The Ride (part 2)

There is this guy, George (my wife refers to all of her clients as George, or Georgette if they identify as female). He is definitely George, as will become obvious. And he’s not my wife’s client. I just borrowed the name.

George was planning a marathon athletic endeavor and thought he would visit his PCP (primary care provider) for a checkup, specifically to be sure he could embark on this months-long endeavor.

The good doctor suggested a PSA (prostate-specific antigen) test, as George was of a certain age. They discussed the pros and cons. (It is not a particularly reliable nor specific [despite its name] test and can result in unwarranted worry.) Please note that nothing in this post should be construed as medical advice. If you have questions or concerns, consult your primary care provider.

The result was worrisome (a greater than 50% chance of cancer) and the doctor thought George should see a urologist. The urologist ordered another test, which yields a ratio of free to total PSA. This shows a percentage chance of cancer if the overall PSA level is in the grey area. This again showed a high probability of cancer. Looking at the two tests, the doctor told George he had a >60% chance of having prostate cancer.

The next step was a prostate biopsy. This involves the rectal insertion of a small tool which snips out 12 pieces of tissue. If you imagine a clock face, one snip is taken at each hour mark. The theory is that, if there are cancer cells present, you’ll find some in at least one of those twelve samples. The test has a couple of side effects. George would likely pee blood for a few days and he might not want to sit on a bicycle seat for a while. If his marathon athletic endeavor were to include any time on a bike, doing this test while in training might not be the best idea.

George and his urologist talked it over and decided there were three possibilities: 1) George didn’t have cancer, and the test would keep him off his bike long enough to disrupt his training, possibly throwing his trip into jeopardy; 2) George did have cancer, but it would be a slow-growing cancer. (Hence the oft-heard “prostate cancer is a cancer you will die with, not of.”) Again, his trip would be in jeopardy for no good reason; 3) George had a fast-growing and aggressive cancer. He would need serious interventions which may include chemo, radiation, and surgery. His trip definitely would be canceled, likely forever.

George decided that what he didn’t know wouldn’t hurt him. If 1) he had no cancer, he didn’t want to lose the chance to embark on this endeavor. If 2) he had a slow-growing cancer requiring no treatment, he didn’t want to waste his training. If 3A) he was going to require extensive treatment, or 3B) he was going to die soon anyway, he didn’t want to miss out on this (now clearly once-in-a-lifetime) opportunity. His doctor agreed that he could go on the trip and come and see him after it was over. George told no one of this, not seeing any reason to worry others.

He went on his marathon athletic endeavor (which might be compared to a coast-to-coast bike trip), and went back to the doctor afterward. They repeated the PSA tests. It now showed a 20% chance that he had cancer. A year went by. The numbers were back up again. He had a prostate biopsy. He peed blood, he stayed off his bike for a while, and the result was negative. He didn’t have cancer.

Why did the test show he had a 60% chance of cancer before the trip and 20% chance after? Did a marathon athletic endeavor cure him of cancer? Not likely. The doctor said that inflammation could cause a false positive. Would sitting on a bike seat for two months make inflammation in that region more or less likely? Well, more, it seems. Evidence is inconclusive – the best evidence we have (a meta-analysis of multiple studies [Prostate Cancer and Prostatic Diseases, 2015]) shows no correlation between bicycling and elevated PSA. So why would he have inflammation before and not after? The doctor couldn’t say.

So what is this prostate cancer thing? And why is it so hard to detect? The symptoms look a lot like the symptoms of BPH (benign prostatic hypertrophy). That just means your prostate got bigger but isn’t harmful. BPH is considered a normal part of aging. The symptoms are things like: needing to pee more often (including waking up multiple times during the night); incomplete bladder emptying (therefore needing to pee more often – maybe even peeing, going back to bed, and getting right back up to go finish the job); urinary urgency – having to pee right now.

The National Cancer Institute says there were nearly 200,000 new cases in 2020, with more than 33,000 deaths. Prostate cancer is the second most common cancer in men (after lung cancer) (World Journal of Oncology, 2019). The incidence is higher for Black men.

Side effects of treatment may include urinary incontinence and erectile dysfunction. There continues to be controversy over whether men should be tested and, if cancer is detected, if they should be treated.

The Carbone Cancer Center performs research and treatment. One of the trials is known as the International Registry to Improve Outcomes in Men with Advanced Prostate Cancer (IRONMAN). Seems fitting for George, eh?

Prostate cancer tends to be ignored because it is “seldom” fatal – tell that to the 33,000 men who will die this year. In September I will be riding to support the Carbone Cancer Center to help people like George. Please join me in donating at: Thank you. (Since this is not a scholarly article, citations are incomplete. Ask if you want more detail.) (This post dedicated to KR2 and “George”.)