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In the New Yorker last week, there is an interesting article about current ultra-wealthy survivalists who are spending all sorts of money buying up property in New Zealand, or outfitting old missile silos in Kansas in preparation for the dissolution of society. The tone is definitely post-apocalyptic, much like the book/movie, The Road, and causes me to ponder, “What would life be like in an underground silo for the last years of my life?”
Personally, I’m not going there! But the matter of personal choices is a very real one in dealing with prostate cancer. I am reminded of the exploding genre of molecular tests that assist in prognosticating about prostate cancer outcomes – whether that is the likelihood of developing metastatic cancer if you have an elevated PSA with the OPKO 4K test, or the chances you have a cancer that was missed on an initial biopsy with ConfirmDx, or the predicted behavior of a cancer with OncotypeDx. All of these tests have been validated using 1000’s of patients for whom the outcome of their cancer is known. None have been validated in terms of how often using such a test prospectively led to a patient/physician making the “right” decision. Nevertheless, they are the way “personalized medicine” is playing out in the management of prostate cancer, and I discuss them with my patients.
So, back to the bunker. Do you build one if the chances of the stock market crashing, governmental chaos and nuclear war is 2%? What if it is 50%? And in the case of prostate cancer, what does “meltdown” look like? To start with, we too often ignore our inevitable mortality and the competing causes of death. The Charlson comorbidity index is a great place to start and should be used far more often in prostate cancer counseling. There are a variety of online calculators, including this one that you can use to peer into the future. A 60 year old man with none of the diseases listed has a 90% chance of 10 year survival. If you are over 71 and have had a heart attack, it drops to 21%. Overall, my impression is that patients do better than this in the current era, but it is nevertheless true that competing causes of death play an increasing role in decision making, and that age plays the dominant role. Given that we can control prostate cancer fairly well for 5-10 years in most patients, even if they have metastatic disease, what should a 78 year old otherwise healthy man do with his elevated PSA? Biopsy? Molecular test? The range of answers is broad indeed. Before ordering any of the more sophisticated tests, it is worth sitting down and looking at the way the results will be reported and asking “what if” the test comes back in one way versus another – will that change my mind or help me make a decision?
The bunker all of us geezers should be building, however, is our own physical one. In a great review article by my colleague, Mark Moyad, he notes the following:
Kenfield et al17 studied a population of 2,705 male health care professionals (mean age at prostate cancer diagnosis about 70 years) with nonmetastatic prostate cancer and found that those participating in vigorous physical activity (metabolic equivalent task [MET] value21 ≥6) for a duration ≥3 hours/week demonstrated a 49% lower risk of all-cause mortality and a 61% lower risk of death specifically from prostate cancer, compared with men who did <1 hour/week of vigorous activity.
It is hard to imagine ANY fancy test, supplement, or other intervention that could have a greater impact on your prognosis. Therefore, hard as it is, and whether you have prostate cancer or not, your bunker awaits at the local gym. The Psalmist said we are given 3 score and 10 years or with strength, 4 score, but he had a morbid view of the last of them. 2000+ years later it may not have changed that much. But if you look out the window, the world still looks like a pretty nice place to me and I say make the most of it!
5 responses to “Build your own bunker”
Speaking of “sophisticated tests,” I asked to have the new Prolaris test (by Myriad) done and it was. Turned out to be worthless. The company that owns and analyzes the test said that my Gleason 9 was too high to yield useful results. it did say I had a 31% chance of BCR within 10 years but that was way off since I already had BCR after just three years. Caveat Emptor, I guess.
In general, the tests confirm what is already known clinically. (That is, someone with a nodule and high psa has cancer, or a Gleason 9 is not good). They are of help sometimes in the gray zone cases (what to do about a very small Gleason 3+4=7 for example), although they may just show “low risk” and be in the middle of that zone. That’s why it is important to discuss what one would do with the results of a given test before ordering. If they won’t change any management, then not worth ordering.
Dr. Glode: Indeed! My urologic oncologist always asks me, “What would we do differently, if anything, with the information?” An excellent question to always challenge one’s self with.
Thank you so much for sharing with us the CCI calculator from the above source (The Calculator or how is it called). It is really handy. I had no idea that such tool is for free out there.
My name is Damien Amouyel, I’m doctor and journalist from Paris. I will be in Orlando for the ASCO GU symposium to make news report for french oncologists. I would like to know if we could have an appointment for a short video interview about the study you will present thursday afternoon ?
I’m waiting for your answer.