Three British physicans speak about their own prostate cancers


Patients often ask what doctors do when they get diagnosed with prostate cancer themselves. For once the UK’s Daily Mail has actually outdone itself and provided a thoughtful and well-constructed article about the diagnosis and treatment of three respected British urologists.

14 Responses

  1. Hello Sitemaster,

    I’m alarmed by the sheer speed of PSA rise experienced by John Anderson … from 1.74 to 92 ng/ml in the space of 4 months. I know that different tumours express PSA in differing amounts but I’ve never heard of a rise that fast.

    I’ve been getting checked annually as my father was diagnosed with advanced metastatic disease and a PSA just shy of 2,000 ng/ml a few years ago. I’m now rethinking my frequency of PSA checks.

    Is that velocity unusual?

    Regards

    Jonathan.

  2. Interesting, CT or MRI before biopsy. I’ve had CT for my bladder cancer, never for my prostate cancer, though both were probably in the same scan.

  3. An interesting read, but my concern was that the first two of these urologists did not seem to be entirely “up” on appropriate treatment.

    Dr. Anderson mentions known discomfort and having a PSA test, but doesn’t mention having a DRE. And, despite known metastases to the liver, only opted for the LHRH agonist Zoladex as his earlier treatment before chemotherapy became a requirement. No earlier antiandrogen to block AR activity or to prevent the “flare” effect usually occurring with initial LHRH agonist injection? Gleason scores were never mentioned by any of these three physicians.

    Then Dr. Hanbury says the first PSA he ever had came out a 29 (ng/ml?) that he remarks is high, but not necessarily high … say what? And he has metastases to a hip, but also opts for only Zoladex. He says he recommends an antiandrogen to his patients, but opts not for himself. Again, no consideration of the “flare” effect? And again, no Gleason score provided. He did end up with EBRT and, at least for now, the pain in his hip is relieved and his PSA has dropped to 0.06 ng/ml … but for how long?

    Dr. Kirby was more fortunate in catching his prostate cancer early on and robot-assisted surgical removal has apparently/likely eradicated his cancer. I am glad he provided the name of a RaLRP surgeon, Dr. Prokar Dasgupta, he speaks highly of, so I intend to look into learning more about this physician as one who I could recommend patients in the UK to see if RaLRP is an option they would prefer.

  4. Worth reading!

  5. Interesting, typically stoic British.

    The last case illustrated one point well, the physician as a patient who learns empathy for what he does. Every urologist should have to walk around with a catheter for a week. That physician also uses the word “cured” in the first year post-RALP. We know this is a poor choice of words. His cancer is “controlled.”

  6. Dear Jonathan:

    Yes, a PSA rise like that is distinctly unusual. It reflects the fact that there are, in fact, many different subtypes of adenocarcinoma of this prostate that we are only now beginning to learn about. Dr. Anderson’s appears to be among the most aggressive.

  7. Thank you Sitemaster.

    I will be increasing my frequency of checks then. No doubt I’ll have to battle my GP for it as usual, but it’s worth it.

    Cheers

    Jonathan

  8. Dear Mike:

    Actually, I don’t beleive it is possible to do CT and MRI scans “simultaneously” at this time. It would certainly be extremely unusual and require very sophisticated technology.

  9. Dear Chuck:

    This is a newspaper article. Who knows what actually got said in the entire interviews.

  10. @Bob Lederer.

    Being stoical about a major problem is neither British nor new. It was propagated by rationalist Hellenistic philosophers and lawyers in ancient Rome. It’s a reasonable doctrine that comes in various, closely related forms, depending on the writer. It is incorrect to imply, as I think you do, that something’s amiss with it since being stoical is (supposedly) “typically” British.

    I am a Dutch-American citizen, retired, living in Sweden and a stoic with prostate cancer. As a quite smart and pretty well-known American author and expert on Stoicism convinced me in conversation, the doctrine advises one to control your emotions, so as to help you to allow which events and situations (in the author’s neat term) “get” you. These are matters that you have some control over, must decide about your reactions to them, and (most importantly) must do so as rationally as possible. Stoics hold that being rational in a given situation involves good decision-making processes. These demand emotional control, so as not to disturb a reasoning process that has to result in a constructive decision that motivates effective action. In my opinion this is a quite useful attitude to adopt when confronted with a cancer diagnosis. In my case it was probably essential and it worked. I ignored the typically American self-help stuff.

  11. Dear Sitemaster:

    I have been following The “New” Prostate Cancer Infolink closely for the past years and have found it very informative. In fact, it is one of the MOST informative websites available for urologists — for the mere fact that information is updated very fast and well discussed as well as well analyzed.

    However, the article on the three British urologists actually had statements that I hope may be clarified; mainly for the sake of academic knowledge only and not to refute the state of clinical scenarios of the outstanding urologists’ conditions:

    (1) Dr. Anderson:

    POINT ONE: He had done a PSA test 4 months earlier which was 1.74; noticed a lump in the liver; repeat PSA was 92 and after Zoladex was down to 0.2 four months later. This is rather odd — although one can argue that there are possibilities of atypical varieties of prostate cancer which are very aggressive (namely neuroendocrine/small cell cancers of the prostate), the PSA will never have increased from 1.74 to 92 within such a short time span. Could this sudden rise of PSA be attributed to a PSA test done just after the liver biopsy of the metastatic prostate nodule. Obviously, as Dr. Anderson had a very low PSA, he would not have suspected a diagnosis of prostate cancer and would unlikely have had a PSA done until confirmation of the liver biopsy.

    POINT 2: Knowing very well that his actual baseline PSA was low at 1.74 (and the PSA of 92 was probably biopsy-related), liver metastasis at initial presentation clearly represents an atypical presentation with extra-axial metastasis in an aggressive low PSA cancer which is (probably) neuroendocrine/small cell cancer of the prostate. These patients usually do poorly, and chemotherapy used as first-line is usually necessary. (Although of course the histopathology could have confirmed the classical adenocarcinoma indicating the role of hormonal ablation as first-line treatment.) The repeat PSA 4 months along the line may have given a false impression that the PSA has fallen significantly, but this would not have actually meant that the tumor is hormone-responsive as the actual PSA before then was 1.74 (and not 92, which may be assumed to be related to the liver biopsy). The drop of in his PSA from 1.74 to 0.2 may be expected anyway on starting the hormonal ablation. The only evidence of “some” response is the shrinkage of the liver lesion, which then unfortunately re-grew “out of the blue.” He did the right thing later by embarking on chemotherapy. But obviously, he quite frankly mentions that he wants quality and not quantity of life, and may have rejected the chemo in the first instance. Kindly comment.

    POINT 3: He mentions: “Keep an eye on that PSA level — it’s not a perfect test, and did not help me, which is why we don’t screen men routinely.” I would say that a patient with a low PSA and extra-axial metastasis itself is an atypical case; and should not be used as a general statement to infer such a cases on generalization of PSA screening.

    (2) Dr. Hansbury:

    POINT 1: He mentions his PSA was 29, high but not excessively so. I beg to differ. A PSA of 20 risks an incidence of 1% metastasis itself.

    POINT 2: He was right to do a PSA in mid-life which clearly prognosticates e possibility of having prostate cancer in the next 20 to 25 years later.

    POINT 3: He started on Zoladex when he had hip metastasis which is the right first-line management, followed by radiotherapy for palliation at a later stage. Radiotherapy is only palliative and would have benefited the bone metastasis; but the radiation therapy to the prostate is of questionable intent unless he had bladder outflow obstruction unresponsive to hormonal ablation. But then, channel TURP would have been a good modality for this.

    (3) Dr. Kirby:

    POINT 1: The article states that, at the age of 62 years, his PSA level was 3.4 which was “slightly above the normal for a man of his age”. I beg to differ on this statement. The normal PSA is actually the value of the predicted median PSA of an individual, and at his age the PSA should actually be between 0.8 and 1.2 ng/ml.

    POINT 2: A couple of months later he re-tested it and it was 4.4. What if it was “only” 3.6 or 3.8 on the repeat PSA? The following are my firm beliefs in PSA:

    (i) PSA values are not dichotomous, but are based on increasing risk of prostate cancer with increasing PSA results. Hence one cannot say if he has a low or high PSA at the beginning unless one were to compare this to the median value of PSA to that age group.

    (ii) A PSA value of < 4.0 ng/ml does not necessarily imply a normal PSA. This delineation of PSA level is meant for triggering of prostate biopsy based on the ROC analysis curves in view of the sensitivity and specificity of PSA screening.

    (iii) Mid-life PSA predicts the risk of prostate cancer at 20 to 25 years later. PSA at age 60 (above the median PSA value) predicts prostate cancer mortality by age 85

    (iv) A PSA value of 4.0 ng/ml does not rule in prostate cancer

    (v) The rationale for use of a course of antibiotics in a patient with a fluctuating PSA remains a non-evidence-based practice reserved only for selected individuals. Similarly, I feel that, if there is no suspicion of prostatitis symptoms or UTI, repeating the PSA is a non-evidence-based practice.

    (vi) Even if PSA were to fluctuate (with higher levels), the reduction in PSA following antibiotic therapy would decrease PSA to below biopsy-trigger level, but does not necessarily decrease the risk of detection of prostate cancer (see Baltaci et al., 2008). Hence pre-biopsy antibiotics with intent to reduce PSA in asymptomatic patients may be unjustified (except for selected individuals). Prostate cancer is still possible even if PSA declines (see Connolly et al., 2009)

    FINALLY at the end of article mentions: “for men 70 and over, a level of (PSA) of 5 is considered normal, over age of 60 the level be no more than 4, over 50 it should be no more than 3” are very inaccurate and misleading statements. These are bipsy-triggered values of PSA at which the a urologist has to decide whether there is a necessity to proceed with biopsy or not. As I have mentioned earlier, PSA testing is not an technique that reveals a dichotomous result.

    I am aware that this is actually a newspaper article and may not have published all the actual words usewd during the interveiws.

    And thank you to The “New” Prostate Cancer Infolink for maintaining such an efficient and well organized and well analyzed web site on prostate cancer.

  12. Dear Dr. Rajeen:

    First, thank you for your expert opinion on the article in The Daily Mail. I would tend to agree with you that the details of this article leave a lot to be desired. Unfortunately, it is impossible for us to know to what extent this is because of poor decision-making and comment by the urologists in answering questions or simply poor writing/editing by the newspaper. My guess would be that there is a combination of effects going on here.

    It was never our intent to imply that the decisions made by these three physicians were “right.” Indeed, to me, the message that comes across very clearly from this article is that, when it comes to their own treatment for prostate cancer, even urologists are capable of making decisions that are distinctly questionable (as you have clearly pointed out) and to base their decisions on dubious clinical and scientific information!

  13. Sitemaster:

    We surely can misunderstand each other, though I greatly enjoy the conversations. I did not mean a CT/MRI combo. I meant a situation in which a scan of one organ likely includes the other organ, at least in the background. Specifically, it was a prostate CT scan that discovered my bladder cancer (not the other way around as in first post).

  14. I just came upon this post again while looking for Roger Kirby’s name.

    The serendipity is that last September, my best friend since infancy was visiting with his family and we got together in Vegas for a quick trip to Zion. He is a leading breast cancer surgeon.

    I discovered that Roger Kirby is a close friend of Mark’s — they were at Cambridge and med school together. I have often hear him refer to Roger in the context of poker nights, drinking evenings, etc., etc. – never realized until last year it was Roger Kirby. Hopefully, I’ll get to meet Mr. Kirby, FRCS at some point soon.

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