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Cutting Out Surgery for Prostate Cancer

Most men with the disease should keep their prostates, says the author of a book about prostate cancer staging and treatment.
BY MARK SCHOLZ, M.D.
PUBLISHED November 10, 2018
WHEN MEN RECEIVE A prostate cancer diagnosis, their first reaction often is to think surgery. This is largely because most prostate cancer doctors are surgeons, who may be more likely to recommend this course of action. But radical prostatectomy — removal of the prostate gland — is usually unnecessary and can cause irreversible side effects such as incontinence and sexual dysfunction.

A total of 91.5 percent of men diagnosed with prostate cancer live a normal life expectancy and die of natural causes, not from the cancer. Thus, instead of rushing to treatment, men with prostate cancer can slow down and develop an overall plan that takes both survival rates and quality of life into account. Treatment choices based on partial information often lead to permanent regret.

The pathway to optimal treatment is proper staging — assessing a tumor’s size, location and spread — followed by education. If men take time to do their homework, most will learn that they can keep their prostates, manage their cancer another way and maintain a good quality of life.

THE ADVANTAGE OF KNOWING YOUR STAGE AND GRADE


Staging provides insight into the disease’s seriousness, which can range from totally innocuous to life-threatening. Clearly, men need to align their treatment’s intensity with the disease’s aggressiveness. Mild cancers deserve mild treatment. Aggressive cancers require aggressive therapy. Suffering from treatment-related side effects such as incontinence and sexual dysfunction is unacceptable if the cancer is mild. On the other hand, for potentially life-threatening disease, enduring a higher risk of treatment-related side effects may be justifiable.

The key to individualized treatment for prostate cancer is knowing the disease’s specific stage and grade. This reduces the number of therapeutic options, allowing men to bypass vast amounts of inessential information. This can help focus any research they do online and facilitate their conversations with doctors, allowing them to home in on the most commonly used treatments for their specific stages.

HOW TO DETERMINE STAGE AND GRADE


To understand a prostate cancer’s stage, a man must provide several pieces of information that can be found on his medical chart: tumor size; digital rectal exam results; whether scans show that cancer has spread outside the prostate; the cancer’s grade, also known as a Gleason score, which is an evaluation of how healthy or abnormal cancer cells look under a microscope; and blood levels of prostate specific antigen (PSA), an enzyme that tends to increase along with the growth of prostate cancer.

I’ve developed a short quiz that makes it easy for patients to determine the stage of their prostate cancer and understand which treatments may be appropriate. It is available online at keytopc.com or pcri.org, the website for the Prostate Cancer Research Institute, which I founded. It is also published in my recent book, “The Key to Prostate Cancer: 30 Experts Explain 15 Stages of Prostate Cancer.” My quiz breaks down the aggressiveness of prostate cancer using a system I call the Five Stages of Blue, which assigns a color to each stage:

• Sky — low risk.
• Teal — intermediate risk.
• Azure — high risk.
• Indigo — relapsed disease.
• Royal — metastatic or hormone-resistant disease.

FINDING THE BEST TREATMENT


Once a prostate cancer’s stage is known, patients and doctors can determine how dangerous the disease is and zero in on the most sensible treatment options. Treatments run the gamut from active surveillance for low-risk cancers to a variety of therapeutic combinations — perhaps immunotherapy, hormone therapy and/or radiotherapeutic seed implants — for more advanced or higher-risk disease. Surgery may be offered, but I believe it’s appropriate just in very exceptional cases, such as men with intermediate-risk, or teal, disease who have prostate glands that are too large for radiation.

Extensive stage-specific information about treatment options, provided in patient-friendly language by a variety of experts, is presented in my book. Robust information is also available at pcri.org.

I urge men to arm themselves with as much information as possible and seek out a doctor who specializes in prostate cancer and will have a better understanding of the intricacies of the disease. Men who have been diagnosed with prostate cancer have plenty of time to research all their options. If they can arrive at a clear understanding of what modern, state-of-the-art care offers them, they will be happy to discover that there is almost never a need for surgery.
MARK SCHOLZ, M.D., is board certified in medical oncology and internal medicine and specializes exclusively in prostate cancer. Scholz is medical director of Prostate Oncology Specialists in Marina del Rey, California, and executive director of the Prostate Cancer Research Institute. He has written two books, “Invasion of the Prostate Snatchers” and “The Key to Prostate Cancer: 30 Experts Explain 15 Stages of Prostate Cancer.”
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