by Yeong Sek Yee & Khadijah Shaari

Shortly after he turned 70, Mr. Ralph De Angelo, a retired department–store manager in the heart of black America, saw a newspaper advertisement that claimed that prostate cancer screening saves lives. The advertisement also mentioned that 95% of men diagnosed with localized disease are cured.

The following is the tragic story of Mr. De Angelo after his prostate screening and how unnecessary harm can be done to those who go for screening of the prostate, breast, etc. This is a classic example of collateral damage (due to overtreatment) described in the book “HOW WE DO HARM” by Dr Otis Webb Brawley, MD a medical oncologist and Executive Vice President of the American Cancer Society.

In 2005, Mr. De Angelo, after his prostate screening, was diagnosed with prostate cancer, with a PSA reading of 4.3 ng/ml (just 0.3 above what is considered normal). He was urged to have a biopsy. Two of the 12 biopsies show cancer. The Gleason score was 3 plus 3 which is associated with the most commonly diagnosed and most commonly treated form of prostate cancer. There is no way to know whether a patient with this diagnosis will develop metastatic disease or live a normal life unaffected by the disease.

With this uncertainty, Mr. De Angelo was persuaded by his urologist to perform a radical robotic prostatectomy which he (the urologist) thought was the gold standard of care. After the operation, he was told he had a small tumour 5mm by 5mm x 6mm in a moderate size (50cc) prostate. The tumour was all in the right side of the prostate. This means that the tumor didn’t appear highly aggressive under the microscope. Good news? Unfortunately, Ralph realizes that he is now incontinent. Three months later, the incontinence is still there and he has to wear pampers continuously. Besides incontinence, Ralph was also impotent and given Viagra.

With a lingering 0.95 ng/ml (even though his prostate has been removed), a radiation oncologist suggested “salvage radiation therapy” to the pelvis. Four weeks into the radiation, Ralph saw blood in his stool. This was due to radiation proctitis i.e. radiation damage to the rectum. He continued having incontinence, but also developed a burning sensation upon urination. Later, Mr. De Angelo stopped his radiation with one more week to go. For the rectal proctitis, he went to a gastroenterologist, who prescribed steroids in rectal foam that he had to put up his rectum four times a day.

About three weeks after stopping the radiation, Mr. De Angelo realised that whenever he passed gas, some of it comes out of his urethra. He also sensed liquid from his rectum soiling his diapers. He was confirmed having a rectal fistula into the bladder…there is a hole between Ralph’s rectum and his bladder. After several urinary infections and when the fistula didn’t seem to be healing, he had to see a GI surgeon. He performed a colostomy to keep stool off the inflamed rectum and the hole into the bladder. The next step was an ureterostomy, a surgery that will bring urine to the abdominal wall and collect it in a bag, just like his bowel movements.

In Dec 2009, Mr. De Angelo’s daughter called Dr Brawley to inform him that her father had “urinary tract infection” which later progressed to sepsis, a widespread bacterial infection in the blood. On the fifth day of hospitalisation, Ralph passed away (only 4 years from diagnosis). Interestingly…”the death certificate reads that death was caused by a urinary tract infection. It doesn’t mention that the urinary tract infection was due to his prostate-cancer treatment and a radiation-induced fistula….Mr. De Angelo’s death will not be considered a death due to prostate cancer, even though his death was caused by the cure.

In conclusion, Dr Brawley strongly believed that… “the majority of these men, who are treated with radiation or hormones or both, got no benefit from treatment. They get only the side effects (collateral damage) including those that Mr. De Angelo had: proctitis i.e. inflammation and bleeding from the rectum, cystitis, burning sensation on urination and a feeling of urgency, a rectal fistula in which bowels and bladder are connected. The side effects of hormones can be diabetes, cardiac diseases, osteoporosis, and muscle loss.

In the case of Mr. Ralph De Angelo, both the surgeon and the radiation oncologist got paid handsomely. They both likely thought they were doing the right thing. However, Ralph got the side effects, and his quality of life was destroyed (too much collateral damage?).

One parting remark by Dr Otis Webb Brawley which is very relevant to this article:

“Prostate-cancer screening and aggressive treatment may save lives, but it definitely sells adult diapers.”

FOOTNOTE:

On the Malaysian scene, Malaysia’s leading oncologist, Dr Albert Lim passed away on March 8, 2013 due to prostate cancer which had spread to the bones and liver (and possibly lungs as well?) in just less than a year after diagnosis.

Was it overtreatment or was it excessive collateral damage?

Please share with us.