Treatment Dogma - Aggressive is not the same as intelligent

Posted by hans_casteels @hanscasteels, Apr 13 6:51pm

In cancer care, “aggressive” is a word we wear like armor. It suggests boldness, urgency, and strength — the kind of approach that implies we’ve taken control of an otherwise uncontrollable diagnosis. Especially in prostate cancer, where ambiguity reigns and the word “watchful” often precedes “waiting,” aggressive treatment is viewed as a declaration: We’re not waiting. We’re acting.

But after going through what is considered a maximum-strength treatment protocol — brachytherapy, external beam radiation therapy (EBRT), and 18 months of androgen deprivation therapy (ADT) — I’ve come to question a dangerous assumption baked into our current treatment culture:

Aggressive is not the same as intelligent.

Let’s rewind to 2018. My PSA was 1.0. Unremarkable. Unthreatening. Exactly the kind of result that lulls patient and physician alike into six-month follow-ups and benign shrugs. But in that same bloodwork panel was something less discussed: a testosterone level below the minimum reference range.

At the time, no one gave it much weight. Maybe I was just built that way — hormonally mellow. But now, with the benefit (and burden) of hindsight, I wonder: was that early drop a signal? Was my low testosterone a constitutional quirk — or the first biochemical hint that a tumor was already there, feeding silently, growing slowly, and lowering systemic testosterone as it hoarded androgen internally like a rogue tenant stockpiling supplies?

Because today, I know the name of what was growing: a cribriform prostate carcinoma, a histologic subtype associated with more aggressive behavior, perineural invasion, and a knack for avoiding detection. And I know that by the time it was discovered, it wasn’t a new arrival. It was an established resident.

So we hit it with everything we had — radiation from within, radiation from without, and hormonal suppression with all the subtlety of a sledgehammer. Treatment was “aggressive.” And on paper, it worked: imaging showed no obvious spread. My PSA dropped. The protocols had been followed.

Victory?
Not quite.

A PSMA PET scan showed uptake in three areas. Not “metastatic” by traditional definitions, but not ignorable either. It was the kind of result that lives in the margins of clinical certainty — not definitive, but suggestive. Not a relapse, but not quite closure.

And that’s when it hit me: we had waged war, but we never fully understood the battlefield. We deployed firepower, but did we ever formulate a strategy?

I don’t know my father. I have no access to my paternal medical history — no cancer risk markers, no genetic flags, no family roadmap. That alone should have triggered a deeper diagnostic conversation. Germline or somatic testing might have shed light on vulnerabilities we never looked for. Instead, we assumed the standard protocols were enough. We treated the diagnosis, not the biology.

We often conflate doing more with doing better. But cancer is a master of ambiguity. It evolves. It adapts. And sometimes, it lets you think you’ve won, just long enough to regroup. If we’re serious about defeating it, we need more than aggression — we need intelligence.

That means more personalized diagnostics.
That means genomic context, not just Gleason grades.
That means replacing the phrase “apparently contained” with genuine biological insight.

And above all, it means accepting that maximum treatment doesn’t guarantee optimal outcome.

This isn’t about second-guessing clinicians — it’s about challenging a system that rewards action over understanding. We need a shift: away from reflexive overkill, and toward truly strategic, data-driven, individualized care.

Because for many of us, aggressive treatment may buy time — but intelligent treatment buys clarity, direction, and in some cases, a better chance at long-term survival.

And that’s a war worth fighting wisely.

Interested in more discussions like this? Go to the Prostate Cancer Support Group.

nparadisum | @nparadisum | Apr 13 8:55pm

Very insightful and well said.

handera | @handera | Apr 13 10:24pm

FOMO….I always thought it only applied to financial opportunities, real estate purchases and other major decisions where I was the buyer of some fairly large and rare commodity that was being dangled for only a moment with the tantalizing presupposition that others would be sweeping it away ASAP…..then my brother told me something that I, unfortunately, often forget in the bewilderment, confusion and not well understood opportunity of my next FOMO moment…..

“The deal of a lifetime comes every day”.

Aggressive cancer, aggressive treatment, aggressive active surveillance, aggressive medical team and on and on it goes….pretty soon everyone worth their salt is running around like chickens with their heads cut off…usually the more unknowns involved the worse the “aggressive” action oriented behavior.

“Aggressive is not the same as intelligent.”

Thanks for that insight…it’s golden!

heavyphil | @heavyphil | Apr 14 7:52am

Hans, didn’t you just finish EBRT 3 days ago? And you had a PET scan? Makes no sense. How can you have relapse already?
If memory serves, you did NOT have a pre-treatment PSMA so there’s absolutely no way to know if these lesions are the same size or getting smaller.
But more importantly, how would your treatment have changed IF the lesions were seen beforehand? It seems that your RO’s destroyed the gland.

heavyphil | @heavyphil | Apr 14 8:41am

In reply to @heavyphil "Hans, didn’t you just finish EBRT 3 days ago? And you had a PET scan? Makes..." + (show)

And hopefully these possible suspicious areas were within the radiation field and they were treated as well.
Phil

hans_casteels | @hanscasteels | Apr 14 9:54am

In reply to @heavyphil "And hopefully these possible suspicious areas were within the radiation field and they were treated as..." + (show)

I don't know if they were. I know that the radiation treatment field included pelvic lymph nodes. Not sure if that was reactive or precautionary. I also don't know if the "suspicious lesion" on my spine was treated at the same time. They were deemed to be "not suspicious" when the scan was analyzed.

heavyphil | @heavyphil | Apr 14 11:07am

In reply to @hanscasteels "I don't know if they were. I know that the radiation treatment field included pelvic lymph..." + (show)

I had the same thing on my pre-treat PSMA; suspicious lesion on femur. But my RO ruled it out. He said bony lesions usually present with other areas in the prostate bed - not solitary and by themselves.
I want to believe that but haven’t others on this forum had bony lesions without other areas showing? I think they have.
So if my PSA remains elevated or goes up, another PSMA will be ordered and maybe they’ll decide that the ‘previously suspicious but not metastatic’ lesion really WAS cancer and then it’s SBRT time.
One thing to add, many large health facilities use ‘radiology mills’ in Mumbai - not joking! Why pay a staff radiologist with benefits when a certified RAD. In Mumbai will read your scan for pennies?
Unless you can prove otherwise, I would bet that the same MD did not read your scans. It becomes like Gleason scores - depends on who reads the slides.
Phil

surftohealth88 | @surftohealth88 | Apr 14 11:45am

Yes, this is becoming very scary proposition - that PSMA readings can vary depending of the experience of radiologist and also depend of "interpretation" . Hans posted yesterday video link at Mayo about PSMA and MRI and CT and about the way they are "read", oh boy. There are organs and tissues that light up regularly even though there is no cancer there for example and on the other spectrum there are patients with metastasis all over body that just do not show on standard PSMA scan even when they are not small ?! WT* ???
Hans - can you send your PSMA for second opinion to Mayo ? : (
Phil - how about you ? Can you ask for second opinion about spot on your bone ? 🙁
PC is just one crazy beast that has so many variations and often does some wacky and unexpected things in body. That Mayo video just blew my mind ...

kujhawk1978 | @kujhawk1978 | Apr 14 8:35pm

My example...when my PSA started rising in 2022 and we met our decision criteria in April 2023 to image (three or more consecutive increases spaced three months apart and PSA between .5-1.0), the imaging showed a single lymph node.

I met with my radiologist and oncologist. My thought was SBRT and six months ADT for micro-metastatic disease.

My radiologist supported that. My oncologist proposed 24 months ADT + ARI and SBRT.

I countered with SBRT, 12 months ADT, hold off the ARI unless PSA didn't drop to undetectable in the first three months, decide at 12 months based on the clinical data to continue or stop.

We did not add the ARI and at 12 months, I argued for coming off based on PSA dropping to undetectable in the first three months. Radiologist supported that, so did the oncologist though I could see he was gritting his teeth. I think he was ok because he knew I would do labs and consults every three months and go back on treatment when the clinical data indicated.

The other time was triplet therapy in January 2017 after surgery and SRT failed. My clinical data didn't support it but I felt it did and when my medical team didn't support it, went to Mayo, they did, found a new team to administer locally, except my radiologist.

Was triplet therapy over treatment, possibly, I don't think so. While my clinical data didn't support it based on the STAMPEDE and CHAARTED trials I felt my Grade Group, GS, time to BCR coupled with my PSADT and PSAV meant left untreated, I would be soon!

Was either the right decision? We'll never know since we can't run a parallel study of the other treatment choices.

Medicine is based on science but the application to individuals is the art. Guidelines such as NCCN are based on science, but they are population based and historical given the exponential advances brought about by medical research.

So, what do I look for in my medical team...active listening, shared decision making.

Kevin

heavyphil | @heavyphil | Apr 15 7:40am

In reply to @surftohealth88 "Yes, this is becoming very scary proposition - that PSMA readings can vary depending of the..." + (show)

Hey surfer - NO!! I don’t want to know!!🤯. I already did the salvage radiation so that’s one very big area off the table.
If this lesion IS metastasis, it too was exposed to ADT and perhaps has shrunken down; or it will cause PSA to rise and will be reconsidered for SBRT.
One thing I’ve learned with this whole ride is that the waiting - tedious and fear inducing as it is - is probably the most important variable in the whole equation. Best,
Phil