As I waited for my date with the biopsy needle, in January and February of 2023, I investigated my risks from the diagnosis I expected to receive. First off, would the cancer kill me, and if so, when?
No one who is currently healthy can predict what he will die from or when. The word “cancer”, though, automatically carries a premonition. Cancer is not a single disease, like diabetes. It is rather a moniker applied to abnormal cell replication in any bodily tissue or organ. Cells are continually dying and being replaced by the creation of new ones. Almost always, that replication occurs without a hitch. The DNA in a cell’s chromosome makes a copy of itself, and goes on to create another cell with all the same characteristics of the previous generation. Every now and then, though, a mistake is made, and the cell can for one reason or another, change course and worse, start reproducing itself at a faster rate. Usually, our immune system finds and destroy such a renegade. Rarely, one breaks through, and begins to make more and more of itself. Like a snowball rolling down hill, the clump of cells gets bigger and bigger until something stops its growth. It may run out of new blood vessels to bring it sustenance. It may take too many resources from its host body, killing that host. It may be removed by a surgeon. The body might take a poison which stops cell growth (chemotherapy), or specifically latches onto the cancer cells and arrests their activity (immunotherapy). Powerful radiation might be directed at it, disrupting the DNA reproduction process.
Some of these cancerous cells replicate faster than others, or are less easily killed. Some spread more easily (invasion), or are better at enabling the creation of new blood vessel feeders. Some can break off and travel to other parts of the body (metastacize). Some are harder to kill with drugs or radiation; some are harder to remove by surgery. And each person’s own strength, immune system, and the size and nature of the abnormal cells within them have a significant bearing on the life history of their cancer.
For decades, researchers have looked at groups of people with similar cancers, and documented how they respond to treatments, how long they survive, and in what condition. Uncounted studies exist which give percentage outcomes for almost any question one can ask about the cancers of all the disparate parts of the body where it occurs. But…percentages are meaningless for any individual person. For me, or anyone else facing an illness, the outcome of any question is either zero or one hundred percent.
Even so, I’m willing to ask the question, “How long might I live?” Specifically, have studies been done which might help me do more than guess? Here’s one, from Sloan Kettering Cancer institute: in 2013, they published a report on 1,167 Swedish men diagnosed with prostate cancer, and looked backwards at their PSA levels at age 60, then forwards to their death, or age 85, whichever came first. They found that “men who had a PSA level of 1 nanogram/ml or lower had a 0.2 % chance of dying from prostate cancer.” My PSA at age 59.7 was 0.84; @ age 61.3 it was 0.97. Good news, at least for the next 12 years! (And, since this was a retrospective study and many of the men involved were diagnosed and treated 10 to 20 years before me, their care may not have been as good as mine will be.)
Here’s another study, from 2016. The authors are from Yale, Sloan Kettering, Mayo Clinic and Cleveland Clinic. They set out to “Predict risk of death from prostate cancer based on age and PSA level prior to diagnosis.” They looked at the records of 230,000 men in the Veterans Affairs data base aged 50-89 diagnosed with prostate cancer, who had at least one PSA result between 1999 and 2009. They found that, at least during the 10-yeasr time frame they studied, among the men aged 70-79 with a PSA in the range of 5-9.9, 8% died. Well, a little less reassuring, but still, room for optimism. Again, this group includes treatments from 14-24 years ago.
I’m sure there are many, many more studies I could get lost in attempting to find out just when my ticket will be up. But it makes no difference (“all statistics are meaningless”). More important is, how should I be treated to have the best chance of “success”, defined as the longest probable life assuming nothing else goes wrong with my body? The National Institutes of Health, the American Cancer Society, major cancer research and treatment hospitals, highly respected medical clinics all say pretty much the same thing here – you, the patient, must decide.
Here’s an example from my own health care plan, Kaiser Permanente:
- Radiation therapy or surgery may be used to treat your prostate cancer. Both treatments work well. With either treatment, the chance of your cancer spreading is low.
- Both treatments have side effects, such as bladder, bowel, and erection problems. Radiation therapy is more likely to cause bowel problems. Surgery is more likely to cause leaking urine or erection problems.
- If your goal is to treat the cancer by having your prostate removed, then you may want to choose surgery. For some people, the idea of “getting the cancer out” brings a sense of relief. For others, avoiding radiation may be what is important to them.
- If your goal is to treat the cancer and avoid the risks of major surgery, then you may want to choose radiation therapy. For some people, preserving their sexual function for as long as possible is what they value most. Having radiation rather than surgery may help avoid erection problems.
- One treatment may be better for you than the other because of how long you might live (your life expectancy), your other health problems, and how you feel about each treatment. You and your doctor can talk about your situation.
Hmm, a lot of ifs, ands, buts there. How to sort through this? I’d like to say I dived deep into the research, considered percentages and likelihoods, and all. But I started with two immediate reactions to my news of prostate cancer. First, as soon as I saw the text telling me about the biopsy, I felt immediately in my gut – literally, I sensed a feeling within my mid-abdomen – that I wanted it out. And when I asked Cheryl, what was important to her, she said, “I want you to live as long as possible.. Starting from there, I began to look for logical and factual back-up for my initial emotional reaction.
Despite all the experts saying that surgery and radiation are similar in outcomes, I wanted some specific research data to back up that data which might be relevant to me as a 73/4 year old with a PSA of 6.8, Gleason scores of 6, 6, &8, healthy and fit. I found a 2010 study in the journal Cancer looking at 7500 men treated in 40 different urological practices under standard protocols. For my specific stage (CAPRA 3), surgery has a 95.77% survival rate after 10 years, compared to 93.14% for radiation. Two statements stood out in their discussion. “…Among those with higher risk disease [my Gleason score of 8 in one specimen puts me in that category]…men receiving prostatectomy are much less likely to die than those receiving external-beam radiation…” And, considering this study was over ten years ago, they note “…we found that the survival differences were if anything greater when restricting the analysis to a more contemporary cohort.” The subtext of that last statement: it was only after the turn of the century that robotic laparoscopic radical hysterectomy began to appear in the surgical tool-kit of urology cancer specialists. During the past 20 years, incremental improvements have been made in this procedure to improve outcomes. “Cure” rates have increased and side effects have improved in the past 10 years as a result.