What is prostate cancer? First of all, it is a devastating disease which claims the life of many men, is difficult to treat and often impossible to stop. And on the other hand, prostate cancer is a condition which doesn’t cause symptoms, let alone kill patients and probably shouldn’t be called cancer at all. Confused? I hope you are. It is a good starting point for understanding prostate cancer.
First of all, why am I doing this? I am a urologist and I’ve been treating prostate cancer patients for over a decade. What sticks out among many lessons is that prostate cancer patients need to have a far more profound and in-depth understanding of the nature of their disease than other cancer patients. Why? We’ll get to that.
This understanding, however, is regularly sabotaged by media coverage of the disease which invariably focuses on new and usually fancy treatments rather than the bits of information which really matter to patients. So every time prostate cancer is on the news, I have to use a lot of extra time and effort with my patients to put things into perspective again. So this blog is my (probably forlorn) effort to convey the messages I think are important . I work at a non-academic central hospital where I’m exposed to the whole spectre of the disease. I cannot select the patients I want to see. I have to deal with all of them and with every aspect of the disease. I follow them from their first biopsy and in some instances to their death. It is both a privilege and a challenge.
So what makes prostate cancer special?
CANCER is a powerful word. When we hear it we think of discomfort, misery, pain and death. And rightly so! We all know people who died of cancer and we probably all have entertained the thought of what we would do if we get diagnosed with cancer. We all accept without hesitation the notion that when someone is diagnosed with cancer he or she needs treatment, otherwise the tumor will progress, spread to other organs and eventually kill the patient. This line of action is so imprinted in our minds that deviating from it appears to be unnatural and foolish. We are also aware that a lot of cancers are in fact so aggressive that people die despite the intensive treatment they received. Their tumor simply cannot be stopped. Lung cancer usually behaves like this. Some types of prostate cancer do, too.
The problem is that the majority of prostate cancers absolutely do not behave like this. With the widespread use of PSA testing and the resulting increase in prostate tissue sampling (biopsies) we have uncovered a myriad of prostate tumors that look like cancer under the microscope, but who do not behave like cancer. They either don’t grow at all or so slowly that patients die of something else after ten, or twenty, or even thirty years. Because eventually, we will all die of something. The result of our regular visits to the GP and medical specialists is not eternal life.
Many of the prostate tumors that are diagnosed today are rather a sign of ageing than a precipitator of death. They usually have no or very little effect on patient health or survival and they don’t cause symptoms. So why do we call them cancer then? Well, because technically they are. As mentioned before, they look like cancer under the microscope and some can progress at a later stage to a more aggressive form. The issue is under discussion but pending a final verdict we have to call these lesions cancer.
So what makes prostate cancer special is the extreme variation in aggressiveness: Indolent, non-aggressive tumors on the one side and very aggressive, lethal tumors on the other side of the spectrum.
The problem with treatment of prostate cancer
This is a theme that we will have to revisit again and again as this blog progresses. The extreme spectre of aggressiveness of prostate cancer poses some serious challenges to the therapist and ultimately the patient. Willet Whitmore (1917-1995), one of the fathers of modern urologic oncology, summed up the dilemma nicely: “For a patient with prostate cancer, if treatment for cure is necessary, is it possible? If possible, is it necessary?” We may have come a long way in terms of technology since his days, but his famous question nevertheless remains a valid one. We undoubtedly achieve the most stunning results in patients who probably don’t need treatment at all.
Ultimately, this means: Are the tools at our disposal for treating prostate cancer agressive/ intelligent enough to nip the lethal cancers in the bud? And can we allow ourselves to leave the indolent cancers untreated? These are questions which I hope to shed some lights on as we progress. For today, I’m done! When I return, I will give you my opinion on a controversial topic: the PSA
Other blogs: Life outside medicine