It seems we have a national passion for prostate biopsies. A million men are biopsied every year. Two hundred thousand of them will be diagnosed with prostate cancer and about half of these with Low-Risk disease, a condition that can be safely monitored without immediate treatment. Even so, more than half of these men with Low-Risk will undergo prompt, radical treatment.  Sadly, irrational fears rooted in the electrifying word “cancer” drive most men into taking immediate action.

In 2013, the American actress Angelina Jolie made a life-altering decision that fascinated the public and made the cover of Time magazine [1].  Based upon her family history and a genetic blood test for the BRCA1 gene, she was counseled that she had an 87% chance of developing breast cancer.  This led to her decision to undergo a preventive double mastectomy.  The Time article was titled “The Angelina Effect” and focused on the power of genomic medicine to guide clinical decision making.  A family history can be considered part of “clinical information” and would certainly increase the odds of developing breast cancer, but only the genomic test increased those odds such that a preventive procedure became a reasonable strategy.

LDR (low dose rate) brachytherapy for prostate cancer is more commonly known as seed implants. You may be familiar with this treatment option but for those of you who may be new to the confusing world of prostate cancer treatment, seed implants involve the insertion of small radioactive pellets or seeds into the prostate by transrectal ultrasound guidance, in order to deliver a focused dose of radiation to the prostate.

Why Screen for Prostate Cancer?

Screening finds earlier stage cancers, allows for simpler treatments with fewer side effects, and saves lives. For example, in 1985, prior to PSA screening, the prostate cancer five-year survival rate was 69% compared to 99% in 2006. It’s unclear whether this dramatic survival increase is entirely due to PSA screening. Other factors, such as improved therapy have also contributed.

While at Pete’s Coffee to write my bi-monthly blog I ran into another regular who occasionally hangs out at Pete’s. Vandana is a professor at Loyola University.  She is an expert in the psychology of learning.  While we were talking I started to bemoan my struggles to educate people about prostate cancer. One of the biggest bugaboos I face is how people overestimate their grasp of the prostate cancer situation. Once I verbalized my complaint, Vandana immediately proposed I create a basic test of prostate cancer knowledge so men could self-assess their level of knowledge.  Thanks Vandana!

New prostate cancer drugs come to market quite rarely because the studies mandated by the FDA cost hundreds of millions of dollars. The FDA requires these studies to randomly allocate men into two comparison groups. One group receives the new medicine being tested. The other group gets an ineffective fake, called a placebo. Assuming the study is performed in an acceptable manner, the FDA will approve a new drug for commercial use, only if the men who are receiving the new medicine outlive those treated with the placebo by a specified margin without excessive toxicity.

Studies designed to evaluate the effectiveness of surgery for prostate cancer take a long time to perform because prostate cancer grows much slower than other cancers.  Since it is primarily in older men, mortality from unrelated causes—other cancers, heart disease and simply old age—frequently occurs before the prostate cancer progresses enough to impair health. 

Selecting a treatment for prostate cancer is increasingly complex. In an effort to help my prostate cancer patients navigate the complexities of this process, I routinely frame the discussion around these three rules:

Rule #1: If you listen to enough people you will hear just about anything.

Whenever the prostate gets mentioned, excess enlargement is frequently mentioned, as if increased size is the root of all evils. So what follows may surprise you: Having a big prostate can be desirable. For example...