immediate focus, on hearing the word 'cancer' applied to us is the prospect of
dying from the disease. The main driver behind most decisions to do with the disease
is "How long have I got? How soon will I die?" Yet the subject is something
of an Elephant In The Room. There is very little published material to answer
the question. It rarely comes up for discussion on Internet Lists or Forums. If
it does is greeted with a hushed silence.
Many doctors avoid these issues,
if they can, because they are impossible to answer. If they do respond, the question
and answer that is remembered by the patient may not 'match' what the doctor said.
Patients often qualify the question by asking " What is the worst case, doctor?"
The doctor's answer may well be that some men with advanced prostate cancer may
only live three to five years. But this 'worst case' position will be qualifed.
The doctor will likely say that most men, even men with aggressive disease, will
live for many years; that the actual outcome depends on many factors; and so on.
But what the person who asked the question remembers is "Three to five years."
And that is almost certainly the wrong message.
There are no definitive
answers to these questions. There are too many variables. The first, and most
important point is that prostate cancer is not a simple 'one size fits all' disease.
A study in 2009 suggested that there were at least 24 types of prostate cancer.
Very few of these were aggressive.
say that there are only two varieties of the disease - the very aggressive 'tigers'
and the not so worrisome kitty cats. In fact there is a very large feline community
in this Strange World, including kitty cats, feral cats, wild cats, lynx, bobcats,
servals, caracals, cougars, jaguars, mountain lions, pumas, cheetahs, leopards,
lions and tigers. They all represent different variants of the basic disease.
The way in which the disease prowls, attacks and spreads can also vary from man
to man, depending on a wide number of factors, such as genetic background, diet,
body mass, or exercise.
These are some of the issues that have a bearing
on life expectancy after diagnosis:
The diagnosis itself. (The terms used may not be fully understood at this
stage. All are explained later and are recorded here only for completeness.)
"bad" diagnosis - the tiger of the family - carries a high, but
not a 100%, chance of early rather than late death. In this type of diagnosis
there will usually be a combination of several factors. These will include a high
Gleason Score of 8, 9 or 10; a history of continuously sharply rising PSA numbers;
a low free PSA percentage (under 15%); a high PSA level, well over 20 ng/ml and
probably in the hundreds or even thousands; a staging of T3 or T4.
other end of the range is the "good" diagnosis - the kitty cat -
carrying a very low risk of death, but not a zero risk. This diagnosis will typically
have a Gleason Score of 6 - the lowest score for a diagnosis; a history of small
or no continuous increments in PSA levels; a high free PSA percentage (over 25%);
a PSA level below 10 ng/ml; a staging of T1.
These diagnostics are variable.
For example there is a rare but very dangerous form of the disease - you might
liken it to a leopard - with a low PSA level. The PSA generated never reaches
any of the levels that are defined as "abnormal". Men with this rare variant are
often only diagnosed through a positive DRE (Digital Rectal Examination) or the
development of symptoms.
Age at diagnosis:
The latest available statistics show the median
age at death for cancer of the prostate was 80 years of age in the United States
of America. There are similar statistics from other countries. It is important
to understand that this means that half the men who died from prostate cancer
were more than 80 years of age. Almost 40% of the men who were diagnosed
were under the age of 65 but only 10% of the men who died of the disease were
under this age.
There is a view that if the disease is diagnosed in a young
man - usually regarded as a man in his late 40s to mid 50s - it is more likely
to be a 'tiger' and aggressive. This is not supported by available data. The proportion
of men who have aggressive forms of the disease does not vary with age. The limited
data available implies that a young man with a "good" diagnosis will have an even
better survival rate than an older man. If he has a "bad" diagnosis this is may
progress more quickly than a similar diagnosis in an older man.
Risk of other causes of death:
Overall prostate cancer is not a major
killer of men. In most Western countries, prostate cancer deaths account for less
than 3% of male deaths - about one man in 36. 97% of men, or 35 men in 36 die
from some other cause. Generally speaking, most men who have been diagnosed with
prostate cancer still have a higher risk of dying from some cause other than this
Two recent studies illustrate this point. The first was published
in 2008. It was a study of 19,271 men aged 66 years or older diagnosed with clinical
stage T1-T2 prostate cancer. These would be down towards the "good" or kitty cat
end of the range. The follow-up period at the time of publication was a little
under 7 years. During this time almost two thirds of the men died, but relatively
few died from prostate cancer. Causes of death other than prostate cancer accounted
for 11,045 (88%) of all deaths. Far fewer - 1,560 (8% of the men in the study)
were from prostate cancer.
The second study is an ongoing one on Active
Surveillance (the term for decision not to have immediate treatment) and interim
results were published in 2009. The median follow-up in this study of 453 men,
was 7.2 years. In that time 77 (17%) of the men in the study died but only 5 (1%)
died from prostate cancer. The ratio of non-prostate cancer to prostate cancer
mortality was therefore 16:1. The men in this study had diagnoses similar to the
"good" diagnosis set out above.
Much of the available information will
refer to 'average', 'mean' or 'median' life expectancy. Many people do not understand
these terms fully. They are often used interchangeably, but are in fact different.
'Average' and 'mean' may be equated, but 'median' means something else. Stephan
Jay Gould wrote an excellent piece titled "The Median Isn't The Message". He
had been diagnosed with a form of cancer (not prostate cancer) with a median life
expectancy of only eight months, yet he lived for 20 years after his diagnosis.
In this piece he explains the difference between median and mean/average in this
the standard example of stretching the truth with numbers - a case quite relevant
to my story. Statistics recognizes different measures of an "average," "mean"
or central tendency. This mean is our usual concept of an overall average - add
up the items and divide them by the number of sharers (100 candy bars collected
for five kids next Halloween will yield 20 for each in a just world). The median,
a different measure of central tendency, is the half-way point. If I line up five
kids by height, the median child is shorter than two and taller than the other
two (who might have trouble getting their mean [i.e. average] share of the candy).
A politician in power might say with pride, "The average income of our citizens
is $15,000 per year." The leader of the opposition might retort, "But half our
citizens make less than $10,000 per year." Both are right, but neither cites a
statistic with impassive objectivity. The first invokes an average, the second
a median. (Averages are higher than medians in such cases because one millionaire
may outweigh hundreds of poor people in setting an average; but he can balance
only one mendicant in calculating a median).
then goes on to say:
does "median mortality of eight months" signify in our vernacular? I suspect that
most people, without training in statistics, would read such a statement as "I
will probably be dead in eight months" - the very conclusion that must be avoided,
since it isn't so, and since attitude matters so much…….When I learned about the
eight-month median, my first intellectual reaction was: fine, half the people
will live longer; now what are my chances of being in that half?
of the three factors discussed above can, in themselves, produce a firm answer
to the question "How long have I got?". Taken together they can help to give an
indication of the range of potential survival time for an individual. He can assess
where his diagnosis fits into the range; how old he is; what his general state
of health is and what his work and leisure activities are. Hopefully in completing
this exercise he will come to the conclusion that he has many years ahead of him.
He will realize that there is indeed life after Prostate Cancer. He will understand
that this is still primarily a disease of old men, at least as far as death is
concerned. Willet Whitmore, a prostate cancer specialist, said many years ago:
"Growing old is invariably fatal while prostate cancer is only sometimes
HOW WILL I DIE?
Many people shy away
from the second question - "How does death come?" because the word
"cancer" is emotionally laden. It is usually associated with a drawn out, painful
death and this is particularly so as far as prostate cancer is concerned, when
metastasis (spread) to the bone can create significant pain, so let's deal with
is no doubt that bone metastasis can, and does happen to a minority of men. It
is an awful fate for them and their loved ones. In the few discussions that have
occurred on the Internet, experts in the field of prostate cancer have said that
modern pain management techniques can deal with most of the issues. They also
say that the dreaded painful bony metastasis is less common than imagined, at
least in their experience.
piece written by Dr Michael Glode (Professor of Medical Oncology M.D., Washington
University), on his blog in October 2007 says in part:
cancer tends to spread to lymph nodes or bones. There are some studies that begin
to show us why this is different in different patients... but have yet to lead
to more practical management decisions.
treat all metastases first with androgen deprivation. In those patients with nodes,
we ... keep the urethras open as they may be compressed by the enlarging nodes.
Without these interventions, the kidneys can stop working and lead to death from
accumulation of toxins normally excreted in the urine.
those patients in whom bone metastases dominate, the main issue is often pain
management. Radiation to bones that have tumor deposits can be extremely helpful
along with appropriate pain medications. It is highly unusual to have a patient
in whom pain cannot be well controlled with radiation, opiates, NSAIDs and attentive
response to a discussion of this subject on the Internet said in part:
am a hospice social worker who was diagnosed with prostate cancer in 2005. So
I have two perspectives on the disease, as a survivor and as an individual who
has provided counseling, emotional support, education and advocacy to patients
dying from prostate cancer. The focus of hospice is to maximize a patient's quality
of life while assisting him/her with the transition from this life. Prostate cancer
patients generally enter a hospice program when they have six months or less to
survive. The majority of PC patients who have died under my agency's care went
peacefully with a minimal amount of physical pain and emotional stress."
is a somewhat irrational fear that use of opiates to deal with pain will lead
to addiction. Dame Cicely Saunders is regarded as the founder of the modern hospice
movement. She had a clear view on that subject. She ridiculed some of the medical
profession for not giving large doses of pain-killing drugs on the grounds that
they might become addictive. If the patient were dying anyway, what did it matter?
She also did not believe that drug doses big enough to remove pain entirely would
result in the drug becoming ineffective over time. Regrettably many medical institutions
and doctors still hold outmoded views. Too many people suffer unnecessarily if
they are not aware of these issues and are led to believe that there can be no
relief from their pain.
Michael Glode's blog also refers to hospice care when he continues:
"The thing that leads to death in most patients, however, is not direct
involvement of an organ like the liver, lungs or brain. Instead, most patients
seem to have a "wasting syndrome" not unlike AIDS. Loss of appetite, loss of energy
and general debilitation lead to weight loss and patients don't feel like getting
out of bed. Hospice care can be extremely helpful for this stage of illness ......"
'wasting syndrome' he refers to is usually from cachexia or anorexia. This is
not to be confused with the anorexia nervosa of young women. The syndrome can
also come from emotional issues like depression. Depression can be treated. If
caught early on, anorexia can also be treated and weight loss reversed with nutritional
supplements or increased consumption of food. Cachexia does not respond to nutritional
supplementation or increased consumption of food. Some molecular causes of cachexia
in prostate cancer patients are now known. Work is being done to try to address
final point. People who reach this 'end of life' stage will often have fought
against the disease for some time. They, and their doctors, may misjudge how long
they have to live. One study showed that Doctors who referred terminally ill patients
to hospice care were consistently incorrect. In only 20 percent of cases were
their predictions accurate.
VERY IMPORTANT THINGS TO REMEMBER
of the high survival rates and the relatively slow progress of the disease in
One: No one should give up hope as far as this disease is concerned.
The journey to recovery or remission through diagnosis and treatment can be a
long and hard one. It is made easier by the knowledge that there is a good chance
of successfully completing it.
Two: There is time for men and their families
to educate themselves about the disease and then to work with their medical team
to make the best choices they can.
NOW to Part 1 - Preparing ForThe Journey