It has been said that the human’s default state of mind is anxiety. Unfortunately for us, this makes a lot of sense, given what the awareness of our own certain mortality is up against – which is the extraordinary power of our coding (all contained, miraculously, in each first single cell of our being).
It’s this coding that programmes us to: 1) avoid danger, 2) find food and 3) procreate. Our impossible task then, decreed by those all-powerful molecular spiral staircases, is to survive when we know that, ultimately, we cannot. This is the mother of all anxieties.
But having anxiety is not a particularly pleasant way to live. Ask any teenager living in the modern Western world – they all seem to have it. And let’s face it, we’ve all suffered it ourselves at some stage. At over 300 million people around the world suffering anxiety disorders, this makes them the most common mental disorders of all. So, how to deal?
We can keep muddling through our anxiety, trying in vain to douse it with distracting pleasure-seeking hits of dopamine, only to end up spreading our fears like a contagion, and keeping the world in its ongoing state of disorder. Or we could renounce the practical world altogether and live as ascetic monks in the harsh serenity of a cloud-topped hillside. But Buddhism speaks of a so-called “middle way” – neither self-indulgent nor self-sacrificial; a way of somehow reconciling yourself with what is, which itself is in constant change, and finding equanimity even in the knowledge of your own future death. We’ll return to the middle way later.
But there’s something else entirely that I’m anxious about now. And we have to pull all the way back from these lofty thoughts and land strangely in the clinical science of prostate cancer to find it. This is where I live my professional life. But to invite your trust, it might be useful here to take a sidestep and offer you some bona fides.
I’m a practising urologist with a special interest and expertise in prostate cancer. I’m 52 and have been in practice for 16 years, so mid-career. Based in Melbourne, I work in both public and private systems (as surgical specialists typically do in Australia) and have both metropolitan and regional practices, visiting a town called Bairnsdale three and a half hours’ drive east every second month. Day to day I diagnose men with prostate cancer by taking biopsies of tissue that looks suspicious on MRI scans. Then I’ll often (but certainly not always) treat them by surgically removing their prostates by the technique of robotic prostatectomy.
About a decade ago, I was worried about the severe infections we urologists were causing when we performed prostate biopsies via the rectum, essentially inoculating rectal bacteria into the previously sterile and highly vascular prostate gland. Not surprisingly, sepsis – a life-threatening condition – was not uncommon.
In the years since, as an Associate Professor at Monash University, I’ve conducted and published research* which has shown that when you pass a biopsy needle through the skin instead of via the rectum, the risk of causing sepsis is near-zero. We now know you can even achieve this without any antibiotics. This has been a major advance in the diagnostic work-up of men suspected of having prostate cancer, as it practically eliminates a source of potential serious harm. This biopsy technique via the skin is now standard of care in official guidelines.
*There are far more rigorous papers on this subject, but the link above is to a published debate on prostate biopsy in an esteemed journal. As you will see, there is a nod to Montaigne’s famous quote: “Kings and philosophers shit. And so do ladies.” Science is a serious business, of course. But we also need to keep it real.
Speaking of guidelines, I served as the only non-European on the EAU Prostate Cancer Guidelines panel 2018-2023. Admirably, this panel updates its Guidelines every year (no mean feat), based on the latest and highest level of evidence available. Writing for this panel gave me an illuminating insight into how official clinical guidelines are created and I have enormous respect for its work. The panel delivers on its ideals of providing evidence-based recommendations. But sometimes the evidence base itself can only deliver so much. Often the panel has to contend with low level evidence where there is none that’s high. In some areas, there’s just a black hole, with no evidence at all*. And in these shadows, despite the panel’s best intentions, dogma and bias are ever lurking, waiting to pounce and fill the void.
*Absence of evidence does not equal evidence of absence. It just means we need a clinical trial.
The EAU panel was then. Now I’m in a working group to help update Australia’s own official guidelines specifically on the early detection of prostate cancer. (As it’s an ongoing process due out next year, I won’t be making any further comments on it here.)
As of April 2024, I’m also the Director of Urology at Alfred Health, where I’m charged with leading a superb team of eleven urologists, our urology trainees, junior medical staff and our allied health professionals at one of Melbourne’s largest teaching hospitals.
By society’s standards, then, I could be viewed as an authority on prostate cancer. But as a scientist, I hold a healthy skepticism about everything, questioning any information that comes my way, old or new, including from authority (sometimes especially from authority!) in a scientific, open-minded spirit of enquiry, humility and genuine curiosity.
So you can see the dilemma I’m in here. I’m necessarily skeptical of my own opinions! I’m wary of all the biases and heuristics, conscious and unconscious, that might be at play, dipping their toes of distortion into the pool of my thinking at moments of their own choosing.
But I still think this healthy skepticism is a good thing. It’s just a little exhausting at times. The task I set myself is to sustain the mental energy that’s required to maintain this approach. Mental fatigue can lead to the default of “System 1 thinking” - of the recently departed Daniel Kahneman’s Nobel-prize-winning thesis – brilliant for rapid survival instinct, not so good for complex reasoning. Scientific thought is the realm of System 2. It takes effort.
Now that you’ve got some idea of the perspective I’m coming from, it’s time to return to the question of what I’m worried about now.
What I’m worried about now is that we are still overtreating some localised prostate cancers and causing more harm with our treatment than the harm the cancer itself would have caused.
Sure, we have active surveillance and watchful waiting as non-interventional options at one end of the spectrum. These are major advances that are now standard management for low-grade prostate cancers, or for men with a short life expectancy for other reasons.
But when prostate cancer is the fifth highest cause of cancer death in men globally, with a predicted increase of 85% over the next 20 years, they’re clearly not appropriate for everyone. The only other standard option for localised disease is at the other extreme – treatment of the whole prostate, by either its surgical removal or radiotherapy. Unfortunately, despite spectacular advances in technology for both modalities, and while highly effective, these treatments can still leave men with significantly reduced quality of life due to erectile dysfunction, urinary incontinence or bowel symptoms.
If we knew for sure that, if we didn’t operate or irradiate, the cancer would spread and possibly even kill the patient, it’s a sacrifice most men would be willing to take. I know this because when we recommend these treatments, most men do accept this advice. The problem is – and this is the crux of it – we too often don’t know for sure if the patient’s cancer will cause him harm. And it’s this precarious balance of harm versus benefit that’s caused so much confusion about the simple PSA (prostate-specific antigen) blood test – currently our only widely accepted starting point for the early detection of prostate cancer.
So these are the questions I find myself asking in this scenario: what is the chance I’m doing more harm than good here? How am I tracking with that sacred dictum of medicine, primum non nocere – first, do no harm? What if – and here’s where Buddhism (albeit somewhat tenuously, I’ll admit) finally makes contact with prostate cancer – what if there was a middle way? Or perhaps more provocatively, if the Enlightened One himself had today what we call significant localised prostate cancer, we could ask: what would the Buddha do?
In the next instalment of Vermiculations, I’ll dive in to the possibility of a middle way for the treatment of localised prostate cancer, and what it might mean, not just for men already with a diagnosis, but for all men at risk of prostate cancer. In the meantime, thanks for reading.
Notes:
1. Although I admire greatly the teachings of Buddhism, I don’t identify as a Buddhist or with any other religion.
2. AI is great for many things, but I won’t be using it any of these writings. The creative magic of turning wisp-like thoughts into hard-edged words on a page is a joy too precious to relinquish.