I saw a patient recently as a second opinion regarding what to do about his newly diagnosed prostate cancer.
“What is most important to you?” I asked.
He said, ” I want my very best chance of cure regardless of the side effects. I also want to be able to do something curative if the first treatment fails.”
In my mind what this describes is a patient that wants the prostate removed and then if the PSA rises after treatment then curative doses of radiation is still an option. Certainly there are caveats in this scenario i.e. the parameters of the biopsy and the patient’s underlying health.
So this person helped me. He told me what is important to him. That, many ways, helped me advise him what to do. In other words, to me as the doctor, I need to know “who are you.”
Today, a patient told me after my having told him that his prostate biopsy showed small amounts of cancer, told me this.
“I have to work. I cannot risk something happening to me that will preclude me providing for my family or keeping my business going.”
That helped me. To me that took a prostatectomy off the table. I don’t feel there is enough of a difference in cure to push surgery in this patients situation. I told him he might have aggravating symptoms of radiation but that he probably would not have a major complication that would keep him from working. I mentioned that active surveillance, or seed therapy would have minimal impact on what was important to him i.e. his job. Customized care….that’s what I try to give my patients. It’s not about me, it’s about them.
So back to Ted Danson and his cancer on the show “Bored to Death.” Watch the trailer.
“Fiscally responsible, sexually out of control.”
Here is a patient that puts his sexual function to the forefront in the decision. You might think this odd. But prostate cancer is unique that way. Patients often put other issues ahead of cure. The reason is that in prostate cancer, if the parameters are favorable and we don’t know Ted’s, you can balance quality of life with chances of cure. So what to do with Mr. Danson and his cancer.
Let’s assume he has favorable parameters…low PSA, low volume and a Gleason’s of 6….what would I recommend if I am asked to be the second opinion on the show. (By the way I am available and would readily fly to the show free of charge and be on that particular episode.)
Favorable parameters: “Mr. Danson, your promiscuous lifestyle and the importance of sexual activity makes you an excellent candidate for active surveillance.” You would need a PSA twice a year and a prostate biopsy once a year. We would abandon this if any of your parameters progressed. If you can accept the small risk of “doing nothing” you are an excellent candidate for this.”
“If you are not comfortable with surveillance then I’d recommend external beam radiation. The reason I would not recommend surgery is that no surgeon in the world can promise you that after surgery you will regain your potency. With radiation you may experience a deterioration in your function but in most cases this can be corrected with medications. Seed therapy, I feel, has a slight higher chance of negatively affecting your sexual function so that might not be best for you.”
Here’s the caveat here….one can have perfect sexual function after prostatectomy, but you can’t promise that. There is risk with that from a purely sexual consideration. I feel I am very good at a Walsh Nerve Sparing Prostatectomy and my patients do well on all fronts as rule…but I cannot promise continence, cure, or in this case potency. No one can, I don’t care who tells you that.
If the advisors of the show consider all…Mr. Danson will not be having a prostatectomy. The only thing that will trump his concerns about sex, would be if he freaks out about cure. If a patient does this, in most cases they will choose to have the prostate removed.(Of course by the “robotic” method. If he chooses radiation it will be “Proton.” He’ll need to be trendy for sure. A thought just crossed my mind. He may be advised to have HIFU, and fly to Bermuda for the treatment. So very Hollywood like.) It could happen. Funny things happen to a man and his mind and the people who love him when he is told, “you have cancer. ”
Trust me. I’ve been there.