OK, I know I use that line entirely too much, but I also don’t really care. When something fits, wear it. And if it doesn’t fit, you must acquit. Sorry, I’ll stop. I’m in a weird mood as I write this. But it’s really hard not to get into a weird mood after reading the lastest bit by that crank to rule all cranks, that quack who tries to rule all quacks, Mike Adams, founder of NaturalNews.com. Last week, he laid down the vile stupid fast and furious to attack Angelina Jolie’s decision to undergo bilateral prophylactic mastectomy. It was hard not to note his fixation with referring to the surgery as “mutilation” and to rant about how surgeons don’t remove other organs to prevent cancer in patients with gene mutations that predispose them to very high risk of specific cancers. It turns out, as I pointed out, that we do. It was also hard not to note his fixation with testicles and prostate and why men supposedly don’t undergo surgery to remove their reproductive parts in order to prevent cancer. He might have had a tiny spore of a point, buried in a black hole of pure pseudoscientific crazy, if there were in fact a gene mutation that conferred an 87% chance of testicular cancer or prostate cancer.
Then I woke up yesterday morning, and you, my readers, were bombarding me with yet one more article by Mike Adams, entitled Angelina Jolie copied by men! Surgeons now cutting out healthy prostate glands of men who carry BRCA gene. In it he references a story about a 53-year-old British man who underwent a prostatectomy after testing positive for a BRCA mutation. The news titles were almost as bad as Adams’ title: UK Man has Prostate Removed after Tests Reveal ‘Jolie’ Gene Flaw (International Business Times) and British father, 53, becomes first man in the world to have his prostate removed to beat cancer flaw which struck Angelina Jolie (Daily Mail). Indeed, the Daily Mail even began its article by writing, “A British father has made medical history by having his healthy prostate removed after discovering that he carries a defective gene that boosts his risk of cancer, it was reported last night.” As you will see, this sentence is every bit as much a misrepresentatino as Adams’ rant and the statement in the IBT article that proclaimed, “After receiving the news the man asked doctors to remove his prostate, which tests had shown to be healthy.”
Characterizing the decision as “Medical self-mutilation… a new fashion statement for the chronically stupid” and speculating that surgeons (yeah, that’s me) are pushing people into having surgery (we’re usually not), Adams couldn’t help but let his imagination run away with him:
Hey, I want to see Brad Pitt’s prostate gland stuffed into a glass tube and hanging around Angelina Jolie’s neck like she used to reportedly do with Billy Bob Thorton’s blood. That wouldn’t be weird, would it?
I think we should start a “Skin Removal Foundation” to have all the skin surgically removed from people who might someday have skin cancer… which includes everyone.
Or better yet, the “Young Women Breast Cancer Prevention Society” which chops off their breasts at age nine, before puberty really kicks in. Just tell your little girls how much you love them before the anesthesia kicks in. That’s what good mommies do, isn’t it?
And for the young boys, why stop at slicing off their foreskin at birth? Penis mutilation is just a warm-up for today’s insane medical monsters. Why not remove their colons at birth so that they never run the risk of dying from colon cancer? Why not cut off their testicles and make sure they never face the future possible risk of testicular cancer, too?
I know, it’s insane. Disgusting. Outrageous. And yet it’s happening right now thanks to women like Angelina Jolie who are publicizing and pushing this idea that women should have healthy breasts cut out of their bodies even though there is no rational medical justification for doing so.
He finishes up with “satire” (which is about as unsubtle and heavy-handed as you would expect from Adams) in which he advertises “1-800-CHOP-OFF,” drive-through double mastectomies, and the Organ Whacker Saw for “do-it-yourself medical mutilation.” Yeah, that’s just Mikey being Mikey. He’s terminally vile.
But what about the story itself? I didn’t even bother with the Daily Fail or the other article. I happened to see a description of this case on Medscape. it was obvious I should go with that over other accounts. The first thing that I noticed about the man who underwent preventative prostatectomy is that he was part of a research study:
The man who underwent surgery was participating in a clinical trial, conducted by the Institute of Cancer Research (ICR), that involved more than 20,000 men. Previous results from this trial have shown that a man with a BRCA2 mutation has an 8.6-fold increased risk of developing prostate cancer, and with a BRCA1 mutation has a 3.4-fold increased risk. Just weeks ago, the ICR researchers reported that prostate cancer in men with the BRCA2 mutation is more aggressive and more likely to be fatal (J Clin Oncol. 2013;31:1748-1757).
“Knowing you are a carrier is like having the sword of Damocles hanging over you,” Dr. Kirby said in an interview with the Sunday Times. “You are living in a state of constant fear. I am sure more male BRCA carriers will follow suit.”
The man who underwent the surgery is described as a 53-years-old businessman from London who is married with children and has several family members who have had breast or prostate cancer. When he found out he was carrying the BRCA2 mutation, he asked to have his prostate removed.
Initially, the ICR researchers were reluctant, the newspaper reports, because there was no indication of a problem, either from prostate-specific antigen tests or from a magnetic resonance imaging scan. However, a biopsy showed microscopic malignant changes.
Here’s the thing that’s not being emphasized, however. This was not preventative surgery. It’s being represented that way in the press or, if it’s mentioned, the fact that there was already cancer there is mentioned but not put in proper context So I will say it again: This is being represented as a case of a man “emulating” Angelina Jolie, but that’s not what it is. This man did not, as the Daily Mail and IBT reported, have a “perfectly healthy prostate.” He had early stage prostate cancer. We don’t know the details, but his surgeon said that he normally wouldn’t have operated, which implies that the cancer cells seen on the biopsy were considered to be of the kind and level that urologists would consider it safe to watch and only intervene if the cancer showed signs of progressing. But this man’s case was different. He had a BRCA2 mutation, and the clinical trial that he was on had shown that BRCA2 mutations are associated with much nastier, more lethal prostate cancers than your run-of-the-mill sporadic prostate cancers. That put his surgeon in a bind over what to do.
Indeed, let’s take a look at the study cited above, which was published just last month. It’s entitled Germline BRCA Mutations Are Associated With Higher Risk of Nodal Involvement, Distant Metastasis, and Poor Survival Outcomes in Prostate Cancer, and the title pretty much says it all. BRCA-associated prostate cancers are nastier cancers. But how much nastier?
The study examined tumor features and outcomes of 2,019 patients with prostate cancer, 18 of whom had BRCA1 mutations and 61 of whom had BRCA2 mutations. Investigators looked at prognostic factors correlating with overall survival (OS), cause-specific OS (CSS), CSS in localized PCa (CSS_M0), metastasis-free survival (MFS), and CSS from metastasis (CSS_M1). What they found is that BRCA1/2 mutation carriers were more likely than noncarriers to have poorly differentiated cancer when diagnosed (35% versus 15%), locally advanced ancer (37% versus 28%) or cancer that had already metastasized (18% versus 9%). In patients whose cancers had spread past the capsule of the prostate at diagnosis, more carriers had metastatic disease within five years (23% versus 7%). While it is true that this study was a retrospective study, with all the shortcomings of retrospective studies, its results were sufficiently clear that it’s hard not to take them as a strong indication that BRCA2 associated prostate cancer tends to be a lot more aggressive and lethal, with the five year OS being 86% for noncarriers and 58% for BRCA2 mutation carriers. That’s a big difference.
Of course, given my discussions of lead time bias and length bias, in which it is not always clear that earlier treatment actually results in better treatment outcomes, you might reasonably ask if more aggressive surgery earlier in men with BRCA2 mutations who have prostate cancer will really improve their odds of surviving the disease (or, more specifically, significantly decrease their odds of dying from it). After all, this man had no indication of prostate cancer by standard measures, including serum PSA levels and a magnetic resonance imaging scan. It was only an prostate biopsy (a procedure for which he had no standard clinical indication to undergo and apparently only underwent because he was on the study and was a BRCA2 carrier). If you look at it another way, he underwent far more intensive screening than the average 53 year old, and it early stage cancer, leading to the question: What to do?
It’s an open question. However, it’s also a question that can’t be answered until a prospective clinical trial is done, a clinical trial that might never be done because of the difficulty between randomizing men with BRCA2 mutations with early stage prostate cancer that normally would be observed, with intervention reserved for men who show evidence of progression on followup ultrasound and biopsy to either immediate surgery or standard “watchful waiting.” At least, such a trial will be very difficult to do because BRCA2 mutations are relatively uncommon causes of prostate cancer, making it difficult to accrue enough subjects, particularly when the two groups are immediate surgery versus delayed surgery. Most men with BRCA2 mutations would very likely want early surgery and would be unlikely to be comfortable being observed knowing that BRCA2 mutations are associated with significantly worse outcomes in prostate cancer. According to Ros Eeles, MBBS, PhD, professor of oncogenetics at the ICR and honorary consultant in clinical oncology at The Royal Marsden NHS Foundation Trust in Surrey:
“It must make sense to start offering affected men immediate surgery or radiotherapy, even for early-stage cases that would otherwise be classified as low risk. We won’t be able to tell for certain that earlier treatment can benefit men with inherited cancer genes until we’ve tested it in a clinical trial, but the hope is that our study will ultimately save lives by directing treatment at those who most need it,” she said in an ICR statement.
Exactly. This man and his surgeon made a difficult decision based on data with a great deal of uncertainty over what the right thing to do was. In the context of a BRCA2 mutation that is associated with a nastier and potentially more lethal variety of breast cancer, it is not unreasonable for a man with early stage prostate cancer to opt for immediate surgery. For all we know, if this were the US, surgeons might very well have recommended immediate surgery anyway even if the man didn’t have a BRCA2 mutation. In the US we tend to treat prostate cancer more aggressively, and only relatively recently have urologists and radiation oncologists become more comfortable with “watchful waiting” for low risk early stage prostate cancer. This man’s decision had nothing to do with Angelina Jolie. It had nothing to do with prevention. It was a therapeutic surgery. One might argue if it was necessary or not. It’s hard to know without knowing the full pathology found on prostate biopsy. But it was not “preventative” surgery. Given that BRCA2 mutations do increase the risk of prostate cancer by around 8-fold, it might actually make sense to consider prophylactic prostatectomy in men with BRCA2 mutations, but that’s a question for future research, and this case is not a case of doing that.
I expect idiotic nonsense from people like Mike Adams. It’s just a shame that this man’s story is being misrepresented by mainstream news organizations as somehow being an indication that men are rushing to emulate Angelina Jolie.