The arbitrary economics of life and death

The difference is that life can be snuffed out by a semi-automatic that we can purchase for loose change; while we each demand a Ferrari (or Bugatti or Aston Martin) when we’re salvaging a few extra months from metastatic cancer. It always comes back to the consumer.

Though prostate cancer has the highest rates of diagnosis, it has one of the lowest cancer mortality rates. And it’s when dealing with mortality when things get costly.

What do we make of this strange calculus? It’s that the value of our life is what we make of it. (With my brother’s death in October 2024 due to pancreatic cancer, he made the choice that he preferred death over being “kept barely alive by a rotating cast of specialists, medications,….” As his representative, though I disagreed with his choice, it was his choice to make, mine to carry out, and the decision was made to stop treatment. The end came rather quickly after that……and no need for refilling $14,000 Aston Martin medications.)

Fortunately, only a few % of prostate cancer patients die of prostate cancer. That has remained a fairly stable % over the decades. That then begs the question - should heroic (and “Aston Martin” expensive) efforts be spent if it won’t be curative?

Yes, the prostate cancer patient is a “patient” to him and his family. But to his doctor he’s one of dozens; to his hospital he’s one of thousands; to the medical community he’s one of millions. That sounds like a statistic.

All this may not be moral; it may not even be logical. But it exhibits the true essence of humanity.

Excellent statement, @hanscasteels. I am three years into this journey and have had RP, Radiation, and ADT with Zytiga and Prednisone. I would also be willing to try anything new if my journey takes me there. I would do it with hope for myself but ultimately to help those who come after us. I have a son, and I don't want him to experience this journey I am on. Thank you for the statement; it is perfect.

"Fortunately, only a few % of prostate cancer patients die of prostate cancer."

Yes, very true, but it's important to note that there are at least two different things called "prostate cancer":

1. The slow-developing, "you'll probably die of old age before it gets you" type that typically hits in your late 60s, 70s, or 80s. This is what most people think of.

2. The fast-developing type that typically hits in your 40s, 50s, and early 60s, the one that killed people like Johnny Ramone and Frank Zappa long before their time.

The second type used to have a very high mortality rate (and very quickly). It's just in the past few years that we've come up with effective treatments to keep it under control and extend life. It's still often not discovered until it's already at stage 4.

So it's the over-generalisations about prostate cancer, as much as anything else, that kills people: for example, many doctors and agencies recommending stopped PSA screening because of the first type, and the death rate shot up for the second.

Fortunately, these days they're getting better and better at telling the two types apart, so that they don't overtreat the first type (active surveillance is often fine, at least for many years), or undertreat the second (which can metastasise, literally, in months).

@ hanscasteels can we try and be a bit more positive? The world is a dangerous and random place. Terrible things happen to good people helicopter sightseeing in NYC, or Ukrainians attending Palm Sunday services. It’s one thing to be informative on this site about treatment options cost benefit and pros and cons. It’s another thing to be a total downer. Take a happy pill. We are all alive and trying to find the good in the world.

I do appreciate the concern, but let’s not confuse realism with pessimism. If you’re uncomfortable with the notion that cancer, war, and arbitrary death are part of the human condition, I suggest you take it up with the universe’s customer service department. Spoiler: they don’t issue refunds.

I’m not here to sprinkle serotonin on a landfill. I write from a place where hope and horror coexist, where a man can undergo aggressive treatment and still question whether the dogma surrounding it is intelligent or just desperate protocol in a white coat.

“Take a happy pill,” you say — charming. That’s the kind of advice that sounds best cross-stitched onto a throw pillow in a psychiatric waiting room. But I prefer to confront life as it is, not as I wish it to be. If that makes me a "downer" in your pastel world of curated optimism, so be it.

Some of us find clarity in the dark. And sometimes, the truth is more therapeutic than a forced smile and a motivational poster.

Of course I accept the fragility of life and the cards we have all been dealt with PCA. If you don’t want the treatment offered by the establishment then don’t take it. You do the research you know you have options. I still believe that Dr’s and hospitals are trying to help people. That’s been my experience. I’ve had a successful life surrounding myself with smart people with great ideas. It’s my goal to do the same with this nightmare. Put this on your pillow “ take a look on the bright side “ .

All good reasons for early and annual testing, leading to early detection, and then (if needed) taking advantage of the many diagnostic methods, and then (if necessary) taking advantage of the many treatment methods.

Even with Ramone and Zappa (and the many dozens of other celebrities with this disease), had they caught it early enough, the outcome might have been different (or at least not died so soon). And with today’s isotope therapies, immunotherapies, and/or PARP inhibitor therapies, we have tools that they didn’t have back then.

Yes, with the unfortunate decision by the USPSTF in 2012 not to recommend regular PSA screening, more advanced cases went undetected. (I still requested getting annual PSA screening back then. It was in 2012 that we detected my prostate cancer; I was on active surveillance for 9 years before getting active treatment in 2021.)

Fortunately with today’s biomarker (genomic), genetic (germline), and other tracking and testing methods, they can often differentiate the less serious prostate cancers from the more serious prostate cancers, and potentially have more positive outcomes.

I think the point is missed here. It’s not that I reject medical dogma. I do expect treatment options to be based on peculiarities and science, not on dogma and statistics. That’s not too much to ask for?

My experience was atypical because of all the other things going wrong at the time, so I mostly missed the anger phase (or maybe it's still ahead of me), but I suspect that's a normal thing most cancer patients go through.

Yes, I agree that the doctors, nurses, radiology and lab techs, and everyone else (except maybe the private insurers; I'll reserve judgement there) are doing their very best to keep us alive and healthy with the resources they have available: too few staff and facilities for too many patients, serious funding shortfalls, an aging population, etc etc.

But at the same time, I think it's natural to feel shock and surprise that your cancer doesn't seem to matter as much to medical practitioners as it matters to you. After all, this is the only life you have, while a typical oncologist has to care for 100s (?) of patients, some of whom aren't as sick as you, and some of whom are in their final days. They'd burn out in weeks if they couldn't find a way to keep at least a little professional distance.

Eventually, I think most of us reconcile ourselves to that reality. We realise that people are being born and dying in the hospital every day, and while the medical staff really do care and do their best for each of us, we're just individual pixels in a very big picture of life. It takes time to reach that perspective, though, so when I see a new-ish forum member seething with rage at the system, I cut them a lot of slack.

yes, we eventually stop shaking our fists and start filling out forms. We trade indignation for intake. The real trick isn’t in reconciling with mortality—it’s learning to nod politely as yet another cheerful nurse explains the difference between a CT and an MRI, as if it’s our first day in Cancerland and not the sequel nobody asked for.

You don’t rage at the system because it’s not malevolent—it’s just monumentally impersonal. A glacier of protocol moving at glacial speed, crushing individual identity into barcode labels and scan results.

And we accept that. Eventually. Somewhere between the third waiting room and the fifth repetition of our birthdate.