My Favorite Cancer

Most people understand that, while cancer is universally feared, there are some cancers that are more worrisome than others. Prostate cancer, on the other hand, is often perceived to be less fatal than many of the others.  This is true. While very common in men (1 of every 7 men will be diagnosed with prostate cancer), many of these men will be diagnosed later in life and experience cancer as a very slow growing malady.  Only 1 of 6 men diagnosed with this cancer will die of it and most of those will live many years after it is diagnosed. Some in the medical profession believe that treatment of  prostate cancer is often more akin to managing a chronic disease.  The survival data supports this. When including all stages of prostate cancer:

    The 5-year relative survival rate is 99%
    The 10-year relative survival rate is 98%
    The 15-year relative survival rate is 96%

Wow!  It is barely scary!

This perspective of prostate cancer is reassuring to men with the most common form of the disease: an indolent malady which must be treated and tolerated (with some disappointing side effects) but which is probably not life-threatening. For these guys the conversation is about how to avoid unnecessary treatment or at least avoid it as long as possible.  This was true for me as well when I first began my cancer journey. Death was not a concern. I assumed that, since it is slow growing, I would be warned of it's presence well before it would endanger me: "those guys that died of the disease were just unlucky: they weren't getting the best medical care...nobody told them soon enough of its arrival"

This perspective is particularly popular in recent years as medicine has taken a more statistical "big picture" view of prostate cancer outcomes.  If, as this narrative suggests, we are routinely over treating men because of false-positives perhaps we should stop doing the predictive testing.  Some studies suggest, as an example, that PSA testing does not lead to overall better outcomes for prostate cancer survival (some studies disagree).  I have a friend who recently asked his internist if he could have his PSA tested and the doctor strongly discouraged it.

The problem with this view of prostate cancer is that it is a discussion of the non-aggressive version of the disease.  The story is quite different for those of us with aggressive disease.  If not caught early enough aggressive disease metastasizes to distant parts of the body.  If a man has metastatic cancer his future looks quite different: "The relative 5-year survival rate for distant stage prostate cancer is about 29%".  Ouch.

This "mañana" view of the disease extends to the physicians as well. Urologists often view the urgency of prostate cancer in the context of the slow-growing disease. In a recent visit to a new urologist for a second opinion I was told we should wait for 3-4 months until the PSA was higher  and then get more imaging.  It was difficult to make the physician understand that the "doubling time" of my PSA (a measure of aggressiveness) warranted imaging within the next couple of weeks.  Waiting 3-4 months would have resulted in a 16x increase in my cancer.

Cancer still here

Sigh. New PSA test: no longer undetectable. My cancer is back or, more accurately, it never left. It would appear that the radiation treatment did not get the remaining cancer. When the effect of the hormone treatment wore off...my cancer showed itself again.

This is hard news.  There is still some hope for a cure but it is much less likely now.  I had never thought the probability of cure was high (maybe 50%?) because of my pathology but I was hoping for a lot more years.  Now the most likely future is years of hormone (ADT) treatment until it becomes ineffective and then fading away.

There are some hopeful paths: 

• Finding the remaining cancer and eliminating it. There are new imaging technologies that can find small amounts of cancer. My cancer amount is very small right now.  It might be too small to detect...but it will grow. If found it might be possible to radiate/excise the offending area. 
• New hormone treatments. As mentioned in an earlier post ADT is very effective at halting the cancer. Unfortunately in almost all men the cancer eventually finds a way with very minimal testosterone. At that point the cancer is referred to as "castrate resistant". There has been tremendous activity in the last few years to introduce new drugs to delay castrate resistance.
• Immunotherapy. There is great excitement, of course, in this area. So far the effectiveness in treating prostate cancer has been minimal. However, new stuff is coming out each year.

I have good teams on my side.  I am working with urologists and oncologists from Kaiser Permanente, UCSF, and Mayo to develop a strategy.

The news has put a new twist on my career.  Given my shortened lifespan do I want to continue to work?  Full time?  Part time?  Retire?  It is hard to think about stopping now.  I love my field and am at the top of my game.  On the other hand, a stressful job is not going to work now.  I want to enjoy the rest of my life.

More details...

• The team "castrate resistant" is used because historically there were no drugs to inhibit a man's testosterone production: the patient was actually castrated.  Glad those days are over :-)