Why There Are No Easy Answers
Last Revised August 24, 1995
Introduction |
Why can't prostate cancer always be cured? |
If you've taken out my prostate, how can I still have prostate cancer? |
Is it true that some prostate cancers are more dangerous than others? |
But I heard about this new treatment on the news... |
Is every form of treatment for prostate cancer a gamble?
Introduction
Most cancers are complicated diseases. Some cancers are even more complicated than others. It may
be annoying. It is certainly frustrating. For some, it may even become infuriating. Unfortunately,
when it comes to prostate cancer there are very few easy or absolute answers!
In this section, we have tried to discuss why it is that some common questions about prostate cancer
just don't have satisfactory answers ... and how patients may want to try and face up to this very
difficult realization.
Why can't prostate cancer always be cured?
All too often, we don't know why a particular person gets prostate cancer, when they first got prostate
cancer, whether that prostate cancer is actually confined to the prostate or not, whether the most
appropriate treatment will in fact work, and even if it does work how long it will work for! Given all
those things we probably won't know about a particular patient, perhaps it is amazing that we are
actually able to cure as many cases of prostate cancer as we do!
There are two critical problems when it comes to treating prostate cancer. In the first place, prostate
cancer is a very slowly growing form of cancer. This means that by the time it is detected and
diagnosed, it has probably been developing for years, and therefore has had considerable time to
"micrometastacize" -- which means to spread very small groups of prostate cancer cells outside the
prostate. These micrometastatic groups of prostate cancer cells may not be detectable at the time that
the original site of prostate cancer is found in the prostate itself.
Secondly, although some treatments (including radical surgery, radiation therapy, and cryotherapy) are
given with the intent of curing the cancer, none of them in fact can be applied with the
certainty that the treatment will in fact work.
If you've taken out my prostate, how can I still have prostate cancer?
Unfortunately, even the most skilled urologic surgeon in the world, using the best surgical facilities
and equipment available, and operating on the ideal patient with a small focus of apparently localized
prostate cancer in one lobe of the prostate, cannot guarantee to that patient after a radical
prostatectomy that he or she has absolutely removed every prostate cancer cell from that patient's
body. It need only take one prostate cancer cell to have escaped from that man's prostate into the
bloodstream for prostate cancer to reappear in 6 months or a year or more. This is not the news a
prostate cancer patient wants to hear, but every patient with an initial diagnosis of prostate cancer
is at risk of recurrence of the disease regardless of the stage of his primary cancer or the form of
treatment used.
It is now customary practice to use PSA and other tests to "follow" prostate cancer patients after
treatment. Ideally, after curative treatment, a patient's PSA level will fall to an undetectable level.
New forms of PSA test (the so-called "ultrasensitive" PSA tests) make it even easier to detect whether
a patient's PSA has in fact fallen (effectively) to zero. However, as any physician with experience in
the treatment of prostate cancer can now tell you, there is always the chance that PSA level will start
to rise again.
In the future, we may start to see the RTPCR test used to try to detect whether prostate cancer cells
have been left in some patients following curative therapy. However, that will still not make any
difference to the actual ability to ensure that the treatment which is tried will in fact work.
Is it true that some prostate cancers are more dangerous than others?
Well, maybe. What we do know is that some prostate cancers grow faster than others, and there are
various theories about why this happens. All sorts of tests have been devised in the attempt to help
physicians and their patients decide how to act on the basis of such things as "ploidy" (which is a
measure of the quantity of DNA per cell nucleus), nuclear "morphometry" (which is a way of
measuring differences in shape between the nuclei of prostate cancer cells), and a whole alphabet of
new biological markers which have been identified in just the past few years. Some physicians also
believe that prostate cancers that appear first in certain parts of the prostate are more likely to behave
aggressively than others.
Unfortunately, none of the tests available today can provide definitive information about the likely
progression of a particular prostate cancer in a particular patient. All that the doctor is able to do is
discuss the available information with you, and then help you to make the best guess about which
form of therapy is potentially most appropriate for you.
But I heard about this new treatment on the news ...
And unfortunately you may well have! William Randolph Hearst and others did something
utterly amazing. They persuaded millions of people that "the news" and "the facts" are the same
thing. They aren't. When you hear the report that begins, "Scientists today reported a major advance
toward curing prostate cancer," on the nightly news, you should listen very carefully. In particular,
you want to listen for the bit in which someone says, "I don't expect this to be clinically applicable for
at least another three or four years." This means that they have absolutely no idea whether it will
ever be applicable to any patient, let alone you! The best medical news commentators are very
good and careful about how they report advances in medical science. Regrettably, too many
journalists are being asked to "report" on advances in medical science with far too little training in
either science or medicine.
Because prostate cancer has become the most common cancer diagnosed in male Americans, we can
expect to hear many news reports about how to screen for it, diagnose it, and treat it in the next few
years. Very few of those reports will be of practical significance to many patients. Your television
station, and your radio station, and your newspaper have to find information to fill their "news space"
every day. Plenty of organizations and individuals are more than willing to help them fill that "news
space" with news. When it comes to listening for information about new forms of prostate cancer
treatment, be skeptical. Even if it sounds like a real breakthrough, and the reporter is clearly
knowledgeable and well informed, be cautious. Talk to your doctor. Ask him (politely) if he heard
the story. Ask him if he has read (or even heard of) the published scientific article on which the story
was based. You will gradually discover that many of the "big" advances in any area of science and
medicine can be well known to those who specialize in that area of science or medicine long before
the "media" gets the story. And, sadly, many of the medical stories that make the nightly news are
not actually as important as they may first appear to be.
Is every form of treatment for prostate cancer a gamble?
Bluntly, at the moment, yes. However, just like gambling, there are smart bets and there are dumb
bets. Let's say that your brother (who was always a little whacky) dies in a car accident. When they
read his will, you discovered that he had left you $100,000 -- with one condition. You have to bet it
all on one horse in one horse race in the next year. If you win, you keep everything. If you lose, you
lose everything. But so long as there are at least two horses in the race and the race isn't fixed, you
can bet on any horse in any race you like.
Now folks, we all know that horse racing comes with some big risks. Huge odds-on favorites have
tripped over their own feet while leading by most of the home straight. Rank outsiders which no one
has ever heard of suddenly decide that they feel like a good gallop and win races they shouldn't even
be in. You know the sort of thing I mean. So what are you going to do?
One way to look it this is to say to yourself, "What the heck, let's try and turn the $100,000 into $1
million by betting on a 10 to 1 shot. If I lose, I can only lose money I didn't have in the beginning
anyway!"
Another view is to say, "How do I make as sure as possible that I hang on to the $100,000?" And of
course the way to do that is to find a short two-horse race to bet on in which one horse is the winner
of the Kentucky Derby ridden by a champion jockey and the other is a 25-year-old plough horse
ridden by 12-year-old! You ain't going to win much money. However, your chances of hanging on to
the $100,000 look pretty good. But don't say I didn't warn you, funny things can happen in horse
races!
If you are diagnosed with prostate cancer, you are going to have to take some risks. You will have to
take risks with the form(s) of treatment you choose. You will have to take risks with whom you
decide to tell about your disorder. You will have to take risks with which doctor you want to help
you through the treatment. Your job is to take those risks with as full an awareness as you wish to
have about what you are doing. If you've been cleaning up at the horses for the past 20 years, you
may be pretty good at this. If you've lost every penny you ever had to the track, it's time to go and
get some really good advice! Remember, one of the most important things you can do is say to
yourself, "How will I feel if the odds-on favorite trips over its own feet 20 yards from the finish?"
These things do happen.
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