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Protocol over person -The Quiet Tyranny of Standardized Care
I was told I had prostate cancer. Then I was told I would be given a personalized treatment plan. What I received instead was a prescription—straight from a flowchart.
This, I’ve learned, is standard operating procedure in modern oncology: proclaim the gospel of "individualized care" while quietly worshiping the unyielding idol of medical protocol. It's a bit like calling fast food a bespoke culinary experience because you asked them to hold the pickles.
We live in an era of extraordinary medical advances—targeted therapies, genomic testing, personalized risk calculators. And yet, when it comes to applying them, too many physicians retreat to the safety of “guidelines.” The result is not tailored care but templated care, not patient-centered medicine but protocol-driven compliance. It's paint-by-numbers with a white coat.
The problem is not that guidelines exist. The problem is that they have become untouchable.
Woe to the patient whose cancer strays slightly from the statistical median. Woe to the man with a prior cardiac history, or rare pathology, or personal priorities that fall outside the medical script. And heaven help the patient who does his research, dares to ask questions, and gently suggests a deviation from the ordained path. Such a patient is not seen as engaged. He is seen as difficult.
Why are so many physicians unwilling to think beyond the protocol? The answer, I suspect, is threefold: liability, efficiency, and ego. Deviating from guidelines introduces legal risk. It requires time—a precious commodity in a system built on volume. And worst of all, it threatens the established hierarchy, where the doctor speaks and the patient obeys.
And so the burden of tailoring falls on the very person least equipped to bear it: the patient. We must become experts in radiation oncology, hormone therapy, cardiac comorbidity, and statistical outcomes—just to ensure we’re not being quietly funneled into the treatment chute marked “Default.”
This is not a cry for rebellion. It is a call for responsibility.
Medical professionals must rediscover the courage to treat the individual, not just the disease. That means using the protocol as a guide—not a leash. It means taking the time to ask not just what we are treating, but who. And it means listening—genuinely—to patients who arrive informed, engaged, and unwilling to be boxed into a standard that doesn’t fit.
Because when a system values protocol over person, it ceases to be care. It becomes something colder, quieter, and far more dangerous: routine.
Let’s not allow prostate cancer—or any cancer—to be managed by muscle memory.
Let’s bring the thinking back. In an ideal world, a patient would not have to advocate for themselves. In a competent one, at least, they wouldn’t have to do it alone.
Until then, we study. We question. We push. Because we’ve learned the hard way that if we don’t fight for individualized care, no one else will.
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Only time will tell, I am afraid.
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1 ReactionYou make some good points.
My husband has significant cardiac risks which were most likely made worse by the first 15 months of treatment for Gleason 9 prostate cancer . His PSA was 46.6 at diagnosis . Now he is facing Open Heart Surgery while still on ADT… and hard to get well considered advice about whether to stay on ADT or how long to be off of it before / after surgery..I don’t think there is enough research out there .
We may need to make a decision on our own .
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1 ReactionThat's really rough. I'm so sorry.
Co-morbidities like heart disease complicate cancer treatment, and the more of them there are, the less likely that there's a big body of reasearch covering precisely the patient's situation.
It that case, what does an oncology team do? The safe course is to undertreat the cancer and let it take its course, because they're unlikely to be sued for that. Taking more drastic action to try to extend the patient's life is risky, both for the patient and (litigation-wise) for the medical team, but can have a big payoff if it works out.
That's why it's so important to have a conversation about risk tolerance up front. The onco team should initiate it, but if they don't, you can. I told my onco team in 2021 that I wanted to fight (stage 4, age mid 50s) and was willing to take chances and put up with harsh side effects. That made them more willing to take chances, too, since my wishes were clear.
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3 ReactionsYes, we wanted to be very aggressive when he started treatment for his prostate cancer … though stage 3 it was assumed to be micro metastatic with a PSA of 46.6 and Gleason 9 .
He had radiation and he was on Zytiga for a year, with Orgovyx, until his aortic root aneurysm started getting bigger and his BP became more unstable..
His oncologist is very neutral regarding treatment plan … I don’t think he expects a cure anyway.
Now he has a cardiac team at Mayo and he will be scheduled for open heart surgery sooner than later.
Cardio doctors don’t want to advise him re; ADT risks before, during and after surgery . Oncology doesn’t know enough about cardio impact of ADT to advise. No one recommended that he get off Zytiga… even the Oncology cardiology doc.
We made that decision.
At this point we think his heart will kill him before the prostate cancer.
We are also getting a second opinion with a different oncologist.
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2 ReactionsMind boggling. I am in same boat. I had 9 bypasses 13 years ago. I am not exactly the poster child of cardiac health. Coordinating oncology with cardiology has been a full time job. If only one of them would care… the stuff that scares me is the ADT regimen. I am on it for 18 months, but I might stop at 6 and take my chance.
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3 ReactionsIt's a hard place to be — I understand that. Ideally, you'd get the cardiologist and oncologist together in the same room to discuss things with you and each-other, but sadly, with modern caseloads, that might not be likely. It's still worth asking, though (even a Zoom call?).
I hope things work out.
The tragic fact is that NOBODY KNOWS and they simply can’t admit that.
Most patients simply don’t want to believe how MUCH is really unknown.
At some point you have to have a frank conversation with yourself, weigh the pros and cons, risk/rewards and make your own decision.
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