The Case for Prostate Cancer Diagnostics & Treatments
Author: Cassie Whyte
A few days ago, I had the pleasure of speaking with prominent Urologist, prostate cancer specialist and men’s health advocate, Dr. It’s David Crawford. During his many years of experience, Dr. Crawford was dedicated to improving the diagnosis and treatment of prostate cancer, as well as educating students and the public about men’s health and its intersection with urology. As the third leading cause of death in men, prostate cancer remains relatively understudied and ignored by health advocates. But Dr. Crawford maintains a positive attitude:
We need to get out of the way we buried our heads in the sand with prostate cancer. It’s not that hard, really. Prostate cancer is the most common cancer in men, the second leading cause of death. If we find it early, we can cure it, treat it or control it… it’s pretty simple.
Having been dedicated to the field of urology for most of his professional life, Dr. Crawford has been present at every stage of development, progression and regression in the treatment and containment of advanced prostate cancer. He explains how prostate health awareness has tended to lag behind other cancer campaigns:
“It goes back many decades, treating so many patients who came into my clinic with advanced, incurable prostate cancer. Some friends too.”
The breast cancer non-profit and advocacy sphere, for example, was fully established as a benevolent, preventive force by the 1970s. Dr. Crawford continues,
“There was a lot of interest among women and discussions about breast cancer and we were very much behind it. We didn’t see that. And that’s been very successful, the whole breast cancer early detection movement. We really dragged.”
Fortunately, a small group of eminent health professionals, such as Dr. Crawford, helped prostate cancer awareness gain some steam in the popular conversation by collaborating and incorporating public figures into the conversation. Dr. Crawford reiterates,
“There are some well-known men who got prostate cancer a few decades ago. I had the opportunity to work with some of them, General Norman Swartzcoff, General Powell…Bob Dole…and that was also very interesting.”
Encouraging politicians, athletes and celebrities to act as cutting-edge trainers is always a great way to get the public excited. it also has an overwhelming effect on normalization and destigmatization, particularly regarding health issues that are otherwise considered embarrassing or marginalized. Prostate cancer, particularly before the ubiquity and triumph of the Prostate Specific Antigen (PSA) test, is very much one of those issues. The intrusiveness of the classic prostate exam proved to be a difficult hurdle for both professionals and patients to overcome:
“The way to diagnose prostate cancer back then…we didn’t do a mammogram. The only thing you would do was a rectal exam. The reception to this was not great, as you can imagine.’
The introduction of the PSA was a transformative effort. Dr. Crawford recalls when PSA was first approved, stating that,
“The rectal exam, even when you felt something, was usually more advanced… but then a kind of miraculous thing happened: this blood test, the PSA, came out. That was it game changer.”
Not only is PSA less intrusive and therefore less intimidating, it is consistently more effective and beneficial. PSA is a protein produced by prostate tissue, which can be either cancerous or non-cancerous. The test measures the amount of this protein and detects abnormally high levels, then indicating that a man may have prostate cancer. An enlarged prostate and other related conditions can also raise PSA levels, but the test is a uniquely effective means of weeding out those at very low risk. Dr. Crawford refers to this process as…
“Casting a big net and catching the big fish.”
But the success of PSA’s growing popularity has not come without its own detriment. Due to the rapid and widespread adoption of PSA use, coupled with a desire to learn more about prostate cancer,
“There was a lot of overdiagnosis and overtreatment,”
says Dr. Crawford. It states that this…
“It led to a number of organisations, and rightly so, saying, ‘Hey, we’ve got to put the brakes on this, we’ve got to stop the screening, because we’re doing more harm than good.’
While PSA was revolutionary in detecting prostate cancer, it required a complementary tool that would distinguish which cancers required treatment. Prostate cancer is unique in that it is somewhat inevitable in older men:
“If you rip the prostate off a hundred 90-year-old men off the street, you’ll find that 80% of them have prostate cancer.” And even more shocking is the fact that, “They don’t know and they never will.” Because of this peculiar disposition, primary care physicians and urologists must be equipped not only with PSA, but also with molecular markers, which help isolate life-threatening cases of prostate cancer from less dangerous manifestations or, as he calls them Dr. “Toothless Lions”.
Following a consistent pattern of overdiagnosis and overtreatment of prostate cancer and the resulting pressure from organizations and stakeholders to minimize the use of PSA screening. As Dr. Crawford puts it,
“We were overmedicating people and they were having side effects and they didn’t need the treatment… we got together and said, we’re harming the most people, let’s not do it. Then it blew up in everybody’s face because prostate cancer, the advanced disease, is starting to come back in and become very common again.”
Prostate cancer prevention and treatment is, ultimately, a balancing act. Health professionals and researchers must walk a very fine line and avoid overcorrecting on either side. Fortunately, Dr. Crawford argues that there is one way to do this: PSA testing, molecular markers.
“It’s not that hard, but we make it hard” He says.
Dr. Crawford also stresses the fundamental importance of taking personal precautions, such as prioritizing diet, fitness and moderation. Additionally, men in particular have a detrimental tendency to ignore recommended health practices. they routinely skip annual exams and fail to follow up with their primary care physicians, even when there are problems.
Dr. Crawford recalls a comical but telling anecdote:
“I will tell you a story of a man who came to see me two years ago. I said to him “Yes sir, why are you here?” and says “I don’t know”. I say “What’s the problem” and he says “Nothing”. …I said “Who told you to come here?” He says, “My woman!” I said “Oh yes, why did your wife send you here?” He says, “He sent me to see you because I get up to pee 6 times a night. It doesn’t bother me, it bothers her!” There is something to be said for that.”
Men are socialized to pull themselves up by their bootstraps. Even for matters as potentially deadly as their own well-being, seeking health care is sometimes framed or perceived as weakness. “Men tend to be kind of stoic and say, ‘Oh, nothing’s going to hurt me.'” says Dr. Crawford. But this perception is terribly wrong. And this deeply flawed reasoning is, perhaps, upstream of men’s lagging behind in critical health metrics, such as the staggeringly disparate gender gap in life expectancy.
Throughout my conversation with Dr. Crawford insisted on highlighting one question in particular: “How do you motivate people?” In other words, how can we, as health professionals and advocates, consistently and persistently encourage people to proactively pursue their own health?
“Most people know you shouldn’t smoke, you shouldn’t drink too much, you should exercise… it’s hard to find someone who disagrees with most of that, none of it. Except we don’t,” he says.
Approaching one’s health as an integrated constellation of environmental factors and biological predisposition can be extremely intimidating. But knowing the facts about one’s family history, genetic risk factors, and psychological disposition provides a great foundation. As for health professionals and advocates, it can sometimes feel like a frustrating and impossible task. it all boils down to that aforementioned question: how I am doing do you motivate people?
Dr. Crawford provides a functional answer:
“Well, everyone’s buttons are different. That’s where the art of medicine comes in, what turns some people on and what doesn’t. That’s where we need a team approach. For some people it’s their apple watch. For some people it’s “Hey, if you don’t change your lifestyle, you won’t live 10 years.” It is variable.”
This may seem like a pessimistic takeaway on the surface, but it really isn’t. Health is less a singular metric than it is a continuous process of self-improvement, personal initiative, and pharmaceutical intervention when necessary or beneficial. The good news is: we are all, at least to some extent, masters of our own well-being.
As for his final advice, Dr. Crawford offers…
