According to an article in The Sunday Times in the UK over the weekend, a well-known surgeon in the UK is claiming to have carried out “the first” radical prostatectomy on a man with no other indicator for treatment except a BRCA2 mutation and a significant family history of breast and prostate cancer.
Whether this is really the first such case — and frankly we doubt it because we are aware of a very small number of other cases of prophylactic radical prostatectomy in men with a serious family history of metastatic prostate cancer, going back years — the claim by this surgeon, originally reported in The Sunday Times, but also discussed in a Medscape article today, makes the “New” Prostate Cancer InfoLink feel distinctly uncomfortable. Frankly, it seems to us to smack of self-promotion and scare-mongering.
It is absolutely the case that certain genetic mutations do seriously increase risk for aggressive forms of prostate cancer — and we have already discussed the recent article by Eeles et al. that has attempted to quantify that risk for men with BRCA1/2 mutations. It may also be the case that prophylactic treatment of some type is appropriate for a very small subset of men who carry the BRCA2 mutation and who have clear clinical evidence of aggressive prostate cancer associated with this gene mutation in their family. However, there are a lot of things that we don’t know yet (as is the case with breast cancer as well):
- We don’t know that carrying the BRCA2 gene inevitably results in men having prostate cancer, let alone aggressive and potentially metastatic prostate cancer.
- We don’t know that there is any need to carry out prophylactic treatment of any type for men who carry this gene; it may well be sufficient to ensure a rigorous monitoring strategy in such patients and treat them if there is clear evidence on early diagnosis.
- We don’t know that a radical prostatectomy is the most appropriate method by which to treat such men at all.
What we do know is that the following type of statement, supposedly offered by the surgeon in question during his interview with The Sunday Times (but not actually included on the newspaper’s brief web report), is certain to put a high degree of fear into a large proportion of men with any family history of BRCA2 mutation:
Knowing you are a carrier is like having the sword of Damocles hanging over you. You are living in a state of constant fear. I am sure more male BRCA carriers will follow suit.
Is this really the right way to be offering men sound guidance about medical risk? The “New” Prostate Cancer Infolink thinks it absolutely is not. We also have an uncomfortable feeling that way more women than necessary will now be seeking prophylactic radical mastectomies as a consequence of Ms. Jolie’s decision to “go public” with her surgery.We are not criticizing Ms. Jolie for her decision, but the media reaction was distressing and unfortunate.
Decisions about radical prophylactic therapy of this type come with a range of complex medical and ethical questions that relate to risk and quality of life. This is serious business that involves risk for life and death (especially if something goes wrong with the surgery; people still do die quite regularly during “routine” surgical procedures). “Promotion” of the unproven “benefits” of prophylactic radical prostatectomy in the media feels distinctly questionable to those of us who still think ethical behavior is something we are meant to apply in our day-to-day lives.