In the beginning …

Cancers are complicated diseases, and some cancers are 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 few easy or absolute answers!

In this section, we will try to explain why it is that common questions about prostate cancer just don’t have good 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 have answers to any of the following:

  • Why a particular person got prostate cancer
  • When they first got prostate cancer
  • Whether their prostate cancer is actually confined to the prostate or not
  • Whether it is a good idea to actually treat their cancer at all
  • Whether the most appropriate treatment will in fact work, or
  • Even if it does work, how long it will work for!

Given all those things we don’t know about a particular patient, perhaps it is amazing that we actually seem to be able to cure as many cases of prostate cancer as we do!

There are three critical problems when it comes to treating prostate cancer:

  • In the first place, and very importantly, for men with low- or very low-risk prostate cancer, and most especially for men with these forms of prostate cancer who are > 65 years of age (and therefore have a relatively limited life expectancy), it may well be better not to actually treat their disease but rather to just monitor it. Why? Because the harms associated with treatment may be riskier that the fact that you have a low-risk form of prostate cancer which is most unlikely to kill you.
  • Second, in the majority of men, prostate cancer is a very slowly growing form of cancer. By the time it is detected and diagnosed, it may have been developing for years. This means that there has (potentially) been a lot of time for very small groups of prostate cancer cells to spread inside and outside the prostate. Small groups of prostate cancer cells way outside the prostate (known as “micrometastases”) are often not even detectable at the time that the cancer is found inside the prostate itself.

You Took Out My Prostate, How Can I Still Have Prostate Cancer?

Unfortunately, even the most skilled urologic surgeon in the world, using the very best surgical facilities and equipment available, and operating on the ideal patient with a tiny focus of apparently localized prostate cancer in one lobe (one of the two sides) of the prostate, cannot guarantee after surgery that he or she has absolutely removed every prostate cancer cell from that patient’s body. It is possible (not likely, but possible) for just one prostate cancer cell to have escaped from that man’s prostate into his bloodstream or some other tissue and lead to prostate cancer reappearing — in 6 months or a year or even 25 years time. And of course if lots of these cells have escaped, the chances of recurrence start to increase.

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 cancer or the form of treatment used.

Doctors now use the prostate-specific antigen or PSA test 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. However, as any physician with experience in the treatment of prostate cancer can now tell you, there is always the chance that the PSA level will start to rise again.

Are Some Prostate Cancers More Dangerous Than Others?

Yes, they are. We know that some prostate cancers grow faster than others, and there are various theories about why this happens. All sorts of tests have been devised to help physicians and their patients deal with this issue, and there is evidence that prostate cancers that appear first in certain parts of the prostate are more likely to behave aggressively than others.

Unfortunately, no tests widely 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 decision about which form of therapy is potentially most appropriate for you.

One of the “holy grails” of prostate cancer research is to find a test that can accurately and specifically distinguish (“discriminate”) between the really slowly growing types of prostate cancer that probably don’t need treatment at all and the more aggressive types of prostate cancer that may lead to patients’ deaths.

But I Heard About This New Treatment on the News …

And 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 a news report that begins, “Scientists today reported a major advance toward curing prostate cancer,” listen very carefully. In particular, listen for the bit when someone says, “I don’t expect this to be clinically applicable for at least another 3 or 4 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, many journalists are asked to “report” on advances in medical science with far too little training in either science or medicine.

Because prostate cancer is the most common cancer diagnosed in American men, we hear many news reports about how to look for it, diagnose it, and treat it. Very few of those reports are of practical significance to many patients. But your television station, your radio station, your newspaper, and the blogosphere have to find information to fill “news space” — 24/7/365. Plenty of organizations and individuals are more than willing to help them fill that “news space” with news — especially if someone famous is involved.

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 if he or she heard the story. Ask if he has read (or even heard of) the scientific article on which the story was based. You will gradually discover that many of the supposed “big” advances in any area of science and medicine are not actually as important as they may first appear to be.

Is Every Treatment for Prostate Cancer a Gamble?

Yes, to at least a small extent it is. However, just as in gambling, there are smart bets and there are dumb bets.

Let’s say that your whacky uncle Mel dies in a car accident. When they read his will, you learn he has left you $100,000 — with one condition. You have to bet it all on one horse in one horse race in the next 12 months. 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 that no one 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 at 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 in which one horse is the winner of the Kentucky Derby ridden by a champion jockey and the other is a 20-year-old, overweight plough horse ridden by 12-year-old! You ain’t going to win much money, but your chances of hanging on to the $100,000 will look pretty good. However, don’t say we 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 which doctors you want to help you with treatment. You may even feel you have to take some risks with who you tell about your illness. 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 at the track (or in Las Vegas for that matter), 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.

Content on this page last reviewed and updated December 18, 2012.
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