What Hollywood Is Not Telling You About Prostate Cancer

Prostate cancer management and treatment is a rapidly evolving field as technology and medical knowledge expands. Treatment of this disease has changed drastically over the past ten years. Knowledge has brought about a deeper understanding of the nature of the disease and allows many patients to safely avoid the invasive treatments that were the only option in times past. We want to examine two artistic representations of characters being diagnosed with prostate cancer on two contemporary television shows. The first is from the episode “The Funky Walnut” from Grace and Frankie and the second is from three episodes of The Kominsky Method. Unfortunately, both these representations convey information about the disease that is incomplete at best, and erroneous at worst. The portrayal of these cases can misinform viewers about how prostate cancer should be diagnosed and treated today. Thus, the following is an analysis of the dubious lessons from these shows complete with accompanying corrections.

The prostate cancer story in Grace and Frankie’s “The Funky Walnut” begins with the show’s two septuagenarian lovers, Robert and Sol (played by Martin Sheen and Sam Waterston), sitting at a desk together across from a physician.  The doctor informs the couple that Sol has an indolent form of prostate cancer and that he has three options.  He can have surgery—a radical prostatectomy—with its risks of infection, loss of sexual function, and the risks from anesthesia.  Or he can choose to undergo radiation treatment, “that whole megillah.” Or he can choose to do nothing at all—Sol’s doctor explains that considering his age and the cancer’s slow growth rate, he is more likely to die from something else before the cancer. Sol initially decides to do nothing—he explains to Robert that his quality of life is more important than his quantity of life.  Robert, afraid of losing Sol, presses the issue throughout the episode until he eventually convinces Sol to schedule a major surgery within a week on the premise that his life is more important than his sexual function.

“The Funky Walnut” gets a number of things cartoonishly wrong about prostate cancer; however, for clarity, it is best to attribute most of that to artistic license and to focus instead on the character Robert since his misapprehension of indolent prostate cancer influences Sol to get surgery.  The show presents this moment as a moral resolution of the story; however, Robert is misleading Sol into a major and complex surgery that will likely change his life.  This part of the story nicely illustrates the controversial history of prostate cancer management since the invention of the PSA test in 1987.  

The PSA test measures levels of the prostate-specific antigen in the blood.  PSA is overexpressed in prostate cancer, but it is also expressed by all prostate tissue, so it is not specific to prostate cancer.  The test’s original and least controversial use was for monitoring men who had their prostates removed—since any level of PSA in a man without a prostate was highly suggestive of a prostate cancer relapse.  The test can also be used as an imperfect screening tool for men who have never been diagnosed and, despite its limitations, it has been the only effective tool for the early diagnosis of prostate cancer.  Before the advent of multiparametric MRI, the typical story would be that a man would have an elevated PSA, he would get a 12-core random biopsy, and then the results of the biopsy would come back as non-cancerous or cancerous with a certain Gleason score.  Some Gleason scores represent benign cancers that are unable to metastasize (some cases of Gleason 3+4=7 and everything lower) and others represent malignant cancers that require aggressive treatments with significant side effects (some cases of Gleason 3+4=7 and everything higher).  The problem that developed from the PSA test was that men and their doctors began finding and treating non-malignant cancers, especially Gleason 3+3=6, and incurred the side effects of treatments they did not need.  It got so bad that in 2010, Richard Ablin, the inventor of the PSA test, advised against its use as a screening tool and in 2012 the United States Preventive Services Task Force did the same (it since changed its position in 2018). 

The way that Sol was diagnosed in the “The Funky Walnut” was nonsense and there was a lot of missing information, but if we assume that Sol was diagnosed with true Gleason 6 prostate cancer (which is a reasonable inference since the doctor called it “indolent”), then Robert’s advice to Sol would be typical of the mass hysteria of 1987-2012 that caused such a harsh reaction against the use of PSA testing as a screening procedure.  If Sol followed through with the surgery, then he would be putting himself at the risk of incontinence and sexual dysfunction to remove cancer that had no potential to metastasize and thus no potential to cause harm.  If it had not been for the PSA test—opponents of the test would argue—then Sol would have never known about his Gleason 6 cancer and thus never been at risk of being implored by Robert into life-altering surgery.  But, of course, if it had been a more serious form of prostate cancer—say a Gleason 4+3=7 or higher—then the PSA test may have been Sol’s only chance to discover the cancer before it metastasized and thus achieve a cure.  

Now, in 2020, there is better education about the different forms of prostate cancer and PSA testing, and so attitudes have become more nuanced.  However, “The Funky Walnut” is evidence that there is still a lot of misinformation and that men in their 40’s need to seriously educate themselves before making any life-altering decisions.  

(To Robert’s credit, he did try to research prostate cancer, but unfortunately, he did so on the “Stand Up To Cancer” website which does not have any educational information about prostate cancer.)

Compared to Grace and Frankie, The Kominsky Method gives a much better representation of prostate cancer and the issues surrounding it, but there are still a couple of misconceptions and anachronisms—the real-world analogs of which are still preventing optimal care for many people in 2020.  

The Kominsky Method’s prostate cancer story spans three episodes, “A Prostate Enlarges,” “A Kegel Squeaks,” and “An Agent Crowns.”  It begins with Sandy Kominsky (played by Michael Douglas) going to a urologist for urinary symptoms.  The urologist (played by Danny DeVito) hypothesizes that his urinary symptoms are most likely the result of urethral obstruction from benign prostatic hyperplasia, but he administers a PSA test and DRE to exclude the possibility of cancer.  He says that if the PSA is elevated, then Sandy will have to undergo a biopsy.  “A Prostate Enlarges” ends without Sandy ever having received the results of his PSA test, but “A Kegel Squeaks” begins with Sandy telling his friend that he underwent a biopsy and is waiting for the results (suggesting that his PSA test came back elevated between episodes).  Sandy spends the episode in existential reflection, both having cancer and not having cancer, “Schrodinger’s cancer,” as his friend describes it.  At the beginning of “An Agent Crowns,” however, Sandy’s urologist calls and informs him that his biopsy was positive for cancer, but that it is the “friendly” kind of cancer that does not require treatment.  The urologist prescribes Sandy an alpha-blocker for his urinary symptoms and the issue is considered resolved. 

Unlike Robert in Grace and Frankie, Sandy accepts the urologist’s suggestion that “friendly” cancers do not require treatment; however, there is one part of the story that illustrates an antiquated and dangerous way of monitoring prostate cancer that is still surprisingly common in 2020. When the urologist orders a biopsy after Sandy’s elevated PSA result, we can assume that this is referring to the 12-core random biopsy.  A 12-core random biopsy uses hollow needles to remove 10-14 samples from different regions of the prostate gland for examination under a microscope.  It is an invasive procedure with risks of erectile dysfunction and infection—sometimes requiring hospitalization.  More than that, the 12-core biopsy is significantly less accurate than the most up-to-date protocols using a multiparametric MRI.  Although the 12-core random biopsy is still commonly used, the current standard of care for a patient with suspicious PSA levels is to undergo a multiparametric MRI.  If a radiologist finds a suspicious lesion, then a targeted biopsy should be performed in the suspicious area(s).  This protocol, made possible by recent advances in imaging, bypasses the risks of the 12-core random biopsy and large formal studies have demonstrated that it is significantly better at finding and characterizing prostate cancer than the 12-core random biopsy.  Men, like Sandy, who are diagnosed with indolent forms of prostate cancer (e.g. Gleason 6) should be placed on an “active surveillance” protocol which includes repeating MRIs and regular PSA testing.  The risk of Gleason 6 cancer progressing into something dangerous is low, but there is an appreciable risk that a man in Sandy’s situation could harbor occult (or undiscovered) cancer of a higher grade than the cancer cells that were originally discovered.  Modern active surveillance protocols with repeat multiparametric MRI, regular PSA tests, and other blood tests are designed to ameliorate this risk. 

Sandy would be right to be comfortable moving on without treatment if he had true Gleason 6 cancer; however, a single 12-core biopsy does not provide Sandy or his doctor with enough information to be sure that his cancer is truly Gleason 6.

It is unrealistic to expect television show writers to give a perfectly accurate treatment of a topic as complex as prostate cancer.  However, it is worth being aware that in these two cases, especially in Grace and Frankie, there are misleading ideas that correspond to misleading ideas that are still pervasive in the real world.  The moral of “The Funky Walnut” is that Sol should get surgery so that he can be around as long as possible for Robert, but this moral is based on a scientific misapprehension.  The Kominsky Method certainly has a better scientific grounding when it comes to understanding cancer, but the medical information it presents is based on an outdated (but still commonly practiced) standard of care.