Starting at the Beginning With Prostate Cancer

After sitting down with a new patient Tom, a charming 80-year-old man who was recently found to have a prostate nodule and a PSA elevated up to 50, I asked him why he had not visited a doctor for over 10 years or undergone any PSA testing. He responded, “I have always enjoyed perfect health. Why see a doctor?” Sounds sort of like a stupid response, but judging by his healthy appearance (looking more like 70), one would have to say that until now his policy has been pretty successful. 

However, if Tom was going to participate intelligently in further discussions about the selection of optimal treatment, his level of prostate cancer knowledge would need a major upgrade. Since he is a medical outsider, I knew my instruction had to begin at an elementary level. Just as I shared with Tom, this article imparts the most fundamental themes that need to be introduced to men who have been insulated from knowledge about how prostate cancer behaves.   

Doctor showing senior patient brochure in office
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Not All Cancers Are the Same

Many patients introduced to the cancer "world" fail to understand that lung cancer, breast cancer, brain cancer, and prostate cancer are distinctly different illnesses. Therefore, men with newly diagnosed prostate cancer need to realize that notions related to personal experiences with one type of cancer that has occurred in family members or friends will be totally misleading if they are applied to expectations about prostate cancer. ​

Prostate Cancers Themselves Are a Mixed Bag

It’s fairly easy for patients to understand that different cancer types, such as bladder cancer and skin cancer, may behave differently. I have observed that it is more difficult for patients to grasp that prostate cancer itself can behave in a variety of ways. Part of this diverse behavior is due to stage variations—-no one would be surprised to hear that early stage cancer has a different outlook than advanced stage disease.

However, even when comparing two different prostate cancers of exactly the same stage, what we call “prostate cancer” is still extremely variable. Consider the following. In 2014, 70,000 men were diagnosed with a type of prostate cancer considered to be so harmless that experts universally agree that no treatment is the best management. However, at the other extreme, also in 2014, a very different type of prostate cancer led directly to 28,000 deaths, despite every attempt to prolong life with surgery, radiation, hormone therapy, immune therapy, and chemotherapy. What we call “prostate cancer” is actually a spectrum of different illnesses being grouped together under a single umbrella term.

Prostate Cancer in the Bone Is Not Bone Cancer

Another very common misconception that needs to be rectified is that cancer originating in the bone—that is, primary bone cancer—is completely different from prostate cancer that has spread to the bones. Primary bone cancer grows quickly, often spreads to the lungs, and does not respond to hormones. Prostate cancer that spreads to bone tends to grow slowly, only rarely spreads to the lung, and usually regresses with hormone therapy. Prostate cancer in the bone and primary bone cancer are two separate and distinct illnesses that should not be confused with each other. 

Doctors and Patients: The Human Factor

The human factor further complicates the selection of optimal treatment. Doctors who treat prostate cancer come from different schools of thought. Urologists, the primary care doctors of the prostate cancer world, are trained differently from radiation specialists. There is also a designated specialty just for treating all types of cancer called oncology—yet medical oncologists are practically never involved with the treatment of early-stage prostate cancer. There are also additional important patient variables to consider: age, fitness, and prostate size, for example. Thus, two patients may be treated differently despite having the same exact stage of disease and the same exact type of prostate cancer. 

Tom’s Situation

With a high PSA of 50, Tom will need a bone scan to determine if metastases have occurred. If the scans turn out to be clear, and if Tom were 10 years younger, radiation to the prostate combined with hormone therapy would give him the best chance for a cure. However, either one of these treatments alone may control the disease for 15 years. Therefore, in an 80-year-old, it is quite reasonable to consider a less aggressive treatment approach with radiation alone or hormone therapy alone. Less aggressive treatment limits the risk of treatment-related side effects.

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