I (Davis) Have Been Fighting a Six and a Half Year Battle with Prostate Cancer. It is a Battle I think I Have Won. I Examined Several Treatment Options in Detail, Eventually Trying Two of Them. This Is The Fourth of a Multi-Post Series on Prostate Cancer in General, and my Experience in Particular.

In my last installment, I had whacked my prostate cancer with Androgen Deprivation Therapy (ADT). Five years later it was back. Details here.

Now what? I had to do something. I could do ADT again. The alternative is to kill the prostate. I decided to get the latest update on all the methods available.

There are quite a few ways to kill a prostate, and there are specialists in each field. All the methods have their plusses and minuses. The problem, though, is that each specialist thinks his method is the best one. This leaves the patient with a bewildering array of choices.

It is alleged that some physicians exploit this, since a man that has just been diagnosed with prostate cancer may be in a bit of a panic, and susceptible to signing up for just about anything that promises a cure. Most likely, for this reason, it is generally thought that the disease is “overtreated,” which is a very nice way to put it. One would suppose the cure for overtreatment might be to change the rules so that men would not be rushed into surgery, but first might have to have some counseling from an impartial person, or something along these lines.

This isn’t what the Grand Gurus of prostate cancer thought of though. They instead decided to reduce the overtreatment problem by reducing the number of men detected. They recommended stopping PSA testing. What brilliance. By the same reasoning, we could cut down on drunk driving by getting rid of the blood alcohol test. “Yes, your honor, he was running into trees, but I don’t know if he was drunk, because we got rid of the alcohol test.” It is hard to predict what Grand Gurus are going to think of.

Now besides being a stupid policy to begin with, it leads to another huge problem. Suppose a man does get a PSA test and it is, say, 3 ng/ml. This is a little high. Is this normal for this particular person, is it rapidly shooting up (rare but possible), or is it slowly rising. There is no real way to know unless this person has had a prior measurement, and under the current guidelines, he probably won’t have. So since there is a chance that the rare, aggressive prostate cancer may be present, there would again be the possibility of a rush into therapy. Perhaps this man’s PSA was normally 3. Or perhaps he has prostate cancer, but the disease is stable and can be watched, possibly forever.

Get a Series of Measurements

Measurements are cheap. Medicare won’t pay, other insurances may not pay, but get the test anyway, preferably annually or semiannually. Insist. This way, the trend can be assessed. The cost of the test—cash price—should be under $50, and more likely under $25. Basically peanuts. You can’t really make an informed decision without a series of measurements.

Many Options

In my case, I had a series of over 50 measurements, so I was on pretty intimate terms with my prostate. Five years after my Androgen Deprivation Therapy, PSA was creeping up, and an MRI showed an almond size tumor. So the prostate cancer was back, but how aggressive was it? My PSA had hit 3, and so I decided to see if it would stay put at 3. Six months later is was at 3.8. Wasn’t staying put, but wasn’t moving fast either. Time to pull the trigger, but no rush, really.

There are basically two ways to get rid of a prostate: cut it out or kill it in place.

Cutting it out means surgery. The traditional way open a guy up. This gives the surgeon the best access, but this is big surgery, and hence has the longest recovery period. Two other methods involve sticking tubes into the patient and removing the prostate that way. In one case, the surgeon directly manipulates the cutting gadgetry, and in the other, he controls a “robot.” The outcome of all three methods are similar, although in the hands of the top practitioner, the open method would be best. Surgery is usually successful if the cancer has not escaped the prostate. The side effects, potency in particular, depend largely on the skill of the surgeon.

Most commonly, killing the prostate in place means radiation, and that comes in two major flavors as well: external and internal. In external, beams of radiation (basically strong x-rays, gamma rays, or charged particles) are aimed at the cancer. It is popularly believed that it “fries” the cancer, but this is not the mechanism of action. It instead damages the cell nucleus. Cancer is, by definition, an out of control reproduction of cells. Radiation doesn’t kill the tumor, but messes up its ability to reproduce, so it dies off by itself. To minimized damage to the surrounding tissue and organs, the beam is shot from different angles, so that the tumor always gets zapped, but the surrounding tissues receive a lighter dose.

It is also possible to work from the inside. This method, called brachytherapy, consists of placing radioactive seeds inside the prostate. Here the radiation will also cause the prostate to die, but has the advantage of having less effect on the surrounding tissue and organs. In fact, radiation from the seeds has range for about ½”, so anything further away than that is safe.

Finally, two other methods of killing the prostate are cryotherapy—freezing it to death, and High-Intensity Focused Ultrasound (HIFU)—killing it with heat (here, the prostate really is getting fried). Cryotherapy usually means impotence. HIFU is not widely available in the United States.

Overwhelmed? It Gets Worse

The above methods can be, and frequently are, combined. This yields dozens of possibilities. However, the combo therapies are primarily used with advanced cases, where a bigger hammer is called for.

A Key Paper in 2012 Sorts This Out

Most therapies give results for five year survival and side effects. It would be nice to know a bit more, like 10 and 15 year survival rates.

In 2012, a huge project was led by Dr. Peter Grimm, a brachytherapist (radioactive seeds) and 24 other practitioners, including Dr. Mark Scholz from the previous post. The author list reads like a Who’s Who of prostate cancer, and includes practitioners from all the different methods. They formed a group called “The Prostate Cancer Results Study Group,” and proceeded to aggregate a huge amount of data comparing all these methods in terms of prostate cancer relapse, but instead of 5 years, they looked at as many years the data reported. The results were rather stunning.

For all three levels of prostate cancer—low, medium, and high risk, the most commonly used methods—surgery and EBRT (a type of external radiation) were not the best. This flies in the face of conventional wisdom., particularly for surgery, which has promoted itself as the Gold Standard for decades.

In the next post on this subject we’ll announce the winner, but if you can’t wait, you can look at the paper here.