An Opinion by Don Cooley

PREFACE

This is a five-part paper on what happens in the real world of prostate cancer treatments and with the doctors involved therein. It is a critical view of what I have found to be true over the past six years as I have extensively studied this disease and its treatments, its studies, and the medical professionals involved. There are things here one may not like to hear, there are things here that might be upsetting to some, there are things here that apply to far more medical professionals, well beyond the treatment of prostate cancer, than what anyone might admit to. Of course not all doctors fit into the unflattering pattern that I describe here - but more probably do than you realize. The treatment that a doc might recommend may not be "GOOD ENOUGH" for you, your disease and your future life.

We have been told to trust doctors, to accept what they say as being in our best interest, and to follow their instructions. This is a deeply seated cultural mold. Yet, in approaching any life threatening disease, prostate cancer, breast cancer, whatever, it is becoming increasingly important for patients to break out of that mold. The simple and somewhat terrifying fact is that too many doctors do not have the knowledge, or perhaps even the courage, to defy the peers with whom they work and thus to work with the patient’s best interest in mind, always. With prostate cancer, you are not having a heart attack….your treatment decision need not be made in the next 30 minutes, or even the next 30 days. Therefor, YOU must take the ultimate responsibility for your treatment decision. You must become informed, question your physician team, and do the study and work needed to arrive at a treatment decision that is more than just good enough, for the only good enough decision is the one that is most likely to provide you with a disease free future.

Table of Contents:

PART 1: Good enough?

WHEN IS GOOD ENOUGH TREATMENT "GOOD ENOUGH"?

DO DOCTORS KNOWINGLY LIE?

PART 2: Peer Review and Failure

PEER REVIEWED PUBLICATIONS - ARE THEY EQUAL?

GAMES THAT CAN BE PLAYED

PART 3: Which Treatment?

HOW THEN DO WE KNOW THAT A TREATMENT IS THE BEST?

TREATMENT CHOICES BASED ON ???

DIAGNOSTIC TOOLS - ARE THEY USED CORRECTLY

PART 4: Doctors and the real world!

WHAT ABOUT THE LOCAL DOCTORS, UNIVERSITY DOCTORS, ETC.?

WHAT MAKES A DOCTOR ACCEPTABLE

WE WANT TO BELIEVE

PART 5: Choice

THE FINAL CHOICE - BASED ON?

THE CONVENIENCE TRAP

INSURANCE COMPANIES 

FINAL THOUGHT

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PART 1 - Good Enough

WHEN IS GOOD ENOUGH TREATMENT "GOOD ENOUGH"

The simple answer is: Any treatment claim, by any doctor or clinic, that is not backed up with substantial evidence is NOT GOOD ENOUGH. What kind of evidence? Publication of their treatment record for at least a five year period in a peer reviewed journal is the minimum you should look for. In general, the longer the study, in terms of years of patient records, and the more men included in the study, the more stock you can place in the guidance that a study provides. (However, a number of "games" can be played within studies. The most common are discussed later in this paper.)

The bottom line is this: A treatment claim that is not backed up with at least five years of data is a hollow claim. Without a peer reviewed, published, study any treatment selection is a crapshoot. Most of us do not want to make our prostate cancer treatment decisions as a crapshoot, and should not allow our doctor or medical team to make unsupported treatment recommendations for us either.

While it is life threatening, prostate cancer is not like a heart attack. We don’t have to make a treatment decision in the next 30 seconds, 30 minutes, or even 30 days. Yet, as a newly diagnosed patient, you may feel a lot of pressure to make all important treatment decisions rapidly and without enough information. Your physician, your family, and even your own survival instincts may cause you to feel the pressure to make a quick decision. Take your time. Become informed, don’t rush the decision. As difficult as it is to fathom cancer within your body, as repugnant as the thought is, it has probably been there for several years before you discovered it was there. Taking another month or two or three to make a good treatment decision is time well spent, it is just not easy for us to do when we are frightened and feeling the pressure all around us. Resist the temptation to take the first option offered by your doctor, or pressed on you by family. Fall back, calm down, and make the BEST decision, not the easiest or quickest or most convenient one.

While you have some time to make a good decision, be aware that prostate cancer is a life threatening disease. Left untreated it will kill you, if something else doesn’t kill you first. So, we can’t bury our heads in the sand either. There is also something else to think about and be aware of: There aren’t many places "to retreat to if you decide to proceed with a treatment and it fails. There are ways to delay the disease, but your first shot at a "cure" is by far your best shot. So, take careful aim, know what the best treatment options are, given your Gleason score, stage, etc., and take your best shot, because it is often the only shot you get for a "cure". Most of the time, a second shot is only to keep the enemy at bay, and is not likely to be a complete victory. Make your first shot count.

To make intelligent treatment decisions we can look at published studies and come to conclusions as to the record of the particular clinic and compare it directly with other published studies. By reducing studies all down to a common denominator they can be directly compared over a ten-year period. However one must always understand that the particular results of any doctor or clinic and their treatment modalities, are not transferable over to other doctors or clinics. All doctors are not equal in their skills - even though they may have been trained by the best. I could take golf lessons from Tiger Woods, but would I ever be able to golf as well as Mr. Woods? Most of us know the truth of the golf analogy, so why would we think differently about the skills of a doctor? Just because a doctor receives instruction from a doctor with an excellent, proven and published, record, doesn’t mean that he or she will be as good as the doctor that gave them lessons.

What makes a skilled doctor? Intelligence helps a great deal but it does not replace the hand coordination and skill of the best and well-trained physician. A well trained doctor who is good with his hands and can coordinate this hand skill with his intelligence and common sense makes the skilled doctor that we want doing our procedure in surgery, brachytherapy or Cryo. When you consider any external beam radiation, the hand skill is not as important (replaced by careful measurement and machine precision,) but the application of intelligence and common sense based on his training and experience would be what we are looking for. And, a full training course on the exact equipment is vital. A doctor who was skilled to do a simple Four Box EBRT may not have the intelligence and computer skills to be as expert in the use of IMRT.

DO DOCTORS KNOWINGLY LIE?

Do doctors lie, YES, and you have no way of knowing that they are lying if there are no published studies. Sometimes I believe that frequently doctors do not publish simply because they really do not want anyone to know their results. Also, publication requires additional effort on the part of the doctor. He must stay in contact with former patients, inquire about the state of their prostate cancer, and keep records. Perhaps, most difficult of all, he must face his own failures, and deal with them. If there are no published peer review studies, doctors have complete freedom to say what they want or to say they get the same results as the top docs and use the top doctors’s studies to sell you on letting them treat you. (In our golf analogy this is like your neighbor telling you that they are as good a golfer as Tiger Woods. Because Tiger can golf well are we to believe that our neighbor golfs just as well?) How about in house publications? They are just short of being a marketing tool with little or no peer review or outside checking to see if it is accurate. In some cases I have seen urologic surgeons use the results of Dr. Pat Walsh, the foremost urologic surgeon in the world. They essentially represent Dr. Walsh’s results as representative of their own results. This is not unique to urologic surgeons but runs rampant among many doctors/clinics/universities, etc.

Unfortunately, I have seen it time after time when doctors tell patients that they have the best results for the treatment they are offering - when that is not true. Treatments are not equal, nor are the doctor’s skills or results equal. One has to adopt the Missouri code "Show Me" - not just tell me. You can’t believe it until you see it in a peer reviewed journal article. An article that has been carefully reviewed, scrutinized, torn apart, and has still been found to contain the truth. I have seen doctors that called themselves experts at their chosen treatment craft and that have not yet worked on a single patient.

Have you ever told your wife that the wedding was scheduled for 5:00pm, only to find that the time had been changed and you didn’t know it? We know how hard it is to keep up with the routine changes in our own lives and jobs. It is hard to keep up with everything these days. Besides that, we are human, and most of us are a little bit lazy too. It is hard work to keep up, so we often take the easy way. We rely on what our wife or a friend or a colleague tells us. We accept it as truth and use what they tell us to make decisions. Doctors are human too. It is hard work to keep up with advances in medicine. They often rely on old or outdated knowledge, or what their friends or colleagues tell them. Sometimes they know that what they tell a patient is not current and is not based on the best information, but they tell the patient anyway. They have not spent the time to do the reading to keep up with the times, they are just as human as you and me. In the doctor’s eyes they may honestly believe that they are telling the truth - many time they know no better.

This is bitter information for a newly diagnosed patient to swallow. We want desperately to trust our doctors. We want to be rid of the cancer within our bodies. We want to get it over with. Yet, if you want the highest probability of being free of prostate cancer for the rest of your life, you must stop. You must question, you must learn for yourself. You must seek and demand truth about treatment options. You must have the courage to force the issues and make the best possible decisions.

PART 2 - Peer review and Failure

PEER REVIEWED PUBLICATIONS - ARE THEY EQUAL?

No - they are not. One can scale them down a scale of really excellent publications that are well known for the quality of the publications they accept and the peer review they do all the way down to the very lowest one who will publish anything, guaranteed, in two months. They claim peer review but that really may amount to someone quickly reading over the study with little or no critical thought given to the truth of what is written.

Where does this fit into the scheme of things that you read? If I am a clinic doing a study, I want it published in the best place I can - I start at the top and work down. However if I know the market well and know what each of the main journals will accept - I write the study to get accepted there. Now if I just want to get published and don't care by whom - I start at the bottom. After all when they get to PubMed (a leading index of published medical articles) many do not know the difference. In PubMed all things seem to be equal but in reality they are far from that. So in the reading of studies one must consider the journal it was published in. You want to investigate the reputation of the journal as a guide to how good the information might be.

GAMES THAT CAN BE PLAYED

Perhaps a better title for this section should be "Do the Doctors Manipulate Numbers?"

Definition of failure: There are many definitions of failure used by different clinics and different definitions on each of their studies. It appears that with computers they can run their numbers with one definition and if the results do not make them happy - try another definition. This goes on until they find something they like and makes their studies look better than what they really are. (Back to our golf analogy: This is like saying that any ball within six inches, or a foot, or three feet, of the cup is in the hole! Most of us could improve our golf scores by changing the definition of "in the cup.")

There has long been a battle as to the definition of failure. The noted surgeon, Dr. Patrick Walsh, uses the definition of anything over 0.2 as failure. Many of the rest of docs who have to try to equal the results of the very best doctors and clinics, who are using any PSA of above 0.2 as a definition of failure, play the "definition" game. Simply put, less stringent definitions of failure tend to result in a higher reported "cure" rate. As you read journal articles be aware of what definition of failure is being used, and how that is likely to affect the reported results.

During the past 6 years as I have read hundreds of studies. I decided that there had to be a way that we could find a common denominator in which we could weigh the various treatments and doctors. I researched every paper I could find that had anything to do with definition of failure for prostate cancer. In doing so I found the necessary data for me to come to some logical conclusions. (2) Now I can look at any study and reduce it down, based on a PSA nadir of 0.2 at 10 years, and compare each of them side by side. Read what I have written on this subject, and you will be able to do this too.

One of the more interesting developments is the use of the ASTRO definition (3). This definition was developed by the Radiation Oncology Society from data of patients who had prostate cancer and who were treated with radiation. They had to have something that would show equal results for patients treated with radiation to compare with surgery. But now study after study has poked holes in the ASTRO definition. However now other modalities of treatments outside of radiation, having realized the great benefit it makes to their figures, have started using the ASTRO definition. Using it in places where it was never designed for and has never been designed for or even tested for.

Now we are finding that some studies are coming out with a bastardized manipulation of the ASTRO definition that adds things that were never there - and they still refer to it as the ASTRO definition. Undoubtedly this is being done to make results look better.

Who is included and who is not included in a study: Another way to "manipulate" the results of a study is through the definition of which patients are included in a study. What is an average golf score? If we include only touring professional golfers, we will come up with one answer. If we include All golfers who have ever played a round of golf, we will see quite a different answer. Which is the truth? They are both the truth, but based on a very different group of people. If we publish a prostate cancer paper that is based on men with stage T1c disease and Gleason scores of 5 or below, we will get a very different result than if we include all men that present with prostate cancer. Which is the truth? Which group do you fit into?

Look carefully at who is included in the study. Common things to look for: Including men (or at least too many men) in the study who have not been treated long enough ago to experience failure! Including men that can’t yet have failed is bound to increase the "cure" rate. (This is the main reason that studies of less than five years duration are not very useful, and may b nstance. That, too, will comers: That is, all men treated at a facility irrespective of stage, Gleason score, etc. (No study is likely to have all comer’s because some refuse to participate by providing on-going information. Yet, a high percentage of those treated should be included.) Yet, there is even a caution here: Some clinics weed out men who are not likely to benefit from their treatment. That, too, will increase the reported "cure" rate.

PART 3 - Which Treatment?

HOW THEN DO WE KNOW THAT A TREATMENT IS THE BEST

Only one way - through comparison of studies published in the leading peer reviewed medical journals, reading them carefully and allowing for changes in the definition of failure. You also must pay attention to and balance for such things as Stage, pre treatment PSA, Gleason, Length of follow-up, range of follow-up (anything less than five years minimum has little value), median or mean figures, the publication it was published in, how it was conducted, how much radiation was used, and other factors. (It appears that even the order in which treatments are given can alter the outcomes significantly.) The question becomes where can one learn how to do this and to make those adjustments. It is not easy and it takes years of reading of studies to fully understand what they say. If you don’t read the paper referred to above (2) you must either have this ability or know someone who does and regularly publishes comments on the various studies. There is only one place that you can consistently get this information and that is Prostate-Help on its web sites (4), Groups (5) and Conference/Chats (6). Yet, you must still do some reading and you must still pursue the truth in order to make a good, informed, decision for yourself.

TREATMENT CHOICES BASED ON???

We are fighting a life threatening disease. There is only one criterion that should be considered first and that is the chance of being cured and living a long life. If all else is equal in terms of disease freedom - then and only then should one consider the morbidities! If you die from this disease one really doesn't care what the morbidities might be. If you worry about becoming impotent and make your choice of treatment based on this one item - remember always that an erection on a corpse does you no good. (How good is sex after death? How good is sex when your bones are so fragile and the pain is so great from advanced disease that you can no longer have sex?) Try not to fall into the trap of making sub-optimal decisions. Sub-optimal decisions are those that are made to maximize the possibility of something happening that is less important than something else happening. In this case, making a decision based on having the highest probability of an erection, rather than the highest probability of being alive and well in ten years.

DIAGNOSTIC TOOLS - ARE THEY USED CORRECTLY

Years ago Urologists bought ultrasound machines as their latest toy. They found that they could locate the prostate and could insert 4 needles, one in each section (we hope) for a biopsy. They were all stuck into a single dish and taken to the pathologist. Then they moved to 6 needles as that is what became common and today most of them are still doing 6 needles. However the world of biopsies has moved on to 10, 12 and 15 needles (or more) still using the same ultrasound machine. Those who are really expert may locate an area that looks suspiciously like a tumor and they insert a needle directly into the tumor. These docs are few and far between because most Urologists are probably doing well if they do one biopsy a month.

Then we have the real experts like Dr. Fred Lee who uses Color Doppler to confirm the actual tumor before he biopsies. If he sees no suspicious areas - he does not do a biopsy. The point is that there are, at most, only a handful of real experts in the country. Is it worth the time, expense and effort to be examined by a real expert? That is a question that you must answer for yourself. At least try to find a urologist that is up to date. This probably means at least 12 needles. This certainly means keeping the needles separate, and clearly labeling the location of each stick in the prostate. Discuss this before the biopsy.

When does a visit to a real expert become paramount? Lets put it this way: Something is causing an elevated PSA. If infection and/or enlargement have been ruled out as causes, and a well done biopsy doesn’t find cancer, then what? Something is causing the elevated PSA, so it may take a real expert to find out if there is cancer present.

PART 4 - Doctors and the real world!

WHAT ABOUT THE LOCAL DOCTORS, UNIVERSITY DOCTORS, ETC.?

Referrals many times are not made because of the skill of the doc but because friendship, golf partners, club members, same staff at hospital, but rarely on the real qualification. We have operating what we refer to as "The Old Boys Network" or "I scratch your back and you scratch mine". If they were a teenager, they would be referred to as "Clicks" and you know how they work. It takes an exceptional individual, doctor or otherwise, to go against the flow.

It happens everywhere!

If you are dealing with a doctor in a University and need to see another specialist they are duty bound to refer you to one of the docs within the University - that is the code of the Professors - the old boys network. In addition, if the University is involved in trials (that means the University receiving money for their work), then their first order of thinking is what trial will this patient fit in - even though there may be curative treatments available for his disease. I had a prominent doctor at one of the best prostate cancer research Universities tell me, when I brought up this problem, "we are a research University and any patient that comes here ought to expect to be put into a trial".

If you are referred within this old boys network - there is little chance that you will learn anything new. They tend to go along with what was found by the first doc. They might offer you another treatment modality but always with the consideration of their friend doctor’s feelings and not wanting to step on toes. The same is true for grading of your biology slides that are the result of a biopsy. They say they had two path doctors verify the slides. Now these two pathologists are sitting next to each other, how often do you think they might find a difference in the slides? All second opinions on diagnosis and pathology should be done outside of the network. (In terms of pathologists looking at your biopsy results, seek someone who looks at a lot of prostate cancer, not someone who sees it a few times a month. A person who sees a lot is in a much better position to accurately grade your cancer. I have a listing of such pathologists elsewhere on this site.)

Now we all know if you go to a urologists - he will most likely recommend and talk about surgery, a radiation oncologists will tend to talk about radiation etc., etc., etc. Each of these doctors you talk to have their own special pet treatments and most of the time they are without any real, verifiable, data as to what is best for the patient. A real consideration of what is best for the patients is never a part of the conversation simply because the only thing a doctor reads is in his own specialty and sometimes that is very little – very very few read in other specialties, so the doctor never knows, other than a cursory overview, as to what treatment is best for the patient. Without the continued education and gaining of knowledge - many doctors get trapped into making the same mistake over and over again and believe they are doing a good job. It is, too often, a case of the blind leading the blind.

Now lets take into consideration the petty jealousies between the various "Old Boys Networks" which operate both on a local and national level. There is great competition for a doctor to get recognized by his peers and if his peers are doctors A, B and C then it means the doctor must denigrate doctors E, F and G regardless of their skills and their results. I hear this all the time!!! A prominent doctor runs down a different treatment when all studies show that it is superior to what that doctor is offering. (This is a lot like proving that your baseball team is better by calling the other team names. This is pure, ego based, adulation, and has little to do with which team is actually better. Look, instead, to which team wins more games if you seek the truth. The problem, as has been pointed out, is that many doctors or teams of doctors, don’t keep score, so no one knows who wins the games. Thus, we are back to looking only at doctors and clinics who do keep score if we want to make the best decisions.)

One might just say that patient considerations come after all of the above.

WHAT MAKES A DOCTOR ACCEPTABLE?

Frequently we see someone say that Dr. X was trained by Dr. A. This indicates that Dr. X has all of the skills of Dr. A and this is impossible. These basic skills are really not fully trainable - they are inherited, improve with a great deal of experience and with constant criticism/correction. Unfortunately, few doctors practice in such an environment. Many times we see where a doctor was trained by Dr. Pat Walsh to do surgery. Does this mean that he went to Johns Hopkins Medical School and became a Urologists and observed Dr. Walsh at work. How many procedures did he do while under the watchful eye of Dr. Walsh. It is my understanding that Dr. Walsh does ALL of his own procedures, which would mean that Medical Students could observe. In addition Dr. Walsh does many demonstration at Medical Conventions along with videotapes of this surgeries - is this also trained by Dr. Walsh? What about each doctor’s inate abilities? What about the role of long experience? What about constant criticism and correction of technique?

In Brachytherapy we have a prominent center in Seattle. They run a Brachytherapy training school. Here students come from all over the world to get this training under the tutelage of Dr. Blasko. Sounds wonderful until you learn that the school is a day and a half long and the highlight is that they get to watch a procedure either in the O.R. or by video. No one touches a patient. Part of the school day is spent in teaching how one must sell the product and also how to set up a Brachytherapy clinic. Now these "Graduates" return to their local communities and become the local "Center of Excellence" and on their wall they will proudly display their "graduation certificate" from the day and one half school. Of course the time is never mentioned. I call them the Weekend Wonders (7)

What it really boils down to is does this kind of superficial training really matter. I don't believe it does.

A doctor may take a short course and learn the basics and then, on his own, do the procedure and commit the same mistake on every procedure because there is no one there to correct him. It is a flaw within the system. If he does not know he is doing something wrong - he can never improve.

WE WANT TO BELIEVE

Throughout history we have been taught to "do what the doctor ordered" - and we did. We did it simply because we knew no better - the doctor had all the information and we had no access to the information or even our medical records. This has all changed now as we have access to the information and, by law, can obtain our medical records. We no longer have to take the word of the doctor without doing our own research. We are empowered to participate in the treatment decision in a way that we never have before. Frankly, and this is another problem entirely, many physicians are threatened by the empowered, questioning, informed, patient. This means that we, as patients, have to be willing to ”fire“ members of our medical team, seeking those that welcome our questions and our participation, those that will help us to find the best treatment options, not hinder us. This requires that we be strong, not an easy thing in a world where we have been taught to be sheep for so long.

However, this is a hard habit for doctors to break. Depending on the doctor, he/she can talk with such authority that it is almost impossible not to believe what they say. Then you do your research and find the "authority" may not have been as smart as you though he/she was. You have questions to ask and you want answers. If you don't get the answers and/or the answers are wrong or insufficient - you simply change docs. I start my interview of a doctor by asking questions that I already know the answer to - that way there is little question as to ot to steer us to his favorite treatment - the treatment he, or worse yet, his friend, gives.

PART 5 - Choice

THE FINAL CHOICE BASED ON? When to treat?

Now that you have read and know some of the ins and outs of this medical world, you need to understand the disease and its treatment. In "Things You Should Know and Have" (8) I extensively cover the disease and its treatments and things you need to know. Once you understand how the system works by reading this paper and by reading the above paper and following and reading its links you will be ready to make treatment decision as to what treatment is the best long term for you at the level of disease that you have. You will be an educated, knowledgeable patient and know what to do and what may not be the best for you. You will be able to ask intelligent questions and understand what the doctor is talking about. But it is up to you to do this research - it does not just come from osmosis, you have to work at it. I guess it depends on what you believe your life is worth as to whether you are willing to spend the necessary time to do that research.

One prostate patient realized how important it was to assert ones self in the treatment decision process and posted the following:

"Despite my preparation and clearly greater understanding it was bloody hard to take charge. I'm no wimp at this either having worked as an expert witness undergoing hostile cross examinations. He used multiple subtle verbal and physical techniques to make me feel insecure, instill self doubt, and encouragement to re-consider. I believe he was probably unconscious of his actions, almost an autonomic response.

This is, I believe, the greatest reason people cannot make their own decisions. I would encourage anyone going thru this to fully prepare yourself, role play with someone who has been thru it. a lawyer would be good, so you can feel what its like in the hot seat. Learning how to deal with your feelings, sublimating anger, frustration and doubt. Then and only then enter the office for your FTF(Face To Face).

The complexity of this situation bears further study, perhaps the annals of military interrogation/persuasion might be a good place to start. " Carl Reller 10/31/03 Post to PHML

THE CONVENIENCE TRAP

Even knowing what the best treatment option is, men too often fall into the convenience trap. Simply put, the best treatment is often not the most convenient. It may mean traveling far from home for several weeks. It may mean that friends and neighbors and business associates will find out that you have prostate cancer - that you are human. Even the best informed men can fall into this trap. You have to look at yourself in the mirror and ask the question: Is it worth the trouble, the inconvenience, for me to get the best treatment? Another question to ask: "How will I explain to my wife, my friends, my associates, and ultimately to myself, that it was just too inconvenient for me to get the best treatment, if the convenient route that I choose instead, fails?" All I can say is that when it comes to your life, do your best to not let convenience enter into your decisions.

INSURANCE COMPANIES

The biggest bug-a-boo with all of this is the insurance companies. Doctors no longer have the right to do what they think is best for you simply because it is not an approved thing to with the insurance company. Then you have little choice for treatment often times because you have to be treated within the HMO or within the plan. If you go outside the plan they will not want to pay for it - even though you might prove it is less expensive and longer lasting. They have to support the doctors in the plan so they try to force you to go to them. At this point this many times is an unsolvable problem and one that every person has to deal with until they get on Medicare and then they have many choices. If you are on Medicare and covered by someone like Kaiser where you are restricted to Kaiser doctors - I believe you are far better off with just Medicare and a supplemental policy or, in my case, Medicare and the VA. Yet, don’t give up without a fight. Insurance companies and HMOs can be persuaded, not easily, but others have succeeded, you may too.

Sometimes when your life is at stake - one may ultimately have to bite the bullet and go outside the plan. What price do you put on your life?

FINAL THOUGHT

With all of this said, I believe that we have the best medical professionals in the world for research and treatment of prostate cancer. The best in the world is available - but you may have to fight to get it. The final question always has to be "How much is my life worth to me and my loved ones?" Since you have only one chance for a cure - it has to be the best choice you can make.

The treatment that you choose is only "Good Enough" when you and your team of medical professionals have discussed all available treatments that you have researched and jointly you reach a decision.

Page Reviewed and/or Updated:

September 21, 2008