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Active Surveillance VS aggressive treatment for localized P Ca

Posts: 79
Joined: Nov 2011

Please read the confessions of a Physician who rushed to treatment for a localized Prostate Ca.

VascodaGama's picture
Posts: 3429
Joined: Nov 2010


This is a very interesting story and I thank you for posting it. This is not the first time that physicians express their anguish in regards to radical treatments for PCa.
Independently of age, one must be informed of the risks each treatment entails and the consequences which may include a failure to get the success. Physicians should be obliged to explain patients about anything that can go wrong instead of focusing on the benefits.

The article recalls me a symptom I had post surgery in my left thigh that took approximately two years to disappear. It was a sort of warming urticaria topic sensation at the region of the “Tensor Fascia Latae” (as they call it).
My surgeon could not explain the reason simply saying that it was common in prostatectomies, and that some guys would get it in either leg, the right or left, but not at both.
The sensation would be felt occasionally and it was never that intense to bother me.


Kongo's picture
Posts: 1166
Joined: Mar 2010

Thanks for sharing. I'm gobsmacked that this oncologist who specialized in prostate cancer did what he did. While we shouldn't be treating ourselves, you would have thought that he knew better.

Posts: 261
Joined: Sep 2010

Hey rch,

Thanks for a great link!

When I made the decision to treat a Gleason 6 prostate cancer a little over three years ago I did a bunch of research; however, in hind sight I am now a lot like the doctor in this article and I do wonder if not doing AS was the correct decision.

I talked to my urologist about AS and he said it was an option, but that was about all he said about it. My research lead me to believe that it was difficult to ascertain if indeed my PCa was a low risk cancer, and it appeared that at that time a significant percentage of AS patients (40%?) went on to treatment. So I chose to be treated.

Well, that was then and now is now. There have been a lot more studies published in the past three years (five years for the doctor) that support AS. So in hind sight, I wonder about AS ... could I have stayed the course knowing cancer was in me (probably not)? ... would my cancer have been worse than the original biopsies (yes based on post-op pathologies)? etc. etc.

With what we know today, I wonder why any Gleason 6 chooses not to try AS? My answer is ignorance and/or fear. I think this forum helps address the former ... the later can only be addressed by the individual. In my case I feared the cancer and wanted to attack (treat) it.

Thanks again for a great post, I think it will help a lot of guys trying to make difficult decisons. Like Kongo has said, and the doctor has found out, there are no Mulligans in this game.

Posts: 1013
Joined: Mar 2010

Thanks for the link. It makes the case that I keep making for why surgery is NOT worth the risk and IMHO is entirely unnecessary.

The article isn't that long, so I've just reprinted it below for those of you who don't care to cut and paste the link.


Six years ago, after celebrating my 50th birthday, I chose to begin an annual ritual of having my prostate-specific antigen (PSA) level checked. I have been a practicing academic oncologist with a clinical practice that is devoted exclusively to prostate cancer for 25 years. I also have a PhD in health policy. My dissertation found that older men who are diagnosed as having prostate cancer are less likely to have complete staging evaluations and are also less likely to undergo a prostatectomy or radiation therapy as treatment.

At that time, my PSA level was 1.5 ng/mL (to convert to micrograms per liter, multiply by 1.0), raising some concern. One year later, I had my PSA level checked again; it was 2.5 ng/mL. I met with a urologist, a faculty colleague with whom I had collaborated on research, and requested a biopsy, which was performed 6 weeks later. I was anxious: did I have cancer? If so, what was my Gleason grade? How much tumor? I had treated hundreds of patients with prostate cancer and had seen thousands of prostate biopsy specimens, but now this was my biopsy. Two days later, I called the pathologist, another faculty colleague, anxious to hear the results. The slides had just finished processing. Would I want to look at the slides myself? I ran downstairs, sat at the microscope table with my friend, and together we were the first to see the cancer. Gleason 3 + 3 in 1 of 12 biopsy specimens, 5% of the gland, and no evidence of lymphatic, seminal vesicle, or extraprostatic involvement.

Now, what do I do? I had counseled hundreds of men with similar biopsy results. Most of the men my age had opted for surgery, a small number opted for radiation therapy, and a smaller number chose active surveillance. I chose to be an informed patient and got an opinion from leading medical, surgical, and radiation oncologists throughout the country. In the end, I decided to undergo a radical prostatectomy. My selected urologist was a national leader. I came away from a discussion with him believing that a prostatectomy, performed by him on a healthy person like me, would have an extremely low risk of sexual, bladder, or bowel dysfunction and 100% 20-year prostate cancer–specific survival. I chose surgery, viewing the risks as small and the benefits as great.

Fast forward 5 years: cancer free. However, as a result of the surgery, my right arm and right leg are permanently weak, with this deficit appearing immediately after surgery. The reasons for this outcome are unclear. My PSA level remains 0, but my daily 5-mile jog is no longer possible.

Where am I now on the PSA dilemma in light of the recent US Preventive Services Task Force recommendations? It is clear that prostatectomy results in a very high chance of 20-year prostate cancer–specific survival, but even when the procedure is performed by an expert urologist, it can also result in significant rates of sexual, bladder, and bowel dysfunction and other less common adverse effects, such as my weakness. Active surveillance with longitudinal PSA tests and physical examination is associated with very low rates of bowel, bladder, and sexual dysfunction and has a high probability of correctly identifying when to move from surveillance to treatment.

If I could do it all over again, I would not undergo the surgery; instead, I would opt for active surveillance. Even the most informed patient (me in this case) has difficulty making a truly informed decision.

hopeful and opt...
Posts: 2339
Joined: Apr 2009

Even though 70 percent of cancers for low risk patients are considered indolent, being on Active Surveillance as I have been for the last three years, with delayed treatment if necessary is still no picnic. Because doubt exists, and science today does not have the capacity to determine which cancers will be aggressive and which will be indolent, and in fact even accurately determine all the cancers that exist in and outside the prostate, it is extremely stressful at times, especially when bumps occur that may or may not be due to the cancer, such as I am experiencing now as a result in the rise of an indicator, my PSA.

Not saying advanced treatments, such as surgery and radiation are better. The side effects are very severe for those who fail at the treatment, however for those who have a successful procedure the chances of a cure is greater than for those with similar low risk disease who undergo Active Surveillance, and less long term stress (in my opinion, although I have not undergone any of the treatments).

I also believe that the doctor who wrote this article is second guessing, "what if , could of, should of" and is beating himself up. If his operation was successful as many are, he would be dancing around, avocating, and recommending surgery to his patients instead of writing his article of sour grapes (although informative).

Posts: 261
Joined: Sep 2010

Hey Ira,

I'd never heard anyone talk about the trials of taking the AS path ... thanks for sharing yours.

I am sure you are right, if his surgery had no side effects he would probably be advocating for it. I feel that whoever reads the Doctor's story walks away with a unique understanding of what the guy was trying to say. For me it was summed up in the last line, "Even the most informed patient (me in this case) has difficulty making a truly informed decision."

I wish you well in your fight against PCa.

Posts: 31
Joined: Oct 2011

Unusual side effect. Cause? I wonder if he had a perioperative stroke.

Posts: 797
Joined: Jan 2010

Interesting that a doctor would second guess his treatment since they so readily provide one to “you”....and more interesting the “doctor” does not mention his post surgery results…Anyway, I believe that you never second guess your selected treatment and I believe what ever your treatment it was the best for you no matter what the outcome…Life is to short to “regret”…

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