Okay, you received the bad news from your urologist – the biopsy that was performed on your enlarged prostate showed some cancer. Most of the time they will tell you – unless you have a high Gleason score and high PSA – that this is usually a slow-moving cancer that can be monitored and may be years before it may need you to take some sort of corrective action. The choices to do something that you may be facing are a bit scary, including: prostate removal (radical prostatectomy); radiation; chemo; and or hormone therapy. So doing nothing starts to look pretty good for the moment. But it may not be the right choice.
Doing nothing for now has the advantage of keeping your prostate, delaying the operation, putting off possible side-effects into the future, and continuing to have somewhat control over your urine flow and not dealing with impotence. However, here are the choices just in case:
Or you may wish to go part way proactively and consider radiation. This has the advantage of leaving you with your prostate and possibly killing off the cancer cells within it. It’s really nice to still have a prostate. It surrounds your main urinary sphincter valve, helping it to close when you want it to stay closed. (Woman don’t have this type of aid and therefore tend to make more bathroom stops.) The state-of-the-art for prostate radiation therapy has greatly improved in recent years. They have a gel that they can shield the surrounding tissues so that the radiation is mostly localized to the area being targeted. However, if the radiation for some reason does not work, the scarring done to the prostate and urethra by choosing this treatment would eliminate the chance of future prostate surgery.
Chemo would also allow you to keep your prostate. But the rest of your body may not be very happy with this choice. The poison may or may not work to kill all the cancer cells, especially if they have metastasized. Chemo will weaken your body, your immune system, possibly make you very ill, and may need to be repeated for years … if you survive it. This might be one approach to consider when everything else has not worked.
Hormone therapy, also known as ADT – androgen deprivation therapy. According to the U. of Pennsylvannia (Penn News), works by reducing levels of male hormones in the body, called androgens, to stop them from stimulating prostate cancer cells to grow. It is typically used in patients who have an advanced state of the disease, when the cancer has metastasized, or in those with a high risk of recurrence after their initial treatment. Unfortunately, this therapy may increase risk factors for Alzheimer’s and dementia, including loss of lean body mass, diabetes, cardiovascular disease, and depression. American men already have a 12% risk of Alzheimers occurring during their lifetime. So this is not a number that anyone would want to cause to further increase.
So this leaves us with the last choice – a radical prostatectomy. Many urologists don’t like to recommend that this be done right away, especially in the early states of prostate cancer. This is a major operation, though certainly not on the same level as a heart operation. Afterwards, you will have a catheter stuck in you for at least a week. Not fun. Then you will experience mild to severe incontinence and impotence for a while or possibly permanently. There is also no guarantee that some prostate cells haven’t already metastasized to other parts of your body … in which case you are back to a “wait and see” approach again, but this time minus your prostate and already dealing with the side-effects of the operation.
However, if the cancer is caught early enough, is still encased in the prostate capsule, has not migrated into the seminal vesicles or lymph nodes … this choice may be your best bet. Because, if it does work, you can be free of cancer. You can overcome impotence and incontinence with proper exercise (Kegel muscles) and if necessary some medication. You also do not have to live with a cancer in your body festering and slowly growing that might slowly reduce your choices of therapy to cure the problem if you do a “wait and see”. Remember, the older you get with the “wait and see” approach, the harder it will be to recover once you get to be 80.
Whatever your choice, what might seem best for you will not necessarily be the best path to take for someone else. However, it is important to consider all the choices and their side-effects and not necessarily sit back and do nothing, or maybe just go diving and forget about this for a while.
Hello Richard, I was considering same line of logic. After consulting with two highly-rated Urologists ( one at North Western Hospital and a Med School prof), both said it would be premature overkill; like a woman having a radical mastectomy, rather than simple lumpectomy when cancer is encapsulated. Both said most cases of lower Gleason score and moderate PSA do not progress and never require any further treatment. Your thoughts and any further inside sir. Thanks
Hello Phillip,
I am not a doctor and don’t have your two doctors’ credentials to give you medical advice. So I will tell you why I decided to go ahead and remove mine even though I similarly had a moderate 7-8 PSA and low (3+3) Gleason score.
First of all, I cover my advice of not doing the “wait and see” approach in more detail in Stage I Prostate cancer – what can you do? (Part 1). So you might want to read that article in addition to my reply.
The biopsy itself is very inexact science. These are just 12 needles sampling a very tiny area compared to the size of the prostate. You probably have an enlarged prostate which triggered the decision to do the initial biopsy. It is unfortunately very common that you can have an area in your prostate with a higher Gleason score that the biopsy sampling misses entirely. I have read enough accounts of cases where the post-op biopsy when they now have the entire prostate in the lab to analyze rather than the needle samples, and found that the actual Gleason score was higher … a lot higher in the tissues that the needles did not sample. So these men did not have an accurate accounting of their real condition other than there was some cancer detected.
It is theoretical that the cancerous cells are still contained within the capsule with low PSA and low Gleason. They really are just guessing based upon statistical probabilities. With a low Gleason and moderate PSA, there is still a 92-95% likelihood that the prostate removal will catch all the cancer cells before some have escaped. Which also means there is a 5-8% chance that some cells may have already escaped. An MRI and a full-body (bone) scan will not see those cells. They just detect tumors. When my doctor did my operation, he also took a sample of a couple of nearby lymph glands and connecting seminal vesicles to see if it had spread into nearby tissues. It did not appear during the operation that anything else was affected and the lab confirmed it.
I went to the head of UCSD’s Dept. of Urology for my second opinion and then to have that doctor perform the operation. It of course was my decision. Doctors advise, but they are not the ones with the cancerous prostate. If you are in your 80’s then maybe the time for the cancer to escape the capsule and spread and do any harm is limited. But if you are younger, then that scenario changes quite a bit.
You also have to consider that you will be getting regular biopsies from now on if you decide to do nothing. Those biopsies may or may not be accurate. They really don’t know that cells have not or may not in the future escape the capsule. If your real Gleason is not 3+3 but is or progresses to be a 7,8 or 9 … it becomes a different game and then that 92-95% likelihood of eradicating it with an operation becomes lower.
Doctors are not infallible. I would say that if you were told that low Gleason and low PSA will “never” require any further treatment, then that would make me very skeptical of their advice. Good luck with your decision.