Beyond the “All-or-Nothing” Paradigm for Prostate Cancer, Part I

surgery for prostate cancer is not always necessaryWhen I was diagnosed with prostate cancer in December 2011, I was told unequivocally that I needed surgery or radiation. I spoke with four experienced prostate surgeons, and they all said that because of my high PSA level and multiple biopsy cores positive for cancer, radical treatment that either removed the entire prostate gland or fried it to mush were the only safe choices.

The only other option was watchful waiting, in essence, doing nothing. This was a risky and psychologically difficult choice when one knows he has cancer in his prostate gland. So I placed myself on the surgery schedule and waited for my turn to arrive, worrying constantly about whether the treatment would render me impotent or incontinent or both for the rest of my life.

Then it occurred to me how much we didn’t know about my prostate cancer. The three biopsy cores that were positive for cancer had come from the left lobe of my prostate gland. How big was the tumor? Where was it located? Was it located innocuously in the center of the gland or near the edge and ready to spread? Was it located in one area or throughout the gland? Because no tests could tell us the exact location of the cancer, these questions couldn’t be answered.

I realized that many treatment decisions are based on statistical paradigms: if your PSA is above a certain number, and your biopsy cores positive for cancer are above a certain number. Even if your cancer is low grade (Gleason 6 on 6-10 scale) as mine was, you still need radical treatment.

This has been the method for more than 20 years. Because of the inability to actually define the cancer’s location and dimensions, doctors have recommended surgery or radiation if there was any risk at all of lethality. The greatest fear of doctors has been to under-diagnose a dangerous prostate cancer and then watch a man die slowly and painfully. So doctors have erred to the side of overtreatment — but at what cost?

“Out of 50,000 radical prostatectomies performed every year in the United States alone, more than 40,000 are unnecessary,” states Dr. Mark Scholz, one of the premier prostate cancer oncologists in America. The numbers are similar for radiation therapy. Today, many experts agree that overtreatment of men with prostate cancer is rampant.

And the problem is getting worse. Just last month, a study in the Journal of the American Medical Association reported that the inappropriate use of radical treatment for men with low-risk prostate cancer continues to increase (Jacobs BL et al, June 26, 2013). The harm done is extreme. And, today, unnecessarily.

I was almost one of the 40,000. By the time the hospital called with a date for my surgery, I politely declined. I had learned a lot in that intervening month.

Although most hospitals and doctors don’t yet offer it, I learned that at the upper echelons of cancer care, new technology was already bringing prostate cancer diagnosis and treatment into the 21st century.

In Part II of this article, I’ll tell you about those new, cutting-edge technologies and how they’re being used for diagnosing and treating prostate cancer.

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