The wisdom of the urologist

A system that comprises pipes, tanks and valves filters out your fluid wastes as urine. Illustration by C Y Gopinath using AI

Let me tell you about a curious cancer.

Half the men on the planet have it by the time they reach 70 or 80 and don't know it. They don't die by it, they die with it.

You can have it for years and feel fine. There is no accurate test for it.

Many will have a slow-growing kind that will mind its own business till you die. A smaller number will have a fast-growing, aggressive, lethal variety.

What would you do if your urologist called one day and said, "Your biopsy results are in. Are you by yourself or is there someone with you?"

I first got interested in the prostate gland because I have one. When you're around 50, they'll start screening for Prostate-Specific Antigen (PSA) as part of your routine work-up. If it's elevated, the doctor may wonder whether all is well with your prostate gland. Is it inflamed? Is there an infection? Could it be a cancer?

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The second time I got interested in the prostate gland was because Joseph Biden has one. News came about 10 days ago that America's ex-President had been diagnosed with aggressive Grade IV prostate cancer which had spread to some of his bones. It had a Gleason score, which assesses how similar or different the cancer cells are from normal prostate gland cells, of 9, considered fast-moving and incurable.

There followed a baffling statement from Biden's office that the cancer could be effectively managed because it was hormone-sensitive. Dr Judd Moul, a prostate cancer expert at Duke University, said men whose prostate cancer has spread "can live five, seven, 10 or more years".

I had the obvious question. Why was the US President's cancer discovered only when it was at this advanced stage? You'd expect that every aspect of such an important man's health would be closely and
continuously monitored.

It got curiouser. Biden's last PSA test was in 2014, 11 years ago, when he was 71. Many professional organisations will recommend discontinuing PSA screening for a man after 70, not because he's almost at the finish line but because about half of all men on the planet have some cancer in their prostate by then, without any symptoms. Nearly all these cancers are ‘indolent' or slow-growing. They will not spread or cause harm if left alone.

This is a good place to reflect on your plumbing, the system of pipes, tanks and valves that filter out your fluid wastes as urine.

The kidneys, your master filters, each about the size of your clenched fist, sit high up in your lower back just below the ribs, flanking the spine. Urine is carried away in tubes called the ureters, heading south towards your storage tank, the bladder. Think of it as a muscular balloon that expands as needed.

Urine exits the bladder (and your body) through the urethra, your ‘pee pipe'. In men, a walnut-sized, doughnut-shaped gland wraps around the urethra just where it emerges from the bladder: the prostate. Its main job is to produce the fluid in which your sperm will swim when you ejaculate. When infection or cancer makes it swell, the prostate can squeeze the urethra, making peeing difficult.

"The PSA is inaccurate but still useful," says Dr Phiroze Soonawala, Mumbai's top andrologist and urologist. "A raised PSA means there's something wrong with the prostate that needs checking. It could be cancer, or something else."

And if it's cancer?

"In about 40 per cent of cancers, you might live 10 or 20 years without any trouble," he says. "Many prostate cancers can be left untreated but about 20 per cent will progress and become fatal. The problem is, you can't predict which will be aggressive without testing."

"Have you ever advised a patient to do nothing about the cancer?"

"Often," he said. "If it's mild, we might advise watchful waiting, as they do in Scandinavia, with yearly checks. This policy is now used everywhere. Average longevity is above 80 now and most people in their 70s are not in their final years. For them, watchful waiting might be the first choice."

"If I were less cowardly, I wouldn't have chosen surgery," said Pintu, a Delhi businessman who underwent a nightmare prostate surgery that left him bleeding and in pain for weeks rather than wait watchfully. Prostatic surgery can be bloody, and surgeons often work ‘blind'. Collateral damage can include nerve loss, leading to incontinence and impotence.

"I wanted my anxiety out of the way," said Pintu. "I'm still a coward, but if I'd known then what I know now, maybe I'd not have chosen surgery."

What would you do?

Don't panic! Prostate cancer need not be a death sentence. Be deliberate and weigh your choices logically, with a cool head.

Find a wise urologist who will transparently set out your options and their downsides so that you don't rush into a decision you'll regret.

Think like a Scandinavian. Prostate cancer today is a disease where living with the problem can sometimes be better than suffering from the cure.

It's your body, your risk. It should be your choice.

You can reach C Y Gopinath at cygopi@gmail.com
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The views expressed in this column are the individual's and don't represent those of the paper.