Let’s Get Real About The Overtreatment of Prostate Cancer
By Mark Lichty
Eight years ago, at the age of 55, I learned I had prostate cancer. At that time, ignoring three separate doctors’ recommendations, I decided to forego surgery. One of my doctors, a urologist, gave me the name of a patient who was on active surveillance. I contacted Brad Cole and our conversation gave me the courage to try it myself.
My father, who suffered many debilitating side effects from the treatment of his prostate cancer, further motivated my decision to postpone radical therapy in favor of active surveillance. Also, my own study of the medical literature led me to an article that reported impotence in 79% of men after surgery. My perusal of the US Too Inspire Community’s website was another eye-opener. I came across countless lamentations from men who had undergone surgery asking for help with managing their treatments’ side effects. “I Made a Mistake” was a common thread.
My prostate cancer roller coaster started with the PSA test. When my PSA doubled in a year, a biopsy was recommended. The results came back Gleason 6. I chose active surveillance and started monitoring my PSA quarterly. However, over time I have learned that PSA is a fairly crude cancer monitoring tool. A rising PSA could be from cancer, but it can also be indicative of an increase in prostate size, recent sexual activity, or even riding a bike.
Even if PSA remains relatively stable, urologists often call for periodic biopsies. Biopsies themselves can incur profound risks. I have known several people who have been hospitalized with infections from biopsies. The procedure calls for punching through the wall of a contaminated intestine with 12 needles into the prostate. Ouch. Furthermore, several studies now indicate that repeated biopsy can degrade erectile function.
Fortunately, imaging methods such as multi-parametric magnetic resonance imaging (MRI) or color Doppler ultrasound can help determine if cancer is spreading without incurring any risk of infection. I have experienced both and was satisfied with the approaches. Most urologists require annual biopsies for their patients on active surveillance. I choose a different route with better imaging.
No matter which treatment route a patient selects, there is always the possibility of recurrence. Those who are treated still require PSA monitoring. In one sense, every prostate cancer patient is on surveillance. At least one study indicates that the anxiety level for those being monitored with PSA testing a er treatment is about the same as those who are on pre-treatment active surveillance. These findings parallel my own experience with the disease. Over time I evolved from being panic stricken at time of diagnosis, to being anxious, to being scientifically curious.
Active surveillance patients benefit from the fact that treatment technology is advancing at a rapid rate. The treatment that I receive today, if I were to decide to do treatment, would be far less toxic than that which I would have received seven years ago if I chose to treat my cancer back then. However, better technology doesn’t always equal better treatment results. The NY Science Times on March 26, 2013 carried an article entitled “Salesmen in The Surgical Suite” which revealed that robotic surgery may be oversold, and may have no advantage over conventional surgery.
Some advancing technology takes big steps forward in patient care. As an example of this, I have benefited from technological progress for treating my big prostate gland. My once walnut sized prostate gland grew to a small apple size and shut off my urethra holding my urine hostage in my bladder. I passingly considered having my prostate removed to avoid the issue in the future. Instead, I opted for green laser therapy which is a fairly recent technological advance. It opened up the urethra and was done on an outpatient basis.
For me, the apathy towards active surveillance in the medical community is discouraging. For years I have been attending an US Too Support Group, an organization comprised of selfless individuals trying to help men find their way through the morass. Men are generally recommended to opt for intervention, not active surveillance. For as long as I can remember, I have been the only untreated person in my group. Conversation at these meetings invariably revolves around treatment choices or issues with impotence or incontinence.
We have been able to put a man on the moon and create smart phones that would have once taken up a room full of computing power. Why can’t we nail the monitoring issue and promote active surveillance in such a way that low-risk patients will opt for it? If we can change the way the world looks at low-risk prostate cancer, thousands of men will choose monitoring, improve their quality of life, be spared from severe side effects, and save billions of dollars wasted on unnecessary procedures. No one should have to suffer the diminished quality of life that my father did.
Recently, the U.S. Preventative Services Task Force has attempted to cut down on overtreatment by recommending against the use of PSA for screening. The Task Force’s recommendation was based on the fact that survivability was about the same whether men were treated or untreated. However, the task force recommendation has been criticized because missing aggressive prostate cancer can be fatal.
In my case, had I not been tested and learned I had cancer, I would have continued blithely along making no life style changes. The knowledge that I had cancer spurred me on to doing voluminous research. I ended up on a primarily plant-based, living food diet. My last MRI found no detectable disease. I feel that my knowledge of my cancer was a blessing that profoundly affected my well being beyond just cancer. However, it is a bit of an odd tension that is created here, as I am a proponent of testing so men can better make a decision, but am deeply concerned that that testing will lead to panic which will lead to overtreatment.
More about Mr. Lichty:
Mark Lichty was diagnosed with PC in 2005. His father had been diagnosed with PCa and the treatments his father received had a serious adverse impact on his life. When Mark was diagnosed he adopted active surveillance but went beyond what most men do and adopted a raw food diet. He chairs a support group of about 50 active surveillance patients who convene each year at the annual Prostate Cancer Research Institute Conference. Mark’s PSA at diagnosis was 4.2 and ten years later it remains at 4.2.