10 Myths of Prostate Cancer

I have cared for prostate cancer patients for more than 20 years. Patients come to me with all kinds of wrong notions. Here are 10 of the most frequent misconceptions:

1. Big Prostates Are Bad

All problems related to the urinary system seem to get blamed on prostate enlargement. This can’t be true because men with small prostate glands also complain of going to the bathroom too frequently.  Even women suffer these problems and they have no prostate at all.

An increased urge to urinate is normal, as people get older. Why? It is a protective mechanism. Remember, most bodily urges and sensations grow weaker with age. Eyesight dims, libido fails, hearing diminishes. If the urge to urinate disappears, kidney failure and death result.

This is not to say that the increasing urge to urinate, as people get older, is convenient. No, it can be a real problem, especially when it disrupts sleep. However, it’s just not accurate to place all the blame on prostate enlargement. And from a cancer perspective, there is one advantage to having a big prostate gland. Several studies show that larger prostate glands generate lower grade cancers, have less extra-capsular spread and experience lower cancer recurrence rates, after treatment, than small prostate glands.

Having a big prostate gland is not always good; there are indeed some men with big prostate glands who suffer urinary blockage symptoms.

However, men with enlarged prostates can at least be thankful that their enlarged gland has some protective effect against prostate cancer.

2. Prostate Cancer Causes Symptoms

Throughout history, men only visited doctors when some part of their bodies hurt or malfunctioned. But prostate cancer doesn’t cause any symptoms at all until it becomes very advanced.

This is not to say that men can’t have symptoms coming from the area of the prostate due to other things like urinary tract infections or sexually transmitted diseases. But symptoms from cancer such as bone pain, changes in urination, and pelvic pain only occur with very advanced disease, when cancer spreads outside the gland. As long as men do appropriate annual screening with PSA (prostate-specific antigen), cancer will almost invariably be diagnosed long before it is capable of causing symptoms.

3. PSA Comes From Prostate Cancer

Some PSA may come from prostate cancer, but it is mostly produced by the prostate gland. Benign enlargement of the gland occurs as men age, causing the PSA to rise. Another noncancerous cause for high PSA is prostate inflammation, called prostatitis. Therefore, using PSA alone to diagnose cancer is very imprecise, especially if the PSA is under 10.

This is not to say that PSA is useless. As noted above, there are no symptoms from prostate cancer in its initial stages. So, a high PSA only indicates that something is going on with the prostate. It is a totally false assumption to simply conclude that a rise in PSA signals cancer. Men who have a high PSA should repeat the test.

If it continues to be elevated they should further investigate the possibility of prostate cancer by getting a three-Tesla multiparametric MRI, not a random biopsy.

4. 12-Core Random Prostate Biopsy Is No Big Deal

To undergo a biopsy of the prostate, a man is positioned on his side with his legs drawn up toward his chest. After an enema is administered and the rectum swabbed with soap, a needle is inserted multiple times through the wall of the rectum to inject Novocain in and around the prostate. Once the prostate is numbed, 12 or more large-bore cores are extracted with a spring-loaded needle biopsy gun through the rectum.

Antibiotics are routinely administered to lower the risk of infection.

If skillfully performed, the biopsy process takes 20 to 30 minutes. After the procedure, men usually experience bleeding in the urine and semen for a month or so. Temporary problems with erections can occur. Over the next week or two, a small number of men (about 2 percent) are hospitalized for the treatment of life-threatening sepsis. Occasionally, someone dies.

5. Every Doctor’s Main Concern Is Always for the Patient

If a prostate MRI reveals a suspicious spot and a targeted (not random) biopsy shows cancer, you will need to seek expert advice to select optimal treatment. However, there is a problem. All the doctors in the prostate cancer world both give advice and provide treatment. The issue is that they are better paid when they give treatment. Therefore, many are monetarily incentivized to persuade you to pursue treatment with them. The doctors are smart enough to know that you know this. So, they position themselves as being on your side and use a soft-sell approach. Their presentation becomes very smooth and convincing because they constantly share it with new patients every day.

The only way to circumvent this problem with a doctor’s conflict of interest is to arrange consultation with a doctor and designate him (or her) as your advising doctor exclusively. You will need to make it clear from the start that under no circumstances will he (or she) be your treating doctor. The goal of your meeting with the advising doctor is to obtain unbiased information about which type of treatment is best for your situation. You also need the advising doctor to provide you with “inside information” about the skill levels of the other doctors in your medical community.

6. All Prostate Cancer Can Be Deadly

There is much confusion because one label, “prostate cancer,” is applied to all the different grades of the disease. With skin cancer we call the bad stuff “melanoma.” The relatively benign type of skin cancer we call “basal cell.” With prostate cancer, instead of using different names we use numbers. For example, Gleason 7 and above can spread and is occasionally fatal (though it is nowhere near as dangerous as melanoma). Gleason 6 and below doesn’t spread. Gleason 6 acts like a basal cell carcinoma of the skin.

Now that doctors are finally realizing these differences, they are drawing back from recommending treatment for everyone. Selected men are placed on close monitoring without any immediate treatment. This new approach is called active surveillance. Over the last 10 years, active surveillance has become more and more accepted as a viable way to manage selected men with Gleason 6 prostate cancer. Active surveillance is accepted by the National Comprehensive Care Network (NCCN), The American Society of Clinical Oncology (ASCO), and the American Urological Association (AUA) as a standard way to treat Gleason 6.

7. Side Effects From Surgery and Radiation Are Similar

Men with Gleason 7 and above will usually need some form of treatment. Since most newly diagnosed men consult primarily with a urologist (who is a surgeon), surgery is often presented as the treatment of choice. The problem is that surgery has far more side effects and the cure rates are generally lower than what can be achieved with seed implant radiation. Here is a list, by no means all-inclusive, of some of the rather difficult side effects that surgery can cause:

  • Crooked penis disease or “Peyronie’s disease.” In a study of 276 men receiving surgery, 17.4 percent of the men developed crooked erections.
  • Experts have reported that ejaculating urine, so called “Climacturia,” occurs in about 20 percent of the men who undergo prostate surgery.
  • Urinary incontinence occurs in 5 to 10 percent of patients.
  • Stress incontinence, squirting urine with jumping, laughing, coughing, sneezing, etc. occurs in 50 percent of patients.
  • Shrinkage of the penis occurs by an average of one-half inch.
  • Additional, surgically related complications occur, including the occasional death.

8. You Can Do Radiation After Surgery, But Not Vice Versa

One selling point for surgery that many frightened patients find comforting is the perception they are creating a safety net, a backup plan, by doing surgery “first” rather than radiation. Their surgeons tell them, “If the cancer comes back after surgery they can do radiation, but surgery can’t be done after radiation.” This claim is no longer true. Salvage seed implantation in men who have recurrence in the prostate after radiation is being done more and more frequently.

However, there is an even more compelling reason to ignore the surgeon’s “sequence argument.” Starting with surgery made sense 15 years ago when surgery and radiation had equally bad cure rates and equally bad side effects. Today this is a specious argument. Modern radiation has far fewer side effects than surgery and noticeably better cure rates. When you want to cure cancer, why start with a less effective and more toxic treatment while holding a better treatment in reserve?

9. Seed Radiation and Beam Radiation Are All the Same

There are at least five different types of radiation and they can be divided into two groups:

  • Seed radiation—permanent and temporary—in which the radiation is implanted in the prostate
  • Beam radiation—IMRT, SBRT and proton therapy—in which the radiation is beamed through the body to hit the prostate

Often, these two different approaches are combined. Until recently, the assumption was that cure rates were similar with all approaches.

This belief has changed since the publication of a well-designed trial that compares the long-term cure rates of beam radiation, plus seeds, to beam radiation alone. Nine years after treatment, men treated with a combination of seeds plus beam radiation had a 20 percent reduction in their risk of relapse compared to the men who had beam radiation alone.

10. Recurrence of Prostate Cancer = Death

Most cancers—lung, colon, and pancreatic for example—if they recur after treatment, cause death within a year or two. So, it’s no wonder that the word “cancer” strikes fear in people’s hearts. But people need to realize that imminent mortality from prostate cancer, even when it recurs after initial treatment with surgery or radiation, is practically unheard of. If a man previously treated for prostate cancer has a recurrence, i.e., develops a rising PSA from the cancer coming back, the average survival is more than 13 years.

There are many additional reasons for patients to be optimistic. The pace of the progress being achieved with medical technology is very rapid. Immune therapy is probably the most exciting. Former President Jimmy Carter’s amazing remission from metastatic melanoma that metastasized to his liver and brain, is a recent example. Other new types of therapy can target and attack metastatic disease at different sites throughout the body. Lastly, genetically selected treatments are finally becoming practical due to the recent easy access to accurate analysis of tumor genetics. Research is progressing. So men with prostate cancer have realistic hope of many, further, important breakthroughs in the near future.

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