time and training.
5
Spoken like someone with the good fortune of no firsthand experience to the contrary. Remember the bell curve. Someone lives at either end.
2
I have prostate surgery about 13 months ago. the psa score was 8 before the surgery. The urologist also recommended hormone therapy and radiation . the current psa score is at zero or below.
some of my family members got it too.
Leakage control would be an adjustment problem.
I have friends who got their prostate cancer spreading to their bones at stage 4 at early 40's I have empathy for their family..
Lifestyle change is vital for the conquering of cancer.
some of my family members got it too.
Leakage control would be an adjustment problem.
I have friends who got their prostate cancer spreading to their bones at stage 4 at early 40's I have empathy for their family..
Lifestyle change is vital for the conquering of cancer.
3
Six years ago I was diagnosed with prostate cancer with a Gleason 4+3 = 7 score; what I was led to believe by my urologist was “intermediate risk” cancer. The urologist said with a Gleason score like that I should probably seek some kind of treatment, such as a prostatectomy or radiation using seeds. After 4 months of investigation, including poring over medical journals, and reading the information provided by a Seattle medical center where I was considering seeking surgical treatment, I chose to have a robotic assisted prostatectomy at the Seattle hospital. My decision to have the surgery was influenced partly by the hospital information which indicated that only 8% of their prostatectomy customers (I no longer use the term “patient”) were afflicted with incontinence as a result of the surgery and partly due to the supposedly highly skilled and recommended surgeon at the medical facility. After my surgery I learned that, based on a much more thorough pathological examination of the entire prostate tissue that my Gleason Score was 3+3 = 6, low risk prostate cancer. It wasn’t 3+4, it was 3+3; there was no sign of the Grade 4 cancer cells supposedly present in my initial biopsy. Today I remain impotent and incontinent. The surgery may have saved my life, but it definitely ruined my life. I deeply regret ever having a PSA test, the biopsy and particularly the “treatment”. Yes, these were my decisions, my wounds are self-inflicted, and my weapons of choice were doctors.
38
Mephitis, I am sorry to read about the tragic consequences of your surgery. Perhaps someone here will do things differently based on your experience.
2
My father was told at age 73 he had an elevated PSA and should have surgery immediately. We researched PSA levels and discovered his level was within normal limits. He refused treatment and died at age 96. Question authority. The best advise from my wise Grandfather.
11
Always, always not only question, but challenge the establishment. Everything has been corrupted by greed where there is little concern who and how many they kill as long as they get paid.
This is true of our politicians, government agencies, the drug and medical industry, corporations and even our legal system. These crimes against humanity are acceptable practices that makes us all feel entitled to our fair share.
This is true of our politicians, government agencies, the drug and medical industry, corporations and even our legal system. These crimes against humanity are acceptable practices that makes us all feel entitled to our fair share.
2
That could have been 23 years of hell...
1
The comments for this piece are among the most comprehensive and balanced I've ever read. I have 'been there/done that' after a Gleason 7 and robotic surgery 5 yrs ago at age 66. My takeaways: 1) Don't be afraid of biopsies; I'm sure they aren't the same for everyone but in my experience discomfort is minor and over in a day or two. Surveillance w/o followup biopsies would be mighty risky.Without biopsies you are flying blind on Gleason scores which are the most important info. 2) Everybody needs to make their own assessment of the personal impact on themselves of the side effects of surgery, but best to accept that even a very experienced surgeon isn't going to have a great batting average on avoiding impotency. Incontinence is I think far more likely to be transitory and not a long term issue. 3) 10 years from now discussions like these will be far more tilted toward stories of horrible deaths from over-adoption of surveillance and the pendulem will swing back toward treatment. 4) 10 years from now there will be far better treatment options than those presently available. Good luck to all in making this very personal decision.
12
Quote from the article: “The problem with men, when they find out they have something like this, it’s like, ‘Get it out now, I don’t want it in me.’"
I don't think that is a single gender reaction. I'm sure most women would react the same.
I don't think that is a single gender reaction. I'm sure most women would react the same.
13
"Men" is here being used here not to denote a gender-specific reaction, but as the word "people" would be (that's because "people" would sound odd, since women don't have prostates)
It seems that one - but only one - commenter here mentions HIFU, which kills off the cancer with High Intensity Focused Ultrasound and has minimal risk of traumatizing side effects. So let me add this urging to any man facing a prostate cancer decision: Make sure you learn about HIFU as one of your options. In California, it is a state mandate that doctors must tell patients about every single option available. Given how often it seems many men still are not fully informed about every option, it becomes disconcerting that any one article, like this one, would focus on only one option, whatever it is, without at least mentioning all the other options as well. Otherwise, it's piecemeal information that skews perception.
HIFU has been available in Europe for more than 25 years and has become the most sought option in Europe. Urologists in France and Germany have led the HIFU frontier and its research studies. It took more than 10 years for the FDA to finally approve its use in the U.S. as of approximately a year ago. Which is good news.
However, Europe has already refined both the hardware and software of HIFU technology in Europe in a second generation of HIFU called Focal One HIFU that is more sophisticated, more able to access and kill off cancer in trickier areas, for example, just inside the prostate wall. For this latest advance in treatment, one still has to travel to Europe, but the HIFU costs in Europe (blessed Medicare for All) are a fraction of U.S. costs.
HIFU has been available in Europe for more than 25 years and has become the most sought option in Europe. Urologists in France and Germany have led the HIFU frontier and its research studies. It took more than 10 years for the FDA to finally approve its use in the U.S. as of approximately a year ago. Which is good news.
However, Europe has already refined both the hardware and software of HIFU technology in Europe in a second generation of HIFU called Focal One HIFU that is more sophisticated, more able to access and kill off cancer in trickier areas, for example, just inside the prostate wall. For this latest advance in treatment, one still has to travel to Europe, but the HIFU costs in Europe (blessed Medicare for All) are a fraction of U.S. costs.
10
At last some good information existing within the medical establishment. If it works, is it approved for payment by Medicare and most insurance companies?
2
The original HIFU that is now approved in the U.S. is, as I understand, covered by Medicare and presumably most insurance companies, although you'd have to check yours to verify. Going to Europe (the two sites I am aware of are in Nuremberg, Germany - Dr. Andreas Blana - and in Lyon, France - Dr. Sebastien Crouzet - are the lead doctors who developed HIFU, respectively) is not covered by Medicare etc., but the combined hospital and doctor bills tend to run less than $5,000, a bit more if someone also needs a TURP to reduce the size of the prostate as well. Both doctors are googlable if interested (in which case you'll see some entries for Dr. Blana indicate Regensburg - it's the same doctor, still an old listing where he used to be located). A good urologist should be aware of these names in their field and these options. I know of at least one urologist in L.A. area who makes trips with patients from here to Germany for the newer Focal One HIFU procedure, the advance which was developed by Dr. Crouzet in Lyon and for the past year or two has been done in Germany as well.
Good luck!
Good luck!
p.s. to Mr. Magoo: Any urologist now performing HIFU in the U.S. should or would probably have been trained directly by the doctors I named in my prior reply to you, either Dr. Blana or Dr. Crouzet or their respective teams of doctors. To my mind, that would be an important 'credential' or criteria for a U.S. doctor – to have been directly trained by one or more of them.
Our prostate cancer lesson: Do your own research! You will be diagnosed by a urologist, who is a surgeon, and he might tell you that your only option is surgery. Having just absorbed the word "cancer" and knowing nothing about prostate cancer treatment, many of you will opt for treatment that will drastically impact your life and may well not arrest your disease.
When my husband was diagnosed in 2008 his urologist gave him the news somewhat dramatically and advised him to schedule surgery "right away." Luckily, his wife is a researcher and I immediately jumped online. Although it was important to learn about Gleason scores and PSA tests, the best resources were not medical ones but compilations of other mens' experiences--primarily one called "You Are Not Alone" (www.yananow.org) founded by Terry Herbert, an Australian with a dry wit and indomitable spirit (he died in 2014 after 18 years with the disease). He is a hero to many including us.
We learned that surgery was not a viable option for my husband's cancer (Gleason 6 but later biopsy elevated it to a 7) because the cancer was already "out of the capsule" as many cancers are by the time they are detected.
Bob had brachytherapy (implantation of radioactive seeds) and today is 71, healthy and thriving.
I am sure there are highly ethical urologists who will lay out all viable options for their shaken newly-diagnosed patients, but ours wasn't and yours may not be either. Caveat emptor, here as everywhere.
When my husband was diagnosed in 2008 his urologist gave him the news somewhat dramatically and advised him to schedule surgery "right away." Luckily, his wife is a researcher and I immediately jumped online. Although it was important to learn about Gleason scores and PSA tests, the best resources were not medical ones but compilations of other mens' experiences--primarily one called "You Are Not Alone" (www.yananow.org) founded by Terry Herbert, an Australian with a dry wit and indomitable spirit (he died in 2014 after 18 years with the disease). He is a hero to many including us.
We learned that surgery was not a viable option for my husband's cancer (Gleason 6 but later biopsy elevated it to a 7) because the cancer was already "out of the capsule" as many cancers are by the time they are detected.
Bob had brachytherapy (implantation of radioactive seeds) and today is 71, healthy and thriving.
I am sure there are highly ethical urologists who will lay out all viable options for their shaken newly-diagnosed patients, but ours wasn't and yours may not be either. Caveat emptor, here as everywhere.
11
I was diagnosed with prostate cancer five years ago and treated with seed radiation. I chose radiation treatment over "watchful waiting" because of family history, and excluded surgery as an option because of concern about impotence. My experience with the medical community (private practice) was that my diagnosis transformed me into a walking dollar sign, particularly with the surgeons that had invested in multi-million dollar robotic surgical devices. My recommendation to the similarly affected readers is that you need to take aggressive control over your options and your treatment if you choose to treat the disease because a) each situation is different and b) the docs you speak with have motivations that don't always line up with your best interests. Looking back I'm glad I treated my cancer because I haven't looked over my shoulder since, and I was fortunate enough not to have suffered a long spell of impotence. I also stepped up my exercise routines because it leads me to believe that I have a measure of control over the eventual outcome, which is ultimately whether or not the cancer returns. So far, so good!
7
All the articles you see around there are a reaction of the urologists hit hard by the reality of the malpractice that went on for so long, and costed so much of the quality of life of so many men..Who remember the festivals of massive PSA testings? A massive criminal malpractice, not that I say it, the government has disclosed the "mistake". Mistake?
Having been diagnosed with prostate cancer at age 49, I opted to have Dr. Catalona, who you cite in this article, perform traditional prostatectomy surgery. Already I could feel increasing severe pain in the pelvic bones and the urological symptoms worsened markedly from the initial suspicion until I had surgery. And only after the surgery did I discover that the cancer was indeed aggressive and invasive, having destroyed a lot of the nerves in that area. I knew immediately upon hearing the post-op information that I had made the correct choice, though active surveillance was presented as an option. Had I neglected to have the surgery, I'm certain that I would have succumbed to prostate cancer years ago.
11
That is the problem with a surgeon, they do surgery to earn their living.
9
You are correct. Doctors are paid based on procedures delivered. The better system for the patient is where doctors are paid a base salary plus a bonus based on outcome. This better but is also problematic because an all-clear outcome may not be truly known for several years.
There is no perfect system but clearly the one doctors prefer which is getting paid for every procedure and test that can be reasonably justified and/or approved by insurance providers is needlessly increasing medical costs.
There is no perfect system but clearly the one doctors prefer which is getting paid for every procedure and test that can be reasonably justified and/or approved by insurance providers is needlessly increasing medical costs.
1
I'm 59 and am on active surveillance. My second biopsy showed no signs of cancer, indicating how little I have. While the biopsies are not fun, I'm very comfortable with a wait and watch approach.
5
My uncle in Charleston SC died of prostate cancer years ago. That statistic in our family, although he was not a blood relative, has always stuck with me. My father never had prostate cancer but he got tested 2 or 3 times a year. Lived to be 91.
3
If there was a prostate removal surgery that didnt have so many very real lifelong complications, then many many men over 70 would simply have it removed as a preventative.
** But there is no surgery like that ** and the life long complications are very real.
And that is why there is "watch and wait." No one at 60 wants a 20% chance to be both incontinent and impotent.
4
"Watchful waiting" is one of the most misleading phrases to come out of this discourse on prostate cancer. At 44, my PSA was quite high (16.5). While I continue to monitor my PSA, I have opted to pursue an alternative approach to treatment, which includes chelation of heavy metals such as cadmium, which settle in the prostate gland. My treatment includes green juicing of cucumbers, celery, pea shoot sprouts, sunflower sprouts, ingesting the master antioxidant Glutathione regularly, IV treatments with high dose Vitamin C, far infrared saunas and other holistic modalities, that are NEVER mentioned in articles such as this. To the author of this article - why don't you explore the alternative modalities men are using to lower PSA instead of the same old, same old?? Nutrition, Detoxification and Exercise are the answers to this problem, not drugs and surgery and radiation. This article also fails to mention the profit motive on behalf of many physicians who are making a killing performing biopsies and other medical procedures. Why doesn't the New York Times report on that?
Having recently entered the active surveillance world, with a increasing PSA trend that worried me, I would like to share some observations.
Find a doctor that you can talk to, preferably one that doesn't have a jammed office. The first doctor I tried was highly recommended, his waiting room was packed every time I went, and he wanted a biopsy immediately, without much of a talk. I found another doctor, also highly rated, who spent time with me and discussed how to proceed. We watched the PSA trend and then went with a biopsy after a couple 50% increases. The biopsies have not been too bad, certainly much better than prepping for a colonoscopy.
READ and RESEARCH. Look at stuff from medical journals, not the self diagnosis sites (they will more than likely just panic you). I don't understand all of the terminology, but it has helped me understand the process and ask the right questions. Don't be embarrassed to ask questions. Heck, I had never heard of ASAP or PIN/HGPIN before.
My doctor teaches as well and has interns who sometimes examine or talk with me, they have all been great. Don't look at them as adversaries, look at them as team mates. If you have fears and worries, share them, it helps.
The hardest thing is that even the best doctor doesn't know how your diagnosis will progress with 100% certainty. Time may be on your side, diagnosis & treatment options do get better.
Find a doctor that you can talk to, preferably one that doesn't have a jammed office. The first doctor I tried was highly recommended, his waiting room was packed every time I went, and he wanted a biopsy immediately, without much of a talk. I found another doctor, also highly rated, who spent time with me and discussed how to proceed. We watched the PSA trend and then went with a biopsy after a couple 50% increases. The biopsies have not been too bad, certainly much better than prepping for a colonoscopy.
READ and RESEARCH. Look at stuff from medical journals, not the self diagnosis sites (they will more than likely just panic you). I don't understand all of the terminology, but it has helped me understand the process and ask the right questions. Don't be embarrassed to ask questions. Heck, I had never heard of ASAP or PIN/HGPIN before.
My doctor teaches as well and has interns who sometimes examine or talk with me, they have all been great. Don't look at them as adversaries, look at them as team mates. If you have fears and worries, share them, it helps.
The hardest thing is that even the best doctor doesn't know how your diagnosis will progress with 100% certainty. Time may be on your side, diagnosis & treatment options do get better.
6
As a prostate cancer survivor I can attest to the value of active surveillance. I was diagnosed with prostate cancer after a biopsy in September of 2006. I was 65 years old. My Gleason score at that time was 6.
I chose to have radiation treatment in 2016. My Gleason score went up to about 10 and my PSA number rose to 11.9. These numbers were evident after a second biopsy in 2015. Active surveillance is a good alternative to surgery or radiation, especially if diagnosed at an older age. I can't say with any certainty what might have happened if I had chosen radiation treatment earlier. Whether radiation or surgery one must expect complications and side effects. No treatment is perfect and side effects are real.
If you are diagnosed with prostate cancer, do the research, consult with more than one urologist as well as your primary care physician and after make a decision as to how to proceed. Prostate cancer does increase frequency of urination, and that can be more than simply annoying.
Finally, every person is different, and every person must make a decision sooner or later.
I chose to have radiation treatment in 2016. My Gleason score went up to about 10 and my PSA number rose to 11.9. These numbers were evident after a second biopsy in 2015. Active surveillance is a good alternative to surgery or radiation, especially if diagnosed at an older age. I can't say with any certainty what might have happened if I had chosen radiation treatment earlier. Whether radiation or surgery one must expect complications and side effects. No treatment is perfect and side effects are real.
If you are diagnosed with prostate cancer, do the research, consult with more than one urologist as well as your primary care physician and after make a decision as to how to proceed. Prostate cancer does increase frequency of urination, and that can be more than simply annoying.
Finally, every person is different, and every person must make a decision sooner or later.
18
Not once in this article is there a mention of a proactive way to reduce or eliminate prostate cancer. Why isn't diet, exercise, weight loss, and other forms of treatment mentioned in this article? That's what I was looking for.I know there's no magic bullet but any information helps even a placebo. More due diligence please.
13
@g.i.
l.a
That's because there isn't a pro active way to reduce or eliminate prostate cancer. Why not try doing a bit of due diligence of your own.
l.a
That's because there isn't a pro active way to reduce or eliminate prostate cancer. Why not try doing a bit of due diligence of your own.
15
g.i. I think that the reason there is no mention in the article of a proactive way to reduce or eliminate prostate cancer is because there is none known. I am 68 years of age, exercised for most of my life and followed a reasonable diet, quit smoking at age 13, quit drinking alcohol at age 21and yet 2 years ago was diagnosed with Gleason 7 malignant cores in my prostate. I certainly did not hesitate to have a radical prostatectomy. If your Gleason score is 7 or above I do not think that you really have a choice. My surgeon could not even tell me how long he thought the tumor had been growing. He certainly could not tell me what might have caused it. It seems g.i. that medicine and science have not yet advanced to the point where these things can be determined.
It seems that all that is known is that men are at at a greater risk of coming down with prostate cancer if they are black, are getting old (over 50 or so) or have a history of it in their family. The latter risk factor indicates that some genetic condition is involved but if this is so then details are yet to be elucidated.
It seems that all that is known is that men are at at a greater risk of coming down with prostate cancer if they are black, are getting old (over 50 or so) or have a history of it in their family. The latter risk factor indicates that some genetic condition is involved but if this is so then details are yet to be elucidated.
4
Excellent point. I always discuss this with my patients after our initial discussion about how to treat their prostate cancer (PCa). It is especially important for younger men considering active surveillance. The healthier your lifestyle is, the better your chances are of keeping the PCa in "low gear"( or from getting the disease in the first place.)
What is a healthy lifestyle ? I tell men to learn about something called the Metabolic Syndrome. Most of my patients have it to some degree and it is well worth avoiding this deadly mix of medical conditions. If you can become a vegan, do it. Short of that, increase your cruciferous veggie intake and lower your animal fat intake. Exercise every day. A serving of soy every day is a reasonable thing to do, but don't overdo this . Pomegranate juice and lycopene (from raw tomatoes) seem to be a good idea.
Avoid slickly packaged " Super Dude Prosta-Miracle" supplements.
About 10 years ago , Fortune magazine did an article about Michael Milken and his involvement with PCa as a patient and activist. A great read that got me keyed into the nutritional angle of fighting PCa. Check it out if you can.
What is a healthy lifestyle ? I tell men to learn about something called the Metabolic Syndrome. Most of my patients have it to some degree and it is well worth avoiding this deadly mix of medical conditions. If you can become a vegan, do it. Short of that, increase your cruciferous veggie intake and lower your animal fat intake. Exercise every day. A serving of soy every day is a reasonable thing to do, but don't overdo this . Pomegranate juice and lycopene (from raw tomatoes) seem to be a good idea.
Avoid slickly packaged " Super Dude Prosta-Miracle" supplements.
About 10 years ago , Fortune magazine did an article about Michael Milken and his involvement with PCa as a patient and activist. A great read that got me keyed into the nutritional angle of fighting PCa. Check it out if you can.
5
If you are contemplating active surveillance, talk to your urologist about getting a prostate MRI (ideally 3T with endorectal coil). This serves two purposes: 1. to evaluate for areas of the prostate potentially harboring higher Gleason grade disease that may have been missed on biopsy and 2. to serve as a baseline for comparison during surveillance. There is emerging evidence that serial MRI may serve as a non-invasive alternative to repeat prostate biopsy. The MRI should be obtained >6 weeks (ideally >8 weeks) after prostate biopsy, because the artifact from wound healing can increase false positives. The MRI can also be obtained prior to initial prostate biopsy.
http://www.ncbi.nlm.nih.gov/pubmed/26482887
http://www.ncbi.nlm.nih.gov/pubmed/26482887
48
Prior to a follow up biopsy, to use as a guide for the team, possibly more important if you are only showing abnormalities in one or two samples. MRI resolutions are getting better, as is the information that the procedure provides.
3
I was diagnosed with prostate cancer at age 68, in late 2006, with a PSA of 7.1 and a Gleason score between 6-7. After extensive research, I opted for 8 weeks of proton radiation, which is considered the safest form of radiation. My side effects have been minimal since treatment and my PSA has been consistently in the .4 to .5 range for the past few years. Most urologists try to convince their patients that surgery is the best treatment, which I think is a big mistake because of the potential for incontinence and impotence. I highly recommend that any men considering treatment for prostate cancer read the book "You Can Beat Prostate Cancer" by Robert J. Marckini. Robert is a strong advocate of proton radiation. He has a website (https://protonbob.com) with over 8,000 members who have been successfully treated with proton radiation. This is not meant to be an advertisement. My intent here is to help other men who are faced with the tough decision of how to treat their prostate cancer.
30
At the tender age of 55 I too decided after a ton of research, including the "Marckini"book, to receive proton beam treatment at Loma Linda University Hospital. I was a prime candidate. Never smoked, casual drinker, very active, and ate well. Initially, my urologist recommended surgery as soon as possible and NEVER mentioned proton beam therapy. He gave me a book that scared the devil out of me. The thought of impotence and incontinence, all while being a single man was a harbinger of a continuing single life. Surgery, I soon learned is standard practice for most urologists; money in the bank. When I returned and mentioned proton beam therapy his office partner (my second opinion) scoffed at the idea, indicating it was all experimental. That was factually incorrect, as this form of treatment was being successfully conducted at a number of cancer treatment sites all across the country. Moreover, the treatment was so successful that other sites were being developed and constructed. My PSA is now minuscule and I have not experienced any side effects. I've often thought of returning to my urologist's office with a copy of my PSA results folded inside an autographed copy of the Marckini book. My autograph, of course.
1
Even when fully informed, the decision of what course of action to take is an extremely difficult one.
Some people value quality of life above length of life; in the extreme this can mean no treatment in the face of near certain death from cancer. Others will weight the possible outcomes exactly opposite. Some women who are genetically predisposed to breast cancer opt for removal of perfectly healthy breasts. Similarly, some men at the first hint of cancer will choose aggressive treatment.
I suspect that most people fall between these two extremes. Which makes balancing the choices even more difficult. Different treatments have different odds for different side effects such as incontinence. Odds of duration (lifetime or less) also vary. Weigh that against the odds of untreated cancer spreading faster than it can be stopped, or stopped only with more aggressive treatment later.
Throw into the mix the fact that most people are not good at dealing with odds. Add to that medical science that is changing faster than it takes to know the effectiveness of present treatments, let alone new ones. Yet the longer one waits, the older one becomes, and that tends to limit treatment options.
It's an intractable life and death decision. For me, with a Gleason score of 3+4 (untreated life expectancy of a decade or so) I opted for surgery. A better success rate and it leaves radiation available down the road. A score of 6 would seem to make the choice harder.
Some people value quality of life above length of life; in the extreme this can mean no treatment in the face of near certain death from cancer. Others will weight the possible outcomes exactly opposite. Some women who are genetically predisposed to breast cancer opt for removal of perfectly healthy breasts. Similarly, some men at the first hint of cancer will choose aggressive treatment.
I suspect that most people fall between these two extremes. Which makes balancing the choices even more difficult. Different treatments have different odds for different side effects such as incontinence. Odds of duration (lifetime or less) also vary. Weigh that against the odds of untreated cancer spreading faster than it can be stopped, or stopped only with more aggressive treatment later.
Throw into the mix the fact that most people are not good at dealing with odds. Add to that medical science that is changing faster than it takes to know the effectiveness of present treatments, let alone new ones. Yet the longer one waits, the older one becomes, and that tends to limit treatment options.
It's an intractable life and death decision. For me, with a Gleason score of 3+4 (untreated life expectancy of a decade or so) I opted for surgery. A better success rate and it leaves radiation available down the road. A score of 6 would seem to make the choice harder.
20
It was a PSA test high due to other factors that started my journey. I read up and had doctors who were willing not only to explain by to answer my questions. I'd looked into active surveillance but had cancer in 9 of 11 cores taken, mostly G6 but some 3+4. Surgery followed in 3 months, and the cancer was at that point just growing beyond the capsule, which the imaging had not detected.
9
Please post this
This a way to save money for Governments and Insurance Companies
Next they will treat more forms of cancer and sexually transmit dioceses
Also when people died no more government aid to aged and pensions stop
It is all about saving money
This a way to save money for Governments and Insurance Companies
Next they will treat more forms of cancer and sexually transmit dioceses
Also when people died no more government aid to aged and pensions stop
It is all about saving money
14
This is th most ill informed post. I'm disappointed the Times even posted it.
1
My father was diagnosed with prostate cancer (with no spread to surrounding tissues) in his mid 70's. He chose to forego surgery and had a short round of radiation therapy. His doctor told him that any residual cancer was likely to grow slowly enough that it wouldn't be a problem. He started on hormone therapy several years later. My father died in agony, at age 91, with metastases to his bones. Since I'm not a male, this is not a choice I will ever have to make. However, having watched him during those terrible, final months of his life, I am skeptical about "active surveillance". If you play the odds, there is some probability that you will come out on the losing end. I would not wish that on anyone.
64
I'm with you Rebecca. If others wish to play Russian roulette with their lives, good luck with that. With my enlarged prostate, should the decision ever come to my door, I will opt for removal. I've had head and neck cancer and I'm quite familiar with the devastation that traditional radiation leaves behind.
9
Radiation for Head and Neck cancer and radiation for prostate cancer are vastly different with radical differences in side effects. In fact, they are not even remotely comparable. Please don't lump the two together.
2
R, Until the agony at 91 (which is terrible), how was your dad's quality of daily life from 75 to 90? It is a valid question. At 91 he already "beat the odds" (your expression not mine) and lived 6 years past typical male life expediency. I think this is a complicated topic and your view is valid but not the whole story.
6
One size does not fit all.
I had a PSA of 4.5 when I was 54, and because I was in otherwise good health and working in a non-stop job that left me no free time, it would be four more years until I again saw a doctor. A mistake I regretted.
By then 58 years old, my PSA had advanced to 11. The biopsy was a ridiculously painful two minutes of my life, and it revealed cancer in all twelve core samples (eleven had Gleason scores of 6; one was a 7).
I elected for robotic surgery at Johns Hopkins to remove the Prostate. The surgery was successful and I required no radiation after surgery. The side effects were short-lived as incontinence was gone in a several weeks and sexual function returned a few months post surgery, without the assistance of any ED medicine, even though the surgeon had counseled it would be several months, and perhaps a year, before regaining full sexual function.
I elected to change my diet to reduce sugar consumption and continue to stay very focused on protecting the health of my immune system. I test my PSA every six months since my 2014 surgery and, so far, it has been consistently 0.0. I know I've been fortunate, but I don't regret the decision to pull the surgery lever after my initial diagnosis.
My best wishes to every man who ultimately must navigate this process, but please know there ARE good outcomes ...
I had a PSA of 4.5 when I was 54, and because I was in otherwise good health and working in a non-stop job that left me no free time, it would be four more years until I again saw a doctor. A mistake I regretted.
By then 58 years old, my PSA had advanced to 11. The biopsy was a ridiculously painful two minutes of my life, and it revealed cancer in all twelve core samples (eleven had Gleason scores of 6; one was a 7).
I elected for robotic surgery at Johns Hopkins to remove the Prostate. The surgery was successful and I required no radiation after surgery. The side effects were short-lived as incontinence was gone in a several weeks and sexual function returned a few months post surgery, without the assistance of any ED medicine, even though the surgeon had counseled it would be several months, and perhaps a year, before regaining full sexual function.
I elected to change my diet to reduce sugar consumption and continue to stay very focused on protecting the health of my immune system. I test my PSA every six months since my 2014 surgery and, so far, it has been consistently 0.0. I know I've been fortunate, but I don't regret the decision to pull the surgery lever after my initial diagnosis.
My best wishes to every man who ultimately must navigate this process, but please know there ARE good outcomes ...
54
You made exactly the right decision, and show the important benefits of robotic surgery, but your biopsy results would never have put you in the "active surveillance" or "low-risk" groups. A Gleason score of 7 is qualitatively different than a Gleason 6. "Low risk" also means that no more than 33% of core samples show cancer (you had cancer in 100%), and that the total percentage of cancer within each of those samples averages no more than 50%. It's important that your cautionary tale is seen as one reason to consider routine PSA testing (although this is controversial for some), not as a reason to act on a true low-risk cancer.
2
At 63 I was diagnosed with Gleason 6 in 12 of 18 samples. I would have preferred active surveillance but the extent of my (not-quite?) cancer removed that option,according to every urologist I consulted. My urologist recommended surgery or radiation. I did my own research and discovered that HIFU (high intensity focused ultrasound) has been used to treat prostate cancer for over 15 years in Europe and Japan, but was only recently approved here by the FDA. (Previoualy many Americans had traveled to the Caribbean for HIFU performed by U.S. urologists.). After reviewing the available long term results, I sought out the most experienced HIFU urologist and had the procedure performed three months ago. My first post-HIFU PSA IS tomorrow For anyone who has low-grade cancer confined to the prostate, HIFU is an additional non-invasive treatment option with far ewer side effects than surgery.
23
In the article, Dr Cooperberg has proposed renaming low-grade, low-risk cancers to better reflect their relatively benign nature. I've been pushing for this online since 2014, for both small, slow-growing prostate cancer and clinical stage I (CSI) seminoma testicular cancer. I came around to this view after seeing a close relative's diagnosis of low-grade prostate cancer and then a friend's diagnosis of CSI seminoma cause tremendous psychological damage to both men, in addition to the negative consequences that the word 'cancer' carries for working-age people in the job market. CSI seminoma, for example, has a cure rate approaching 100% (according to Cancer.gov), and the risk of recurrence after surgery to remove the afflicted testicle is about 1% after 3 years, down from 15% at removal - without any radiotherapy or chemo, on active surveillance. It, therefore, has a better long-term prognosis than, for example, Type 2 diabetes, or even smoking tobacco. Something needs to be done to alleviate this unnecessary suffering of hundreds of thousands of people globally every year. Renaming these cancers to better signal that they are low-risk conditions would go a long way.
6
you can have a Gleason 6, but it is in 3/4 of the biopsy samples. Then it could well be outside the prostate into the margins, which poses a risk for distant metastases. Then, if you elect for treatment it is more complicated. So I ask, how are they determining which Gleason 6 or 7 cancers are sleepy and which are active? A trans-rectal coil MRI can reveal if the growths are outside the capsule. Better get one, but it isn't mentioned in the article.
8
MRI can reveal but it also misses a fair bit. genomics seems to have some promise in determining rates of growth.
2
Four years ago at the age of 71 my dad was diagnosed with prostate cancer and with his urologist's blessing he decided to take a wait and see approach. I supported his decision, too, having read many articles like this one. One year after diagnosis it had spread into his bones, and although treatment kept it at bay for three years, last month at the age of 75 he died. To anyone facing prostate cancer I will tell this story, for whatever it's worth.
87
Thanks for telling this story. I'm sorry.
15
But when you shine a light on JUST the gone bad scenarios, you cannot make an informed decision. That is all I am reading here, gone bad scenarios.
2
I will never allow myself to be tested for prostate cancer.
8
Sounds like a plan! To possibly die from prostate cancer.
4
Hope that you don't pay a terrible price for that ignorant attitude. Please read, if you have not already done so, the comments section attached to this article.
3
Metastatic bone/spine cancer originates often in prostate cancer and is excruciatingly painful with debilitation and, often, fatality asfter a year or so.
You wish to bet against that. I wish you luck. In the meantime, do check the bedsheets for blood after love-making and have you doctor report any blood in your urine. Have a digital exam if necessary.
Or not.
You wish to bet against that. I wish you luck. In the meantime, do check the bedsheets for blood after love-making and have you doctor report any blood in your urine. Have a digital exam if necessary.
Or not.
2
I have Gleason 8/9 prostate cancer, I think the first number is the grade, the second is the score. I should know this but I can't search it, it's too much information. The last time I commented here in a prostate cancer article some bozo said something and someone else defended my treatment, so I am not saying anything. I don't understand people who say, "get it out of me." I said, "You are going to ruin my favorite activity." The radiologist said, "Do you know how bad this is?" I said, "I do now."
6
FYI and others, the two scores represent the radiologist's grading of the cancer. They always identify the two most present grades, with the most present of the two first. So you have more cancer cells that are grade 8 than 9. In either case, it's pretty advanced, and I'm glad to learn that you had it treated.
1
Why the change from "watchful waiting" to "active surveillance?"
My guess is because the latter sounds more manly -- more like you're doing something instead of just sitting around.
Very clever - especially if it gets guys to choose the more appropriate treatment.
My guess is because the latter sounds more manly -- more like you're doing something instead of just sitting around.
Very clever - especially if it gets guys to choose the more appropriate treatment.
14
The key word is "cancer," as described in the article. This word is gender neutral, if that helps you.
3
Well that was borderline sexist.
3
Because they are two different things. Watchful waiting is not doing anything until the cancer becomes symptomatic. Active surveillance is checking PSAs frequently, opting for biopsies every 1-2 years, and regular followup with your urologists. For example, if you are 85 when you are diagnosed with Gleason 6 prostate cancer, you might opt for "watchful waiting," meaning that you won't do anything - never check a PSA again, never biopsy again, and never receive treatment again, unless the cancer causes symptoms which might cause one to seek treatment. If you 50 when you are diagnosed, you might opt for "active surveillance" (although you could opt for watchful waiting, if you'd like" check your PSA every 3-6 months, get biopsied every 1-2 years, and seek treatment if the cancer is evolving into the more aggressive nature, even if still asymptomatic. Two very different things - it is not a change.
2
As the article implies, this is not an exact science. PSA scores can be misleading. One can have a PSA of less than four but still have prostate cancer cells with a Gleason score of 9.
The extent of the adverse effects following treatment cannot be determined. When it comes to surgery, the surgeon doesn't really know what he's going to remove until he's in there. If he has to remove areas outside of the gland, he could permanently damage nerves which will be needed if the patient is to revert to his pre-op self.
So, what do you do? If the cancer cells spread, they likely attack the bone structures at the base of your spine, so treat the cancer aggressively. You may be lucky with the post-treatment side effects, maybe not. Either way, though, you've given yourself the best chance of being around for a while.
The extent of the adverse effects following treatment cannot be determined. When it comes to surgery, the surgeon doesn't really know what he's going to remove until he's in there. If he has to remove areas outside of the gland, he could permanently damage nerves which will be needed if the patient is to revert to his pre-op self.
So, what do you do? If the cancer cells spread, they likely attack the bone structures at the base of your spine, so treat the cancer aggressively. You may be lucky with the post-treatment side effects, maybe not. Either way, though, you've given yourself the best chance of being around for a while.
28
I had prostate surgery 11 months ago. My Gleason was at 9. Even after the surgery, my PSA was still elevated, and I underwent 10 weeks of radiation treatment. The PSA level now is very low, but the impotence and incontinence impede me from what was a previously active life. I have to stay home, close to the toilet, and as a divorced man, women have no interest in me once I tell them about my situation. It is extremely depressing, and I have not found effective therapy to help me through that part of the experience.
17
altopal,
Do not second-guess yourself. With high Gleason scores and an elevated PSA (which is now low – good news), you made the best decision based on your circumstances. The goal was to get out of a worsening cancer jam. Hopefully, your treatment has done that.
You’re not so far out from surgery; it’s entirely possible you urinary issues will resolve. In the meantime, wear baggy cargo shorts (the only pants my son even owns, lol) and get yourself some of the disposable undergarments that are on the market. Nobody knows what you’re wearing under your clothes. You think they do – really, they don’t.
There are some message boards specific to prostate cancer. I think one is run by the Prostate Cancer Foundation. I mean I would check them out. You’re in a tough spot if you feel alone in this. I will say, though, having a family is not necessarily a panacea. My son was fourteen years old when his father got this. My husband had been working right up until he got sick (lineman for the power company). He was a tough guy. It was difficult for my husband to relinquish his tough guy image as he declined; it was difficult for our son and daughter to see this. I mean it was tough for me. My husband had become really ill really fast. There were no date nights at my house.
I’m maybe oversharing to tell you I get the seriousness of the situation. But, I’m begging you – get out of the house. When you’re in the house, crank up the rock and roll. You have the right to disturb a little peace.
Do not second-guess yourself. With high Gleason scores and an elevated PSA (which is now low – good news), you made the best decision based on your circumstances. The goal was to get out of a worsening cancer jam. Hopefully, your treatment has done that.
You’re not so far out from surgery; it’s entirely possible you urinary issues will resolve. In the meantime, wear baggy cargo shorts (the only pants my son even owns, lol) and get yourself some of the disposable undergarments that are on the market. Nobody knows what you’re wearing under your clothes. You think they do – really, they don’t.
There are some message boards specific to prostate cancer. I think one is run by the Prostate Cancer Foundation. I mean I would check them out. You’re in a tough spot if you feel alone in this. I will say, though, having a family is not necessarily a panacea. My son was fourteen years old when his father got this. My husband had been working right up until he got sick (lineman for the power company). He was a tough guy. It was difficult for my husband to relinquish his tough guy image as he declined; it was difficult for our son and daughter to see this. I mean it was tough for me. My husband had become really ill really fast. There were no date nights at my house.
I’m maybe oversharing to tell you I get the seriousness of the situation. But, I’m begging you – get out of the house. When you’re in the house, crank up the rock and roll. You have the right to disturb a little peace.
27
altopal, as itsmildeyes has already said, you made the best (and only realistic) decision. With Gleason 9 cores you had absolutely no other choice. It is now 2 years now since I had my prostate out because of Gleason 7 cores. Like you I am now impotent and unlike a number of others who have had the operation, I still need to wear 'man -pads' just to be on the safe-side. I know that it would be really hard being divorced and alone. Us blokes very often do not handle being alone very well. My advice is to try to meet someone, perhaps through an online dating site. But just be yourself and be honest about everything. If you are then I would be optimistic about your chances of finally meeting someone. In the meantime you have my very best wishes. Above all else, 'hang-in' there!!
3
"Nothing...is straightforward in the cancer world." That's the truth.
My husband died in 2005 at age 58 from hormone refractory prostate cancer. He lived only fourteen months from his diagnosis. If you have prostate cancer, do whatever you can to prevent it from metastasizing. I'm not an expert (although, I kind of felt I was for a while, back then), so I can't tell you what course of action to take. 'Watchful waiting' may be fine for those with a low PSA value and low Gleason scores. But if either of those numbers starts moving up significantly (I recall something called doubling time), if you were my husband I'd encourage you to re-evaluate. Metastasized prostate cancer is cruel and it can be difficult to get you out of your pain jam.
Everybody's body is different; but the disease process, once it goes beyond a certain point, does have a predictable trajectory. Don't let this be the only article you use when making your treatment decisions. I wish you well.
Commenter Eric Dean below makes some very good points.
My husband died in 2005 at age 58 from hormone refractory prostate cancer. He lived only fourteen months from his diagnosis. If you have prostate cancer, do whatever you can to prevent it from metastasizing. I'm not an expert (although, I kind of felt I was for a while, back then), so I can't tell you what course of action to take. 'Watchful waiting' may be fine for those with a low PSA value and low Gleason scores. But if either of those numbers starts moving up significantly (I recall something called doubling time), if you were my husband I'd encourage you to re-evaluate. Metastasized prostate cancer is cruel and it can be difficult to get you out of your pain jam.
Everybody's body is different; but the disease process, once it goes beyond a certain point, does have a predictable trajectory. Don't let this be the only article you use when making your treatment decisions. I wish you well.
Commenter Eric Dean below makes some very good points.
22
The biopsy is very unpleasant. It involves a probe up the rectum which pokes 12 or more needles into the prostate to get core samples. Depending on how many cores are positive for cancer, and the Gleason of that cancer, a decision is made to treat or watch. It is not an experience you want to repeat even once. Also, you then have to live with the knowledge that cancer is growing (hopefully very slowly) inside you, and hoping again to ultimately get it out before it's incurable. Not a very relaxing and comforting thought in your mind. So most men soon opt for treatment.
17
If I'd had the choice to make, I'd have endured the biopsies. Not fun, but not too bad in my case. But the numbers said treat.
2
I had a 29-core biopsy and did not find it that
uncomfortable. I don't want men to fear the biopsy and therefore try to avoid it.
uncomfortable. I don't want men to fear the biopsy and therefore try to avoid it.
11
I have prostate cancer and had my prostate removed in 2013. Since then, I have belonged to a support group, and monthly, hear from dozens of other men (and their wives) about their situation.
When a man--and especially his wife--hears the word "cancer", he tends to panic, not realizing that prostate cancer is extremely slow-growing. His urologist or radiologist will invariably recommend treatment because, after all, this is how he makes his living. His wife will want it out "that afternoon" because she has little or no understanding of this disease. So, instead of making a careful, informed decision, he forgets the enormous consequences, and rushes into a decision that he will regret the rest of his life.
Thank god at least SOME doctors are suggesting active surveillance! AS for wives, I don't think that's going to change any time soon, but a man should realize that the one who loves him the most, may be doing him the greatest harm.
When a man--and especially his wife--hears the word "cancer", he tends to panic, not realizing that prostate cancer is extremely slow-growing. His urologist or radiologist will invariably recommend treatment because, after all, this is how he makes his living. His wife will want it out "that afternoon" because she has little or no understanding of this disease. So, instead of making a careful, informed decision, he forgets the enormous consequences, and rushes into a decision that he will regret the rest of his life.
Thank god at least SOME doctors are suggesting active surveillance! AS for wives, I don't think that's going to change any time soon, but a man should realize that the one who loves him the most, may be doing him the greatest harm.
3
Some prostate cancers are slow-growing; others are not. Had my husband opted to wait-and-see with his PSA 4 and Gleason 6 biopsy, he would be dead now from a very aggressive cancer that turned out after surgery to be a Gleason 9. We have had to do some adapting to the new sexual reality, but we are very happy and happy to be alive.
10
Five years ago, my PSA was in the 4 range and my GP suggested I see a urologist for a biopsy. I had that procedure done. (It was slightly uncomfortable, but not painful.) The results showed moderate cancer in most of the 12 samples. We discussed treatment options, and, with my health insurance lapsing due to my significant other's retirement, I opted for a Da Vinci procedure to remove the offending organ. The post-op biopsy revealed moderate cancer that had not migrated to the outer walls of the prostate, and no evidence of it spreading to the various tubes that went in and out. My doc said I shouldn't have any further cancer problems. I did lose all erectile function, and I leak a little, occasionally, but there haven't been any other negative side effects. At 67 now, I don't have to worry about prostate cancer ever again. Recent PSA tests are effectively zero. How do I weigh the loss of my sexual function against the possibility of recurrent cancer? Everyone will have to evaluate that question, but my partner doesn't care about the sex, and we're both happy that I won't die of prostate cancer.
44
Sorry, but if I have cancer in my body I want it out. In my own experience mild incontinence, which is very common with this surgery, is far better than death.
13
How do you know?
3
This comment is EXACTLY why many docs want to stop calling low grade "cancers"...cancer. Men will only hear one word...cancer ...and that's it without truly understand the vast difference in the biology this disease can have.
In my case I'd rather die than be impotent through my 50s and 60s....and hopefully 70s
In my case I'd rather die than be impotent through my 50s and 60s....and hopefully 70s
I had a Gleason score of six, about 7 years ago, and was advised to have the prostate removed. Without going into details about the procedure, the husband of a good friend of mine, had been told watchful waiting was best. He died within a year. So it seems to me, even today, the pay your money and you take your chances.
6
Today is exactly 3 weeks since I had my prostate removed. Recovery is not the most pleasant process. However…
My PSA rose earlier this year to 6.5 from 2015s 3.8. My doctor referred me to a urologist. He did the finger exam and noted that while my prostate was normal sized the right side felt a little firm. One month later I had the biopsy (actually not as onerous a procedure as I had read on the internet).
The biopsy came back with a Gleason of 4+3. Lots of reading later I had learned that the first number, the 4, was the more telling of the two numbers.
My doctor, who is a surgeon, recommended to have the prostate removed. At my age, 64, and all the side effects I had read about for prostate removal vs. the side effects I had read about with radiation, I opted to have the prostate removed.
The post surgery pathology reversed the Gleason to 3+4 from 4+3. That is good. There was no cancer spread to surrounding tissue. No cancer spread to the lymph nodes. And no cancer spread to the bladder or color (samples were taken from all places). I'll have a followup PSA at 3 months post surgery. I'm optimistic it will be near zero.
For me, I am glad to have had the prostate removed. Yes, the side effects are daunting (who wants to go around wearing Huggies at age 64 and what man wants to give up sex like a porn star). However, I like the sound of the words Cancer Free. For this, the decision was a no-brainer.
My PSA rose earlier this year to 6.5 from 2015s 3.8. My doctor referred me to a urologist. He did the finger exam and noted that while my prostate was normal sized the right side felt a little firm. One month later I had the biopsy (actually not as onerous a procedure as I had read on the internet).
The biopsy came back with a Gleason of 4+3. Lots of reading later I had learned that the first number, the 4, was the more telling of the two numbers.
My doctor, who is a surgeon, recommended to have the prostate removed. At my age, 64, and all the side effects I had read about for prostate removal vs. the side effects I had read about with radiation, I opted to have the prostate removed.
The post surgery pathology reversed the Gleason to 3+4 from 4+3. That is good. There was no cancer spread to surrounding tissue. No cancer spread to the lymph nodes. And no cancer spread to the bladder or color (samples were taken from all places). I'll have a followup PSA at 3 months post surgery. I'm optimistic it will be near zero.
For me, I am glad to have had the prostate removed. Yes, the side effects are daunting (who wants to go around wearing Huggies at age 64 and what man wants to give up sex like a porn star). However, I like the sound of the words Cancer Free. For this, the decision was a no-brainer.
25
I had prostate cancer when I was 50 and had a radical prostectomy.
With never sparing and fully recovered in repeats in about 18 months.
Now I am 72 and all is good. I think this article misses an important
point that if you wait you will continue to have in your mind the thought
that the cancer will spread. You will live with that everyday.
A heavy burden
With never sparing and fully recovered in repeats in about 18 months.
Now I am 72 and all is good. I think this article misses an important
point that if you wait you will continue to have in your mind the thought
that the cancer will spread. You will live with that everyday.
A heavy burden
12
isnt proton therapy an alternative, treat tumor and avoid post treatment incontinence etc issues?
4
Radiation side-effects typically begin later, and you will have residual PSA.
3
Diagnosed at 62, had surgery and have never regretted the decision. Had a number of complications but no incontince. Prostate was very large so there were complications beyond the cancer. Seems to me age is a huge factor. The decision regarding watchful waiting should be much different for those in 50's or 60's than those who are older. I am 74 now and might make a different decision than I did at 62. These decisions are very personal and shoul only be taken after considering you own situation.
28
In the age of Google, medicine should be about “patient empowerment”, i.e. do the PSA testing, and if the results are troubling, then allow the patient to assess his situation and make an informed decision. People are not foolish and will not jump into surgery that has possible complications—they will assess the risks and decide what is best for themselves.
The idea of not allowing PSA tests, or browbeating men into Active Surveillance (really, at this point, just to get data on how many people are going to die of untreated prostate cancer) is paternalistic and heartless—sort of like the Tuskegee experiments to see what happens with untreated syphilis.
The problem with repeatedly referring to “overtreatment” or treatment as “unnecessary” is that in the long-term, insurance may stop covering some of the traditional treatments for prostate cancer, which are proven and effective. Men who could have been cured will die from prostate cancer.
Give men information and let them decide what is best in their own cases. Stop this drumbeat of “no testing” and “no treatment”.
The idea of not allowing PSA tests, or browbeating men into Active Surveillance (really, at this point, just to get data on how many people are going to die of untreated prostate cancer) is paternalistic and heartless—sort of like the Tuskegee experiments to see what happens with untreated syphilis.
The problem with repeatedly referring to “overtreatment” or treatment as “unnecessary” is that in the long-term, insurance may stop covering some of the traditional treatments for prostate cancer, which are proven and effective. Men who could have been cured will die from prostate cancer.
Give men information and let them decide what is best in their own cases. Stop this drumbeat of “no testing” and “no treatment”.
49
Of course, more than half the stuff on the internet is garbage, or worse.
Anyone with a cheap or free program can make a relatively good looking site, and with it comes the cachet of authority.
I'm upset by the veracity of some promoting views beyond the weight they should receive, often advancing a product they or a friend is selling, and who wouldn't opt for an easy, painless, cheap way to treat with a special diet or additive, in stead of tests, discomfort, infections, etc.
I fully agree that being educated in a subject upon which so much depends (life and quality of life) is the best thing a person can do upon learning of a problem they might have. But learn from and read respected sources based entirely upon the science involved, not something that a friend's aunt read in an online article when she was 'researching' something.
Anyone with a cheap or free program can make a relatively good looking site, and with it comes the cachet of authority.
I'm upset by the veracity of some promoting views beyond the weight they should receive, often advancing a product they or a friend is selling, and who wouldn't opt for an easy, painless, cheap way to treat with a special diet or additive, in stead of tests, discomfort, infections, etc.
I fully agree that being educated in a subject upon which so much depends (life and quality of life) is the best thing a person can do upon learning of a problem they might have. But learn from and read respected sources based entirely upon the science involved, not something that a friend's aunt read in an online article when she was 'researching' something.
5
Damned if you do, damned if you don't...are doctors money grubbers who are always going to recommend expensive interventions, or are we "paternalistic and heartless" by recommending surveillance? The fact is, we don't know what is best, but a 10 year survival rate of 99% plus is a pretty good argument against automatically recommending treatments that have incontinence/impotence rates from 10-20%.
5
You comment oversimplifies the situation. The so-called drumbeats of "no testing" and "no treatment" are only suggestions in specific situations. The reality is most doctors recommend PSA testing after age 50. If anything, treatment may be pushed when it shouldn't be.
Generalizations on testing and treating are not helpful, or necessarily true. Insurance is more likely to pay for early prostrate removal versus dealing with an aggressive and expensive cancer treatment down the road.
Generalizations on testing and treating are not helpful, or necessarily true. Insurance is more likely to pay for early prostrate removal versus dealing with an aggressive and expensive cancer treatment down the road.
1
In the setting of fee-for-service, especially with decreasing reimbursements and increasing overhead costs, most private urologists 'must' recommend treatment. How else would they get paid?
10
If you believe this, yet another reason to go to a major city where the top doctors are busy.
4
you've missed my point...our fee-for -service system of healthcare promotes treatment and that's why non-academic urologists more often recommend treatment. In addition, why isn't there a more comprehensive outcomes registry for urologists and radiation oncologists who actively treat prostate cancer?
2
Dr. Richard Albin, the man who discovered the prostate specific antigen (but not the PSA test to screen for cancer), has asserted that fully half of the urology practices in America would go out of business if not for what he calls the "Prostate Cancer Hoax".
2
The scientific literature long ago showed a 95 percent five-year survival rate for either radical prostatectomy or brachytherapy (radiation) treatment for prostate cancer. The Swedish approach of active surveillance (aka "watchful waiting") had a much lower survival rate of around 80 percent. I'm surprised to see men avoiding treatment although surgery is associated with a high rate of impotence and incontinence than with radiation. I would hope that either the National Institutes of Health or the Institute of Medicine would issue a definitive report using meta-analysis or other sound data aggregation methods to provide doctors and their patients guidance before they decide to forgo any intervention. [This writer is a retired Professor of Health Psychology who performed an early meta-analysis comparing all these approaches to prostate cancer.]
17
I would ask which Universities or Hospitals are currently doing phase one, two or three trials or studies doing virus redesign and site injection with the intention to remit or eliminate prostate cancer. I don't know of any currently. Looks like this is something the federal government should really step up, promote and fund.
2
Duke University appears to be working on the polio approach, but with no current active large member trials.
https://www.dtmi.duke.edu/news/can-modified-poliovirus-fight-advanced-pr...
https://www.dtmi.duke.edu/news/can-modified-poliovirus-fight-advanced-pr...
3
I was diagnosed with Gleason 6, two partial cores out of 25 at the age of 71/ I did a lot of internet research and became convinced that active surveillance was the way to go. My doctor agreed. Two years later nothing had changed. Two years after that no cancer found in 25 cores. Doesn't mean it is gone but for sure it was not getting worse. This year at age 77 I will probably have my last biopsy if nothing is found. There were doctors who wanted aggressive actions and they really tried to minimize the awful side effects of prostate removal.
Note that there is a real possibility of serious side effects from the biopsy including near fatal infections for 5% of the patients. My doctor does not follow the recommended treatment which is to administer a single antibiotic for the biopsy. For me he used two and now it is up to three antibiotics. He does not have patients getting serious infections. This is important!
Note that there is a real possibility of serious side effects from the biopsy including near fatal infections for 5% of the patients. My doctor does not follow the recommended treatment which is to administer a single antibiotic for the biopsy. For me he used two and now it is up to three antibiotics. He does not have patients getting serious infections. This is important!
17
With your admission that your doctor has chosen to ignore the current recommendations (which are as researched and science based as possible) you are saying he is ignoring what has been learned so far about the biopsy procedure.
The risk of adverse reaction, damage to the environment with overuse of antibiotics and just plain ignorance on the part of your doctor with what the outcome data suggest is hard to hear you report, since you seem to have great respect for him. What if he recommended a drug or procedure which hundreds of doctors with thousands of patients have found to be neither effect or worse yet, came with previously unseen danger?
And may I ask how you know he has no infections? Even the most careful pre-biopsy preparation and surgical technique has some associated infections, it always does. For you to emphatically state that this is important means you believe him. Did you survey ALL his patients (no doubt a privacy violation) or did you take his 'word' for it (and what doctor who wants you to believe him as he departs from the best practices) would say anything to undermine his method. I'm happy you're doing fine, but real doctors don't practice wild west medicine any more.
The risk of adverse reaction, damage to the environment with overuse of antibiotics and just plain ignorance on the part of your doctor with what the outcome data suggest is hard to hear you report, since you seem to have great respect for him. What if he recommended a drug or procedure which hundreds of doctors with thousands of patients have found to be neither effect or worse yet, came with previously unseen danger?
And may I ask how you know he has no infections? Even the most careful pre-biopsy preparation and surgical technique has some associated infections, it always does. For you to emphatically state that this is important means you believe him. Did you survey ALL his patients (no doubt a privacy violation) or did you take his 'word' for it (and what doctor who wants you to believe him as he departs from the best practices) would say anything to undermine his method. I'm happy you're doing fine, but real doctors don't practice wild west medicine any more.
1
5% Fatal infections from biopsies? Nothing like that. Review of the PLCO study found 1.8/1000 for cancer-free patients, 3.5 for patients with cancer.
3
Excerpt rom a piece in NYT, 10/5/11,
"http://www.nytimes.com/2011/10/09/magazine/can-cancer-ever-be-ignored.ht...
David Newman, a director of clinical research at Mount Sinai School of Medicine in Manhattan [...] loffers a metaphor to illustrate the conundrum posed by P.S.A. screening.
“Imagine you are one of 100 men in a room,” he says. “Seventeen of you will be diagnosed with prostate cancer, and three are destined to die from it. But nobody knows which ones.” Now imagine there is a man wearing a white coat on the other side of the door. In his hand are 17 pills, one of which will save the life of one of the men with prostate cancer. “You’d probably want to invite him into the room to deliver the pill, wouldn’t you?” Newman says.
Statistics for the effects of P.S.A. testing are often represented this way — only in terms of possible benefit. But Newman says that to completely convey the P.S.A. screening story, you have to extend the metaphor. After handing out the pills, the man in the white coat randomly shoots one of the 17 men dead. Then he shoots 10 more in the groin, leaving them impotent or incontinent.
Newman pauses. “Now would you open that door?” He argues that the only way to measure any screening test or treatment accurately is to examine overall mortality. That means researchers must look not just at the number of deaths from the disease but also at the number of deaths caused by treatment.
"http://www.nytimes.com/2011/10/09/magazine/can-cancer-ever-be-ignored.ht...
David Newman, a director of clinical research at Mount Sinai School of Medicine in Manhattan [...] loffers a metaphor to illustrate the conundrum posed by P.S.A. screening.
“Imagine you are one of 100 men in a room,” he says. “Seventeen of you will be diagnosed with prostate cancer, and three are destined to die from it. But nobody knows which ones.” Now imagine there is a man wearing a white coat on the other side of the door. In his hand are 17 pills, one of which will save the life of one of the men with prostate cancer. “You’d probably want to invite him into the room to deliver the pill, wouldn’t you?” Newman says.
Statistics for the effects of P.S.A. testing are often represented this way — only in terms of possible benefit. But Newman says that to completely convey the P.S.A. screening story, you have to extend the metaphor. After handing out the pills, the man in the white coat randomly shoots one of the 17 men dead. Then he shoots 10 more in the groin, leaving them impotent or incontinent.
Newman pauses. “Now would you open that door?” He argues that the only way to measure any screening test or treatment accurately is to examine overall mortality. That means researchers must look not just at the number of deaths from the disease but also at the number of deaths caused by treatment.
29
Non-treatment of cancer is not a "trend."
It's been a standard option for years and goes beyond prostate cancer.
The human immune system, remarkably, has an ability to fight carcinomas on its own -- and often successfully does.
And though anecdotal success stories are no excuse not to seek treatment, many cancers in their early stages simply disappear.
So ethical medical doctors should always mention the beauty and power of the body's own immune system -- and the option to wait and see -- when early-stage cancer patients are still healthy and strong.
It's been a standard option for years and goes beyond prostate cancer.
The human immune system, remarkably, has an ability to fight carcinomas on its own -- and often successfully does.
And though anecdotal success stories are no excuse not to seek treatment, many cancers in their early stages simply disappear.
So ethical medical doctors should always mention the beauty and power of the body's own immune system -- and the option to wait and see -- when early-stage cancer patients are still healthy and strong.
"The human immune system, remarkably, has an ability to fight carcinomas on its own -- and often successfully does."
Please......are you a doctor?
Please......are you a doctor?
3
When I was diagnosed in 2002 at the age of 60, I was told that it would probably be about 10 years before I started to have noticeable symptoms. My choice was radiation since it was less invasive than surgery, but I remember telling myself that eventually there would be better treatments. Unfortunately, had I not had treatment then, I might not be around now. And since my paternal grandfather had lived to age 95 and since I expected my father to live beyond that, it was important to me to do whatever I needed to do to maintain a chance for a long life. Thus, I accepted that there would be side effects.
Today, there is a lot of research on immunotherapy to cure cancer. A recent report on television showed the use of a modified polio virus to attack a cancer or to induce the immune system to attack a cancer, and at least one research subject who had appeared to have no chance of long term survival had been cured. While such treatments are still research projects, my guess is that similar therapies will be developed for prostate cancer, and if faced with the same choices today, I might well choose watchful waiting in the hope that such a cure will be developed while there is still time for me to benefit from it and to avoid the side effects of the treatments available now. But I had to go with what was available when I was diagnosed and when immunotherapy was just a pipe dream.
Today, there is a lot of research on immunotherapy to cure cancer. A recent report on television showed the use of a modified polio virus to attack a cancer or to induce the immune system to attack a cancer, and at least one research subject who had appeared to have no chance of long term survival had been cured. While such treatments are still research projects, my guess is that similar therapies will be developed for prostate cancer, and if faced with the same choices today, I might well choose watchful waiting in the hope that such a cure will be developed while there is still time for me to benefit from it and to avoid the side effects of the treatments available now. But I had to go with what was available when I was diagnosed and when immunotherapy was just a pipe dream.
14
Not so simple and we still don't have the answers. Prostate cancer Gleason 6 at age 50. Radical surgery. Recurrence age 58 Radiation. Local recurrence, now Gleason 7 at age 65. More local treatment planned. Where would I now be in retirement if I had done nothing? Dead if I were lucky. Hellishly miserable with metastatic prostate cancer, if not so lucky. Surveillance? I'm not convinced.
40
No two cases are alike but my experience for what it is worth.
Based on a rising PSA over 4 years my GP referred me for a biopsy which found localized prostate cancer and some possible pre-cancerous areas. I was just short of my 64th birthday and otherwise in excellent health.
I explored all options, removal, radiation, seed radiation and monitoring. I did background reading, consulted with family and asked a close and objective friend to accompany me to each consultation to compare notes. I was impressed by the integrity of all the specialists I consulted.
I chose seed radiation therapy in large measure because my health profile suggested the potential to live another 25 years. I consider the treatment a success. It has been 15 months and my PSA is well below 1. The side effects are real but have been largely transitory. I have no regrets.
Based on a rising PSA over 4 years my GP referred me for a biopsy which found localized prostate cancer and some possible pre-cancerous areas. I was just short of my 64th birthday and otherwise in excellent health.
I explored all options, removal, radiation, seed radiation and monitoring. I did background reading, consulted with family and asked a close and objective friend to accompany me to each consultation to compare notes. I was impressed by the integrity of all the specialists I consulted.
I chose seed radiation therapy in large measure because my health profile suggested the potential to live another 25 years. I consider the treatment a success. It has been 15 months and my PSA is well below 1. The side effects are real but have been largely transitory. I have no regrets.
15
Hi John, thanks for sharing your story. My dad is about to undergo seed radiation therapy, and I'm wondering what type of side effects you had. Like many others, it's not clear whether he actually needs to be treated, but he's decided to go ahead with it for piece of mind, if nothing else. Thanks for any additional info, and good luck to all.
2
peace of mind:-) sorry
3
Perhaps this will help, beatgirl99. In my case radiation was followed by hormone treatment for 2 years.
The radiation treatment led to extreme fatigue and a brief spell of bladder problems that limited travel somewhat - it passed.
The hormone injections led to decreased muscle mass, increased body fat, osteoporosis, more fatigue and loss of stamina. I attended a kinseologist at our local health centre who put me on exercise regimen: where I was barely able to walk to the end of our block I was soon walking 1-1/2 miles daily and once again perform yard chores and other physical activity. There was also diminished sexual activity. Lassitude and lack of motivation may be an effect of my advancing age, but I feel my meds contribute to it.
No matter, I am clear now for 6 years and my specialist has put me on reduced monitoring - once a year PSA and consult.
The radiation treatment led to extreme fatigue and a brief spell of bladder problems that limited travel somewhat - it passed.
The hormone injections led to decreased muscle mass, increased body fat, osteoporosis, more fatigue and loss of stamina. I attended a kinseologist at our local health centre who put me on exercise regimen: where I was barely able to walk to the end of our block I was soon walking 1-1/2 miles daily and once again perform yard chores and other physical activity. There was also diminished sexual activity. Lassitude and lack of motivation may be an effect of my advancing age, but I feel my meds contribute to it.
No matter, I am clear now for 6 years and my specialist has put me on reduced monitoring - once a year PSA and consult.
2
More men would be willing to choose active surveillance if there was adequate pain management for repeat biopsies, such as conscious sedation. My husband who has a high pain threshold said he couldn't go through a biopsy every 1-2 years. He was also considered in the "grey zone" being in his early 60's with a Gleason of 6 but with a life expectancy in his 90's by family history. He was willing to take the risk of side effects to avoid the repeat biopsies and the probability of metastatic disease within his life expectancy. The patient should have the choice after being well informed about the PSA tests, the treatment alternatives for positive results, and the risks/benefits.
7
It will be 11 years, in a few weeks, since I lost my husband to prostate cancer. Yes, it was a very aggressive cancer. He had been getting annual PSA tests (normal) until he changed to a closer Doctor - highly recommended. He was a Family Practice specialist and their Academy did not recommend annual PSA's. He followed his doctor's advice. Even when a digital exam showed an enlarged prostate, still no PSA. When he became very ill, one was finally done - a PSA of 170. Still, a urologist we saw (actually saw his Nurse Practioner) refused for a month to do a biopsy. When he nearly collapsed at the urologist's office, one was finally done - it was a Gleason 9. He lived for 27 more months before dying at age 64, an otherwise totally healthy man.
While it is true that most elderly me die with prostate cancer, many still due from this disease. Impotence? Incontinence? Better those than an early death. Not only was my husband cheated out of another possible 30 years of life (extreme longevity in his family), but his children were cheated out of his love and his grandchildren were cheated out of a very special grandfather. I was cheated out of a wonderful husband.
Be very aware of the risks you are taking, and only take the watchful waiting advice from a urologist or oncologist in academic medicine.
While it is true that most elderly me die with prostate cancer, many still due from this disease. Impotence? Incontinence? Better those than an early death. Not only was my husband cheated out of another possible 30 years of life (extreme longevity in his family), but his children were cheated out of his love and his grandchildren were cheated out of a very special grandfather. I was cheated out of a wonderful husband.
Be very aware of the risks you are taking, and only take the watchful waiting advice from a urologist or oncologist in academic medicine.
99
I am truly sorry you do not have your life partner to enjoy this portion of your life still at your side. But the article states to evaluate your feelings on what to do, then I would suggest you follow that, or find another doctor willing to help you accomplish that goal.
I do take issue with your hope or continued belief that he, with that high of a Gleason score and the necessary treatments which have their own side effects, of him having much of a chance to live another 30 years, say nothing of enjoying them as you might hope. If only it could be, I would wish it for you and him.
I do take issue with your hope or continued belief that he, with that high of a Gleason score and the necessary treatments which have their own side effects, of him having much of a chance to live another 30 years, say nothing of enjoying them as you might hope. If only it could be, I would wish it for you and him.
4
Thank you India for writing this letter. You will save some lives.
3
Doctors are starting to rely on government guidelines, or mandates, that come out of HHS\CDC ,etc. They are also now mostly owned by the local hospital or health system where they can be fired for not towing the line. Keep our private doctors in private practice, where they know us as individuals. Care must be individualized! Your costs will go down too ss there won't be the 'hospital charge' now going on your bill.
I am a physician who screens HIV infected patient for early stages of anal cancer (anal dysplasia) and I am a woman with history of pre-menopausal DCIS; hence I have some experience thinking through the challenges that "pre-cancerous", "dysplastic" lesions pose on the patient and physician. I am glad to read that active surveillance for these abnormal prostate biopsies is being offered and accepted. I think however, it is a very personal decision and the only role of the physician is to support the patient to find the answer for him, balances current benefits with future risks in the best possible way. I think the discussion on whether to call this cancer or not is almost irrelevant if there is a detailed explanation on the biology/natural history of these lesions. Otherwise one may bias patients by calling it cancer or by NOT calling it cancer. (Also glad to read that active surveillance in these cases does not include endocrine reduction therapy; on the female (breast CA) side, some famous breast specialist call it surveillance when they forgo surgery but initiate long-term hormone ablation).
9
My PSA recently rose for the first time to 5, so my urologist suggested a biopsy, which revealed 6 Gleason. My father died an excruciatingly painful death from prostate cancer, so I am weighing my options very carefully. This article offers hope that active surveillance may provide a viable alternative to surgery, but the risk to such a strategy that has not been thoroughly researched sparks many pauses for concern.
17
Active surveillance for longer periods of time (12-15 years) has been the subject of research, which suggest the right patients do very well with active surveillance. See http://jco.ascopubs.org/content/early/2014/12/10/JCO.2014.55.1192
and http://www.nejm.org/doi/full/10.1056/NEJMoa1113162. Gleason is only one of several criteria that should be used by a patient and his clinician in deciding on a treatment plan. Yes, it would be nice to have 20 plus years of data, but check reputable sources like NCCN -https://www.nccn.org/patients/guidelines/prostate/files/assets/basic-htm.... And talk to an oncologist who specializes in prostate cancer, not just a urologist. I have been on active surveillance for six years and so far there are no detected signs of progression. Good luck and God Bless.
and http://www.nejm.org/doi/full/10.1056/NEJMoa1113162. Gleason is only one of several criteria that should be used by a patient and his clinician in deciding on a treatment plan. Yes, it would be nice to have 20 plus years of data, but check reputable sources like NCCN -https://www.nccn.org/patients/guidelines/prostate/files/assets/basic-htm.... And talk to an oncologist who specializes in prostate cancer, not just a urologist. I have been on active surveillance for six years and so far there are no detected signs of progression. Good luck and God Bless.
5
My father also died from prostate cancer. When I was diagnosed with it I had a radical prostatectomy. Erratic erections, some incontinence, no regrets.
3
Sadly there still isn't a test that can tell if the cancer is aggressive and has to be removed. Biopsy and Gleason pathology is hit or miss. There's no cancer DNA test that is diagnostic. So men who are on active surveillance are betting that ten or twenty years from now the studies will back them and they'll survive. The lack of detail in this article is telling: do Gleason 6 turn into Gleason 10 overnight? What is the ten year survival for Gleason 6 and active surveillance? Any tells on who that 1 out 100 men were? And that is what, tens of thousands of men who bet and lost.
20
A few points that this article didn't mention. According to the American Medical Association, by the time a man reaches age 80, he has an almost 100% chance of having cancer cells in his prostate. By the time a man is 60, he has an almost 50% probability of having cancer cells in his prostate. This is a very common disease in men. Most men will die WITH this disease, rather than FROM it. Most men will never know they had it.
Urologists will assert that prostate cancer is a leading cause of cancer death in men. But 38,000 prostate cancer deaths a year represents only 2% of male deaths. Compare that to the estimated death rates of between 250,000 to 400,000 per year due to medically induced infections and medical errors in America. Far more people in America die from the medical system than from prostate cancer.
Urologists will assert that prostate cancer is a leading cause of cancer death in men. But 38,000 prostate cancer deaths a year represents only 2% of male deaths. Compare that to the estimated death rates of between 250,000 to 400,000 per year due to medically induced infections and medical errors in America. Far more people in America die from the medical system than from prostate cancer.
120
Nonetheless, the Veteran's Administration assumes Vietnam vets have prostate cancer due to Agent Orange exposure, and pays them at 100% disability while they "watch and wait."
2
All very true points, but of limited relevance to a man who is diagnosed with prostate cancer and facing a decision of what to do about it. Even the high number of error/infection deaths means that you have a 1 in 130 chance of dying based on the 52 million hospital procedures performed a year. The man diagnosed with prostate cancer is dealing with a 1 in 10 chance of dying from the disease, so your statistics won't mean a lot to such a man. The fact that far more people died of other things isn't a form of compensation. Telling folks that there are bigger killers in the world suggests that we're wasting our time concerning ourselves with these questions. And given that the man diagnosed with prostate cancer doesn't really know if he's one of the unlucky ones until time passes, I'm having a hard time seeing how your observations are even germane to the questions raised by the article.
6
Health care determined by statistics? These people are amazing, what are the chances they take news of their own diagnosis so casually. There is nothing wrong with watchful waiting but you have to be watchful. My best friends disease profile pretty much fell into the category being discussed. He was treated at the UC Medical Center in San Francisco. It started out small and slow, he and his doctors adopted the wait and watch option. Partially because he was very resistant to treatment consequences. The thing is he died, in a few short years, only sixty years old. I don't know all the details but it seems that if one takes the watchful path be very watchful.
2
Had a radical prostetectomy in 2007 with an excellent surgeon. My Gleasonw as 7. 9 years later (62 years old) I am cancer free, continent and sexually fine. What this story hints at but does not nail down with a concrete example or two are the stories of "young" men diagnosed with lowish Gleason scores who die quickly. This happened to a close friend. "a tragic mistake for some"...I wish the author had given at least one specific example to underscore the risks of watchful waiting to those in their 50's and 60's. I guess many of us seek to justify the paths we chose...for me choosing surgery. My word to the wise...choosing watchful waiting is really just as "radical" as surgery...
30
Had I chosen active surveillance (what happened to "Watchful Waiting"?) when at age 51 my PSA was 7.7 and Gleason score 7, I'd probably be dying. I certainly wouldn't live out my natural life span. The pathology report showed that one of the tumors had reached the outside wall of my prostate. Had I waited, the cancer would have metastasized. Instead, 5 years cancer free.
Recovery from surgery is not easy, and I haven't recovered 100%. But more importantly, I will be here for my wife, my kids, and someday grandkids.
I urge anyone diagnosed with prostate cancer to get multiple opinions, preferably one at a top prostate center. And for those in relationships, make the decision together.
Recovery from surgery is not easy, and I haven't recovered 100%. But more importantly, I will be here for my wife, my kids, and someday grandkids.
I urge anyone diagnosed with prostate cancer to get multiple opinions, preferably one at a top prostate center. And for those in relationships, make the decision together.
64
With your numbers and your pathology, it is doubtful you would have been advised to pursue active surveillance.
3
Keep in mind that this article talks about Active Surveillance for Gleason 6 diagnoses--not Gleason 7. It would generally be considered important to treat a Gleason 7 patient like yourself. Active Surveillance has supplanted "Watchful Waiting" since as the name suggests it's "active." There are ongoing biopsies, MRIs and PSA tests to ensure that the protocol is still appropriate for the patient. If their condition changes, they may make the decision to opt for treatment then. Clearly, that path is safe based on the 1% death rate quoted in the article, which is the same whether Active Surveillance or a treatment was pursued.
1
"Active surveillance" is used now to convey the active, ongoing testing that is involved, versus the more passive implication of "watchful waiting".
In any case, I doubt any urologist would recommend surveillance/waiting for a Gleason 7 tumor, especially in a 51 year old. Likewise for the comments saying their cancer was found in most of the biopsy samples, implying it's large. Based on a LOT of reading about this, I believe active surveillance is only being recommended to those at least in their 60s with a Gleason score of no higher than 6 and cancer detected in very few samples AND being less than 10% of those samples. It's actually not that easy to qualify, regardless of what it's called.
In any case, I doubt any urologist would recommend surveillance/waiting for a Gleason 7 tumor, especially in a 51 year old. Likewise for the comments saying their cancer was found in most of the biopsy samples, implying it's large. Based on a LOT of reading about this, I believe active surveillance is only being recommended to those at least in their 60s with a Gleason score of no higher than 6 and cancer detected in very few samples AND being less than 10% of those samples. It's actually not that easy to qualify, regardless of what it's called.
2
I have been monitoring my diagnosis since 2007.
6
I was born with an irregularly shaped prostate. During a routine physical, my internist decided to refer me to a urologist. The latter decided my irregular shape automatically warranted a biopsy. Bingo! They found 85 cancer cells in just one core.
The radiation oncologist they referred me to struck me as very aggressive in pushing me towards radiation. He made absolute claims about probabilities that I knew enough about statistics to disbelieve. So I requested a different referral.
It's been eight years and my PSA has never hit 1.0, let along the 'standard' limit of 4. What I'm doing, has been called 'watchful waiting' and it's certainly been better than the side-effects of all the treatments I've learned about.
But my PSA has shown unexplained increases at times and I am using a mushroom extract that grows in Taiwan. A dear friend (now my wife) brought this to my attention. While it appears to work for me, one case without any controls proves nothing at all.
I am declining to name the mushroom because there have been no clinical trials I know of and there is no information on side-effects or long-term issues so DO NOT take this as a recommendation.
That original radiation oncologist insisted I would die in the year of my 80-th birthday! He said he could show me the charts to prove it! I wrote a letter to the hospital to challenge his fitness to practice medicine! Then I changed doctors.
The radiation oncologist they referred me to struck me as very aggressive in pushing me towards radiation. He made absolute claims about probabilities that I knew enough about statistics to disbelieve. So I requested a different referral.
It's been eight years and my PSA has never hit 1.0, let along the 'standard' limit of 4. What I'm doing, has been called 'watchful waiting' and it's certainly been better than the side-effects of all the treatments I've learned about.
But my PSA has shown unexplained increases at times and I am using a mushroom extract that grows in Taiwan. A dear friend (now my wife) brought this to my attention. While it appears to work for me, one case without any controls proves nothing at all.
I am declining to name the mushroom because there have been no clinical trials I know of and there is no information on side-effects or long-term issues so DO NOT take this as a recommendation.
That original radiation oncologist insisted I would die in the year of my 80-th birthday! He said he could show me the charts to prove it! I wrote a letter to the hospital to challenge his fitness to practice medicine! Then I changed doctors.
9
PSA, Gleason and Biopsy are definitely the domain of an experienced urologist.
This is not water cooler stuff where you solicit advice from a peanut gallery of pals and family members. Have a solid heart to heart with your urologist - and ask for referrals to radiation oncologists and discuss the results with your regular family doctor.
Early detection of a serious disease is part luck.
If you have blood in your urine or large blood discharge after ejaculation - see a doctor immediately.
Some of these treatments are invasive and inconvenient - but being alive is awesome.
This is not water cooler stuff where you solicit advice from a peanut gallery of pals and family members. Have a solid heart to heart with your urologist - and ask for referrals to radiation oncologists and discuss the results with your regular family doctor.
Early detection of a serious disease is part luck.
If you have blood in your urine or large blood discharge after ejaculation - see a doctor immediately.
Some of these treatments are invasive and inconvenient - but being alive is awesome.
73
"Some of these treatments are invasive and inconvenient"
"Inconvenient" is how you describe incontinent for life? Your word choice is concerning. I think you mean well but geez.
"Inconvenient" is how you describe incontinent for life? Your word choice is concerning. I think you mean well but geez.
1
RE: Men and Prostate Cancer
As a Urologist, 2 points are never mentioned in these kinds of articles, and I wonder why they are not included.
Prostate Cancer in the second leading cause of death from cancer in men. Since we , as a country started to use PSA as a screening tool in the late 1980's, the death rate FELL by 40-45%. Different people come up with different numbers.
The 2 studies that led to the US Preventive Service Task Force recommending that NO ONE be screened were 10,000 patients each and lasted 10 years. Since many prostate cancers are slow growing, these studies are vastly UNDER powered. We would need 100,000 patients studied for 15 years to see if deaths were impacted as they were on a population basis, again by 40-45%.
Men should get screened so they have information, and won't be surprised.
As a Urologist, 2 points are never mentioned in these kinds of articles, and I wonder why they are not included.
Prostate Cancer in the second leading cause of death from cancer in men. Since we , as a country started to use PSA as a screening tool in the late 1980's, the death rate FELL by 40-45%. Different people come up with different numbers.
The 2 studies that led to the US Preventive Service Task Force recommending that NO ONE be screened were 10,000 patients each and lasted 10 years. Since many prostate cancers are slow growing, these studies are vastly UNDER powered. We would need 100,000 patients studied for 15 years to see if deaths were impacted as they were on a population basis, again by 40-45%.
Men should get screened so they have information, and won't be surprised.
57
The PLCO trial had nearly 76,700 patients and reported outcomes with 10 year follow-up. There was no survival benefit to PSA screening. Of course there are other problems with the trial (especially contamination of the control arm), but power and follow up are not among them.
http://www.nejm.org/doi/full/10.1056/NEJMoa0810696
http://www.nejm.org/doi/full/10.1056/NEJMoa0810696
5
Doctor, thank you for the straight facts. Except-- don't measure by death rates. It's not fair. Measure by how many men are treated late due lack of screening. They go through radiation, surgery, drugs, chemo. They suffer and may lose their jobs and lots of money. Family suffers too. But after 5 or even 10 years they are still not dead. Don't these people count? The advocates of less testing argue entirely from death rates. Obviously older men may die from something else before the cancer can kill them.
2
I would second this recommendation, if for no other reason than it establishes a baseline of information to work from. While the PSA ranges are assigned, they are not set in stone. A low reading does not mean that you don't have cancer, and high reading doesn't mean that you do. If you start seeing significant changes in the number, then you can seek a urologist out and check into it.
PSA is easy if you have regular blood tests. It is not infallible, but it is the best tool available now.
PSA is easy if you have regular blood tests. It is not infallible, but it is the best tool available now.
Thank God for the internet and good stories like this....You cannot trust many doctors anymore who are in it just for the money....You may hear others disagree, but many are so busy they don't have time to even talk to you..Surgical doctors working in teams of 10-20 to "make more money". It is really sad...You the patient is not their main concern anymore, but how much money can they make is....They talk a different story, but it is the truth.
57
Of course, one should always trust the Internet and never doctors. Here's a tip: have your PSA checked over the years so your doctor has a baseline. He/she will know what to do or not if it goes up. If you need a biopsy or treatment, do it in a large urban hospital with a physician who can provide good statistics on outcomes. And do your own research about alternatives. It's not rocket science. I am five years from my robotic surgery, with zero incontinence and complete sexual function. What they removed had much more malignant cells than the biopsy showed. I turn 70 this summer. Men, do your homework and then trust your own informed judgment.
61
I'm not sure where you live, but you must be in a pit of unethical, uncaring doctors. I know quite a few, and for the last 20 years it has been very apparent that while some (not all) live good lives on a higher than average income, there are the primary care (peds, family medicine, internal medicine) who make less than your local banker.
For you to not only insult them as being in medicine solely to make money but imply they are willing to give advice that isn't in their patients' best interest really undercuts confidence just when a patient really needs a friend and a well educated adviser.
Maybe you could move to a better neighborhood, and there are many of them around. There are a lot of easier ways to make a living than to be a doctor.
For you to not only insult them as being in medicine solely to make money but imply they are willing to give advice that isn't in their patients' best interest really undercuts confidence just when a patient really needs a friend and a well educated adviser.
Maybe you could move to a better neighborhood, and there are many of them around. There are a lot of easier ways to make a living than to be a doctor.
12
There are also surgeons specializing in prostate cancer on faculty at excellent hospitals like the #1 Cancer Center in the US whose salary shocked me by how low it actually is (that info is online for state-funded institutions).
I'll thank god for that surgeon and his colleagues in radiology, with whom I also met, and for the Internet that allowed me to read studies in all the leading medical journals so that I could ask specific questions and make sure I understood what the percentages are.
I'm also grateful for that surgeon and his very different, more informed perspective. As he said, you are not a percentage you are a specific case about which we know some things now, will know more when you're on the table, and still more after pathology, but that's still not everything.
I'll thank god for that surgeon and his colleagues in radiology, with whom I also met, and for the Internet that allowed me to read studies in all the leading medical journals so that I could ask specific questions and make sure I understood what the percentages are.
I'm also grateful for that surgeon and his very different, more informed perspective. As he said, you are not a percentage you are a specific case about which we know some things now, will know more when you're on the table, and still more after pathology, but that's still not everything.
2
Modernizing the diagnostic and decision-making pathway for prostate cancer.
Polascik TJ1, Passoni NM2, Villers A3, Choyke PL4.