TO DIE OR NOT TO DIE

An Opinion by Don Cooley

To paraphrase William Shakespeare:  To die or not to die, that is the question!

This is a killer disease and the choice you make, after the initial diagnosis, may mean the difference in your living or this disease killing you.  Don't let anyone make your decision for you - you must decide to live by what the doctors says or to die by what the doctors says.  Doctors are eternally optimistic and they will make comments before and following their treatment that they can get the disease out or some similar indications that they can cure you.  Many time this is, of course, the case but many times if the diagnosis itself was not adequately done you stand a chance not to be cured.

Diagnosis, Diagnosis, Diagnosis

To give you an idea how incomplete the diagnosis might be - read http://www.prostate-help.org/littdiff.html .  there is a saying in real estate that the three most important factors in the value of a property are location, location and location.  In this disease the three most important factors are diagnosis, diagnosis, diagnosis.  If you read the "The Diagnosis May Mean Little" web page you will have a better understanding how important it is to have a complete and proper diagnosis.

Insignificant Cancer

If you have "insignificant cancer" you have the choice of about any treatment or no treatment at all.  They all may have the same outcome in the long run.  for more information on "insignificant cancer" see 

http://www.prostate-help.org/insignificant.html.  If you have "insignificant cancer" your choice is to treat now or treat later.  Any of the established mono conventional treatments have about an equal chance of a cure.  The difference may only be a matter of side effects and their many trade offs.  This is assuming, of course, that the diagnosis was correct.

Significant Cancer

This could be defined as any cancer that does not meet the qualifications of "insignificant cancer", these cancers stand a higher chance of not being cured.  However their may be some other parts of the diagnosis which would put you in a more advanced cancer and would stand important in your treatment choice.  These are as follows:

1.  A fast rising PSA (fast doubling time) see: http://urology.jhu.edu/newsletter/prostate_cancer_2008_28.php

2.  Any Gleason with any Grade 4 or 5 in the gland.  If you have a Gleason of 7 it could mean the Grade 3 is only 7% or as much as 93%.  Grade 4 could be anything from 7% to 93%.  Believe me a 3+4=7 with Grade 3 of 93% and a Grade 4 of 7% is a whole lot difference that a Gleason 4+3=7 with 93% grade 4 and 7% grade 3.  This does not take into consideration any Grade 5 that may be in the Gland and not even reported by the pathologists.  for additional information on Gleason Grading click on http://www.prostate-help.org/gleasgrade.html .  The first number in the Gleason indicates the largest amount of tumor of that grade.  This has t be a figure of over 50% of the tumor.  The second figure indicates that an additional grade of tumor was found that is involved in over 6% of a stick.  You accept the higher grade of an one stick as being your diagnosis.  For example if you had a stick at a 3+3=6 and one at 3+4=7 and one at 4+4=8, your diagnosis is a 4+4=8.  the higher the Grade number the higher the aggressiveness of the tumor.  A grade of 5 being the most aggressive.

3.  A large amount of tumor in the gland.  This could be told by a high number of biopsy sticks that contain cancer or it could be one stick that has a high amount of cancer.

4.  A PSA of over 10 and rising.

5.  A low PSA of (usually under 2 or 3) with a high Gleason Grade.  The higher the Gleason grade the lower the PSA score.  See http://www.prostate-help.org/psa.html#gle_grade for more information on Gleason and PSA.

6.  A young age might demand treatment even if the cancer is insignificant.  I believe that all cancers diagnosed at a young age (perhaps under 60) is significant and should be treated as such.

Treatment Choices

To Treat or not to Treat - that is the question!  This is certainly true if you have "insignificant cancer".  However a better saying might be "To treat now or to treat later".  the chances are that all diagnosed prostate cancer patients will require treatment at some time now or in the future.  The question then becomes, for insignificant cancer, not so much how far in the future but how much will my cancer have grown during this time and will I become incurable.  Certainly if the diagnosis is not correct the growth of the cancer may be fast and you will pass the chance of being cured.  Unfortunately the diagnosis is such a "iffy" thing it is hard to predict the future with any degree of accuracy.  If you treat "insignificant cancer" today it is probably curable - if after some time of waiting it may not be.

We do have studies that show some men have not been treated for a long as 15 years before the cancer spread enough to make treatment a necessity.  At this point the spread may mean it is not curable.  The question may then depend on age.  If you are 80 years old and your family history of longevity is 80 then you have a chance of dying about any time.  No treatment may be the best for you.  If the expected longevity is a small number of years then it may make sense not to be treated.  But if you are say 60 and you expect to live to 90, I would suggest immediate treatment and not give the disease a chance to grow.

If the treatment you are looking at for insignificant cancer has a expectancy of a 90% chance of being disease free at ten years this indicated that 10% of the patients have had the disease continue to grow and the initial treatment was a failure.  Know that these 10% of the patients now have a high chance of this disease killing them at some point in the future.  The other 90% still have a chance of failure as each year goes by.  As time passes this percent of failure should be less and less.  At this time we do not have enough data as to long term survival to know which treatment gives us a better chance for insignificant cancer.  It appears that all of the conventional treatments may give the same results.

Now in all treatment choices the doctor chosen to give the treatment is the most important part of the treatment.  I would rather have a more experienced doctor doing a treatment with lower expectant results than a inexperienced or less experienced doctor giving the very best of treatments.  The minimum expectations for a doctor is that he has given 300 of the exact same treatments in the last three years.  This is to make sure his skills are sharp and he is up to date with the latest processes. 

Most urologist do surgery for the removal of the prostate about once and maybe twice a month and feel they are skilled.  Don't you believe it.  Skill is obtained by doing the surgery over and over again in a comparative short period of time.  Remember it is your life that is at stake here.  A poor job at surgery (and you will never know) will cause a failure of the operation and the cancer will return and kill you.  Study after study has verified the more experienced doctors AND the more experienced hospitals do a better job for a long term success.

Our Hope

I hope this paper has given you some understanding of the difficulties of the diagnosis and how important the right diagnosis is to the selection of treatment.  In addition I hope that you now understand how important the doctor is after you have made a treatment decision.  With the proper choice of treatments (see the section "The Treatment Modalities" and the Opinions that may be expressed in that section).  Get an understanding on how to choose a doctor at http://www.prostate-help.org/artist.html .

With this reading behind you it is time to move toward the selection of the treatment and the doctor to do the treatment. You are on your way to a cure, if you follow what I have aid and if the disease is not advanced past the point of cure.

Don Cooley

Owner

Page Reviewed and/or Updated:

September 20, 2008