In 1935, physicist Erwin Schrödinger devised a thought experiment where a cat is sealed in a steel box with a device that will kill the cat if an atom of a radioactive substance decays. Schrödinger's Cat
was intended as a critique of quantum mechanics theory which suggests that at the end of an hour, given a 50/50 chance that the atom has decayed, the box will contain both
the live cat and the dead cat as a probability cloud and that the system only resolves to one of the two states when the box is
At this point as you sit there reading this you have a condition that could be called Schrödinger's prostate. With a fair probability you have indolent disease that will never bother you, much less kill you. At the same time, with a bit less probability you have a slow-growing cancer that will need treatment but will respond well to that treatment. At a lesser probability you have an aggressive cancer that has eluded the biopsy needles and will require more extensive treatment. And, at a fairly small probability you are the guy who will die of you disease no matter what you or your doctors do. You are all those men at the same time and the probability cloud won't collapse to a single state until you
open the uncomfortable box you find yourself in.
Active Surveillance is a good strategy for the first couple of probability states -- your selves with indolent or slow-growing cancers. If you like your luck and you don't mind being in the box its a sensible choice. For your third self -- the one with an undetected high-risk cancer -- AS is a bad idea. It gives your aggressive cancer more time to escape while you are farting around with PSA velocities and repeated biopsies. And as for that last you -- the one with the disease that will ultimately prove uncontrollable -- gee, I dunno. I'm too busy trying not to be
that guy myself to have a good opinion about
Unfortunately the only way to completely
open the box is an autopsy. But surgery is the next best thing. The post-op pathology report goes a long way towards sorting the probabilities out. I opted for surgery even though I was a candidate for continued AS. My oncologist also opted for surgery for his PC. Based on my pathology report, further AS would have been a bad idea for me. I'm glad I went with surgery. Wish I had done it sooner. My oncologist, on the other hand, probably could have done fine with AS. He probably has regrets. Surgery does have side effects.
I can't say I based my decision on the best analysis. It would probably have been sensible to continue with AS given what I knew then. Like IronReb I decided that after four biopsies, and with the expectations of additional biopsies and other tests to come, my prostate was getting to be a high-maintenance organ and it could go. It was a good decision made for questionable reasons.
One other thing to consider is that the issues of surgical side effects and surgical outcomes are not altogether unrelated. When the surgeon gets in there, if he finds a good-looking prostate with nothing growing out of the capsule, then he can take it out cleanly, with minimal damage to the surrounding tissues. On the other hand, if he finds cancer growing outside, on, or near the surface of the organ then he has to take more tissue and the risk of side effects is greater. This somewhat mitigates one of the arguments against surgery for low or moderate risk PC. If the side effects were evenly distributed then we would see lots of men with lots of side effects from surgery that they didn't need to start with (as it turned out.) But, since the side effects tend to cluster in men (such as myself) whose cancer was a bit more aggressive, that takes some of the load off of the men with low-risk cancers.
Slow PSA rise 2007-2012: 1.4=>8
4 biopsies 2010-2012:
1)neg (inflammation observed),
3)positive one of 14 cores GS6(3+3) 3-4%, 2nd opinion GS7(3+4)
Moderate Pre-op ED
DaVinci RRP 6/14/12. left nerve spared
Post-op path: pT3a pN9 R1 GS9(4+5) Pos margins on rt
Start 24 mo ADT (Triple w/ Lupron) 7/26/12
Start adjuvant IMRT 10/17/12 done 12/10/12
Incontinent, Trimix, VED for Rehab