Prostate Cancer: We’ve Come A Long Way

Andrew Siegel MD   3/9/19

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Thank you PxHere, for image above

The Friday, June 18, 1993 Bergen Record (Bergen County New Jersey newspaper) published a letter to the editor that I wrote in response to an article entitled “Hazards of Waiting to Treat Prostate Cancer”:

I take issue with the article, “Prostate Cancer: Difficult Choices” (June 5, 1993), summarizing the Journal of the American Medical Association Report, which concluded that surgery or radiation, provides minimal, if any, benefits compared with watchful waiting.

Not all prostate cancer is the same. Cancer of the prostate can behave in an indolent fashion (very slow-growing), in which case a man will die WITH prostate cancer, but not OF prostate cancer.  But prostate cancer can also be aggressive, resulting in rapid progression and death: 35,000 deaths per year in American men. 

For the most indolent of prostate cancers, intervention will rarely alter the excellent prognosis. For the most aggressive of cancers, intervention will rarely alter the poor prognosis. However, in the gray zone between these two extremes exists a substantial population for which intervention will literally spell the difference between life and death. If physicians could accurately predict tumor behavior and potential for progression, we could more accurately choose between surgery, radiation, or watchful waiting. Unfortunately, despite great technical strides, we do NOT currently possess such a means.

Until the means and sophistication to accurately predict the behavior of individual prostate cancer becomes available, it behooves us as urologists to offer aggressive therapy to most men with this disease; otherwise, “watchful waiting” might translate into watch the cancer and wait for progression and death.

Andrew Siegel MD, River Edge, New Jersey, Assistant Clinical Professor of Urology at University of Medicine and Dentistry of New Jersey

Twenty-five years later times have certainly changed!  No longer are all prostate cancers lumped together with the thought that they are one and the same and are best served by surgical removal. What has not changed is the variability of prostate cancer behavior: some are so unaggressive that no cure is necessary, others are so aggressive that no treatment is curative, and many are in between these two extremes–moderately aggressive and curable. A major advance in the last few decades is the vast improvement in the ability to predict which prostate cancers need to be actively treated and which can be watched, a nuanced and individualized approach.

Prostate cancer can be described through an analogy using birds, rabbits and turtles in a barnyard, the animals representing prostate cancers with different degrees of aggressiveness and the barnyard representing the prostate. The goal is early detection and not allowing the animals to escape the barnyard (and cause a cancer death). The birds can easily fly away, designating the most aggressive cancers, those that have often spread by the time they are detected and are often not amenable to cure. On the other hand, the turtles crawl very slowly, exemplifying non-lethal, low risk cancers that can often be managed with active surveillance. The rabbits are the intermediate group that can hop out at any time, illustrating potentially lethal cancers that would likely benefit from treatment, those cancers that can be cured.

The following editorial comment with reference to an article on treatment stratification based upon risk (published in the February 2018 Journal of Urology) sums up current trends in prostate cancer management:

Low risk patients do not benefit from radical therapy unless perhaps they are exceedingly young.  Intermediate risk patients die of prostate cancer and benefit from treatment.  High risk patients must be selected carefully for treatment, as many will not benefit given the risk of occult metastatic disease.  Most importantly, men have to live long enough to benefit from treatment for treatment to be undertaken.  In practice that is the hardest thing to figure out.  In many regards, this study is reassuring in that it supports the current trends in urological oncology, i.e., surveillance for low risk patients, early intervention for intermediate risk cancers in young patients and strides towards multimodal therapy to improve outcomes in patients with high risk disease.

Dr. Samir Taneja, Professor of Urological Oncology, NYU Langone Medical Center

The following are the sage words of Dr. Willet Whitmore from 1973. He served as chief of urology at what is now Memorial Sloan-Kettering Cancer Center (and died in 1995 of prostate cancer):

Appropriate treatment implies that therapy be applied neither to those patients for whom it is unnecessary nor to those for whom it will prove ineffective. Furthermore, the therapy should be that which will most assuredly permit the individual a qualitatively and quantitatively normal life. It need not necessarily involve an effort at cancer cure. Human nature in physicians, be they surgeons, radiotherapists, or medical oncologists, is apt to attribute good results following treatment to such treatment and bad results to the cancer, ignoring what is sometimes the equally plausible possibility that the good results are as much a consequence of the natural history of the tumor as are the bad results.

Wishing you the best of health,

2014-04-23 20:16:29

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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States.

The content of this entry is excerpted from his new book, PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families

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Preview of Prostate Cancer 20/20

Video trailer for Prostate Cancer 20/20

Dr. Siegel is the author of 4 other books:

FINDING YOUR OWN FOUNTAIN OF YOUTH: The Essential Guide to Maximizing Health, Wellness, Fitness and Longevity

PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food

MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health

Andrew Siegel MD Amazon author page

Prostate Cancer 20/20 on Apple iBooks

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