Prostate Cancer - Starting at the Beginning

After sitting down with a new patient Tom, a charming 80-year-old man who was recently found to have a prostate nodule and a PSA elevated up to 50, I asked him why he had not visited a doctor for over 10 years or undergone any PSA testing, he responded, “I have always enjoyed perfect health. Why see a doctor?” Sounds sort of like a stupid response, but judging by his healthy appearance, (looking more like 70), one would have to say that until now his policy has been pretty successful.


However, if Tom was going to participate intelligently in further discussions about the selection of optimal treatment, his level of prostate cancer knowledge would need a major upgrade.  Since he is a medical outsider, I knew my instruction had to begin at an elementary level. This article imparts the most fundamental themes that need to be introduced to men who have been insulated from knowledge about how prostate cancer behaves.   

Not All Cancers Are the Same 
Many patients introduced into the cancer world fail to understand that lung cancer, breast cancer, brain cancer and prostate cancer are a distinctly different illness.  Therefore, men with newly-diagnosed prostate cancer need to realize that all notions related to personal experiences with one type of cancer that has occurred in family members or friends will be totally misleading if it is applied to one’s expectations about prostate cancer.


Prostate Cancers Themselves Are a Mixed Bag 
It’s fairly easy for patients to understand that different cancer types, such as bladder cancer and skin cancer may behave differently. I have observed that it is more difficult for patients to grasp that prostate cancer itself can behave in a variety of ways.

Part of this diverse behavior is due to stage variations:  No one would be surprised to hear that early stage cancer has a different outlook than advanced stage disease.  
However, even when comparing two different prostate cancers of exactly the same stage, what we call “prostate cancer” is still extremely variable. Consider the following: In 2014, 70,000 men were diagnosed with a type of prostate cancer considered to be so harmless that experts universally agree that no treatment is the best management.  However, at the other extreme, also in 2014, a very different type of prostate cancer led directly to 28,000 deaths despite every attempt to prolong life with surgery, radiation, hormone therapy, immune therapy, and chemotherapy. What we call “prostate cancer” is actually a spectrum of different illnesses mistakenly being grouped together under a single umbrella term. 
Prostate Cancer in the Bone is Not Bone Cancer 
Another very common misconception that needs to be rectified is that cancer originating in the bone, i.e. “primary bone cancer,” is completely different from prostate cancer that has spread to the bones.

Primary bone cancer grows quickly, often spreads to the lungs and does not respond to hormones. Prostate cancer that spreads to bone tends to grow slowly and only rarely spreads to the lung and usually regresses with hormone therapy.  Prostate cancer in the bone and primary bone cancer are two separate and distinct illnesses that should not be confused with each other. 
Doctors and Patients, the Human Factor 
The human factor further complicates the selection of optimal treatment.  Doctors who treat prostate cancer come from different schools of thought. Not only are urologists, the primary care doctors of the prostate cancer world, they are trained differently from the radiation specialists.  There is a designated specialty just for treating all types of cancer, yet medical oncologists are practically never involved with the treatment of early-stage prostate cancer.  There are also additional important patient variables to consider, age, fitness, and prostate size for example.  Two patients may be treated differently despite having the same exact stage of disease and the same exact type of prostate cancer.  

Tom’s Situation 
With such a high PSA of 50, Tom will need a bone scan to determine if metastases have occurred.  If the scans turn out to be clear, and if Tom was ten years younger, radiation to the prostate combined with hormone therapy would give him the best chance for cure.  However, either one of these treatments alone may control the disease for 15 years.  Therefore, in an 80-year-old it is quite reasonable to consider a less aggressive treatment approach with radiation alone or hormone therapy alone.  Less aggressive treatment limits the risk of treatment-related side effects.  Tom and his wife left our meeting with a copy of my book, Invasion of the Prostate Snatchers with plans to study further in preparation for the next meeting.

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