9-years since treatment
I had to look-up the date (because I didn't remember), but I confirmed that it was 9-years ago that my prostate—with fairly small amounts of favorable-intermediate risk prostate cancer—was surgically removed. My how times have changed since then.
Back then, the focus of “due diligence” was centered, first, on a decision between treatment modes (mostly surgery or radiation), and then on finding a highly experienced DaVinci robot surgeon. Both were pretty straight-forward. As a younger man with a favorable-risk case, I kept hearing “you have many treatment options.” My treatment mode decision—the first decision—was largely based on the fact I had so many years ahead of me that I didn’t want to deal with the “late-term” side effects of a radiation treatment years after putting PC behind me—I didn’t want to be leaking poop when I was 65 years old, so I picked surgery. The second decision turned out to be easy, too, because as it turns out I had not one but two NCI-designated Comprehensive Cancer Centers within 40-miles of my home. The only remaining question was how soon could I get scheduled.
Today, nine years after my treatment, the focus of one’s “due diligence” has shifted to the question of whether immediate treatment is even needed for the favorable-risk cases like mine. Biopsied at age 49, I had only three (of 12) positive cores—only one with 3+4, and the other two with 3+3. My PSA was just barely into the “gray zone” at 4.1 ng/mL, and my DRE was negative.
What I didn’t realize at the time was that we were at the height of the PC overtreatment epidemic—some of the estimates at the time were that 60% (incredibly high numbers
) of procedures performed at the time were “overtreatment,” which carries massive physical, psychological, and economic costs. When this first came more-clearly to light, even attempting to measure the grossly wasted human and financial costs was considered almost treasonous in the cancer community...sad commentary, in reflection.
I missed—by merely one short year—the first wave of the tsunami "wake-up call" which hit the Urology/Medical-Industrial Complex eight years ago on when Dr Mark Scholz published his landmark book Invasion of the Prostate Snatchers
. For the first time in a significant way, the profession’s own thought leaders began questioning their peers—this time, not by presenting at a medical conference or publishing a medical journal editorial, but instead going right to the patient himself. The book presented the perfect storm of clinical evidence and economic reality which challenged surgeons and ROs to examine the evidence, examine their souls, and start to carefully look at every new patient asking, before anything else, “Is treatment really needed at all?”
The next tsunami wave to follow was six years ago in 2012 when the USPSTF updated their previous (2008) “I” grade (“Insufficient evidence”) recommendation for prostate mass screening to a “D” grade (“Moderate to high certainty that harms outweigh benefits”). If you missed Scholz's book, then this was the unmistakable wake-up call to prostate cancer overtreatment. The message was, essentially: “If you guys in the medical community can’t self-police this, we’ll step in to exert our influence until you do.” The USPSTF heightened awareness by pulling together the data on the issue of severe complications and patient suffering from overtreatment of indolent PC cases. They provided a teachable and actionable moment for the medical community to improve targeting of PSA screening, reduce over-testing and improve the process of patient education on the risks of overtreatment from PSA screening.
So it’s with a great deal of marveling that I look back at the extent and rapid rate of change that’s taken place. Today, for anyone with favorable risk PC, the first look is at AS. Knowing then what I know today, I would not have sought immediate treatment. Today, my first step (after pathology 2nd opinion/confirmation) would be one of the genomic analysis tests (Prolaris, Oncotype Dx, or Decipher) to help decide whether treatment was necessary or not…this is the real question today.
Looking ahead, the USPSTF is considering changing their “D” grade (“harms outweigh benefits”) recommendation to primarily a “C” grade (“clinicians should help men make informed decision about
PSA screening”) because of the extent of the changes that they have helped bring about
. I’ve posted this important point several time before: It was true that at one point in time it took treating 50 men in order to save one life. BUT, that assumed that you are going to treat everybody with PC. But following a risk-adjusted approach and only treating those that need to be treated, then the survival benefit is astronomical.
We’ve make radical changes in 9-years but we aren’t to the point of “astronomical benefit” yet…but we are getting there.
Anyhow, 9-years…a lot has changed in the PC world in that time (and in my personal world...not the topic of this post).
Post Edited (NKinney) : 4/16/2018 3:18:34 PM (GMT-6)