Negative Biopsy ~ wall to wall cancer ---

While I was at the open Conversation on prostate cancer last weekend, one story really caught my interest.  Dr. Arnon Krongrad was speaking when he mentioned a story of a patient he operated on.  The patient wanted his prostate removed even though he has two negative biopsies.  The reasoning was real;  His father, brothers, uncles ~ all had prostate cancer and had died from it.  With the two biopsies a total of 18 cores showed no cancer.  The doctor agreed to remove the prostate only if he tested the lymph nodes first and they were clean.  The lymphs were clean but the prostate was nearly wall to wall cancer as Dr. K described it.  Watchful waiting was out for this patient when the biopsy said no cancer. 

When this session becomes available in the next few weeks I will link the video here.

Tony

David,
Absolutely not a surgery statement. In fact, I listed only one thought about modality and that was about watchful waiting. Just saying that it is a difficult because one of the other things mentioned at the open Conversation was that we have very little ability to predict which cancers are indolent or life threatening. This patient did not want to even watch and wait on a positive diagnosis and he blindly guessed right. Whether it's with surgery or an ablation therapy he needed action when the biopsy said otherwise. Very thought provoking I think.

Tony

I would think that some other methods such as color doppler or an MRIS would have spotted a cancer that was throughout the prostate. This was a radical solution to a suspected problem.
JT

Hi Piano,
I don't remember Arnon mentioning the age but he may have. It was a few years ago that he did the surgery. Not sure what imaging was done either. The only indication was the family history. It was contained inside the prostate. This was extreme but not a first time to hear of something like this. You all know Christina Applegate, the pretty young blonde girl on Married with Children TV show, who had a very tiny breast cancer that could easily have been removed with lumpectomy. She elected to have a double mastectomy performed to avoid the fate of her mother is still alive and aunts who died of breast cancer. My understanding is she is still undergoing "reconstructive surgery".

Interestingly, Dr. K has removed prostates that were not cancerous before. The reason was severe prostititis or BPH cases. QOL was improved for these patients as it was uncomfortable sitting or standing for them and they already had continence issues. It's kinda eye opening that we think of going in perfectly healthy except for the prostate cancer, and being concerned over the side effects of surgery, when there are many people going through worse symptoms than we do having these procedures all the time. In other words, prostate cancer is not the only reason a patient may elect to have an RP.

These decisions are very personal for all of us. That is why it's not good to criticize others decisions on their treatment modalities. See things through others eyes and you may have a new perspective. I certainly have changed my position on many things involving prostate cancer.

Tony

Tony:

My reaction to this:

1.  I'm amazed the doctor would remove a prostate with no evidence of cancer or other major problems...just the suspicion of the patient.  I guess some doctors will do anything but this sounds like poor medicine to me.  My aunt had a mental illness; I suppose there is a doctor somewhere who will give me a lobotomy if I pay enough...

2.  Sounds like the patient was extremely lucky.

3.  Yeah, and per JohnT, what (good) doctor today would not insist on more complete analysis before sharpening up his knife?

4.  David, this doesn't sound like a good ad for surgery at all...at least not to me.

5.  I have scratched this physician off my list of worthy advisors.  I'm glad you mentioned his name.

Just my take...all opinion...no fact...

Tudpock

LOL, thanks Bob...

Tudpock and John T,
All available tests were performed. All inconclusive and negative. The doctor is a good one and he advised against the surgery ~ and he is famous as one of the pioneers of laproscopic prostatectomies having performed the first ones in the US. But he also may have saved this patients life by agreeing to proceed. Guys we see people have elective surgeries all over the place that doctors will do for various reasons. And I don't think it should be the doctors decision not to in most cases of a mentally sound patient. There was definite reason to suspect this patient would eventually have or already have prostate cancer. And I bet that virtually all experienced urological surgeons and radiologists have faced similar situations. This doctor did mention that there were doctors who would refuse this procedure but...they would be the ones leaving this type of patient out to fend for himself and that isn't good practice either. You may want to ask your radiologists if they would have treated under the same circumstances, or would they in such cases. You might be surprised at their answers. These are stories you just don't here much about, but I have seen more than I ever thought about since I started my advocacy work and started attending these events. This very thought of pre-emptive intervention was a serious discussion at the Prostate Cancer Foundations scientific retreat last year. It's pretty amazing stuff!

Don't be too quick to judge, you need all the data to be in the shoes of this patient and the doctor,

Tony

Hi Tud,
I agree completely that it should be classified as over treatment and extreme. The fact that your doctors would encourage a patient against it is no surprise to me. That was done in this case as well. It was not a snap decision, I'm sure. This I believe was in the 90's. Not too many more extensive ways to diagnose prostate cancers. I bet your urologist might not operate after radiation as well, I know when mine diagnosed me he said he wouldn't after radiation. But many doctors will do it as salvage surgery even though most say it's not worth it and won't do it. Both are extreme cases. LOL ok well one is very extreme.

Tony

David, interestingly,
I don't think the patient would have cared if it was negative. In fact, that would be what they had hoped for. I bet this patient was disappointed that he didn't do it sooner. Tudpock is right this is very interesting. That's why I posted this. But it was strictly for conversation. I could never see me subjecting myself to surgery under these terms.

Tony

Obviously toe pain is not the same thing as the fear of mortality from cancer.  However I do recall a football player (Ronnie Lott) who had a finger hacked off so that he would not miss a playoff game.   LOL ~ but you could be right, he was a mental case, however.

But preventive surgeries for breast cancer is quite common.  And there is a clinical trial for it right now.  The example below is about having double mastectomies.  It from the World reknowned Cleveland Clinic.

http://www.clevelandclinic.org/health/health-info/docs/1800/1865.asp?index=8322&src=news&ref=1800/1865.asp?index=8322

In addition there is another study from 2002 on removing ovaries to prevent breast cancer.  Interesting note, 6% of the girls who had the ovaries removed had cancerous ovaries.  It's from the National Cancer Institute:

http://www.cancer.gov/ClinicalTrials/results/preventive-surgery0502

In both cases the ladies are perfectly healthy.  There is nobody questioning the ethics of these procedures because they do work. 

Again, I would never do it, but I know a few guys that had localised disease but insisted to have the orchiectomy as well as RP.  In fact it is still common for doctors to recommend young men with high risk of testicular cancer...to lop them off when it is found that they may become cancerous.  Yuk.

http://www.surgeryencyclopedia.com/La-Pa/Orchiectomy.html

Tony

I think you will see more of this in the future if the medical field can come up with a gene test similar to what has occured in breast cancer.  I know two ladies that did a preemptive strike and had their breast removed very early in life due to the suffering they saw their mother go through and the fact that their genetic testing indicated they were at high risk.  PSA tests are not failure proof as was the case with my father who is still doing well but who always had a normal psa yet had stage 3 prostate cancer after a biopsy.  I have a friend who recently discovered he had stage 4 prostate cancer at age 55 and he had gotten a dre and psa every year since his early 40's.  I am not trying to scare anyone but if a genetic test was available that indicated I was at risk for moderate to aggressive prostate cancer and I was 35 years old, I think that gland would be coming out.  Life goes on quite well without your prostate!