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Treatment Dogma - Aggressive is not the same as intelligent
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.
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I hope 2nd guessing after treatment doesn’t live in my mind. My hub’s case is not typical (lung only Mets with low PSA 0.36, low mtb, low ctDNA with Gleason 7=4+3). About to slide down into very aggressive combined treatment recommendations to go for the kill of the parasite, not the host! A wee bit scared it’s too much but we will never really know about any path, right? I just don’t want to look back and think we shouldn’t have….. argh. No matter how smart we can get about it, there is the unknown in each decision. If we choose a less aggressive route and that fails, then we wonder what if we had?…..
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2 ReactionsRules I've developed over the years, 11+ now:
Once I make an informed decision and carried it out, I never look back. Well, that is not entirely true, I look for lessons learned from that decision. The path is always forward: I continue to learn about PCa and always look ahead. What counts is today and what lies in the future.
Yesterday is gone, so forget it, well, learn from it.
I educate myself as completely as possible and took the time I needed, I always know that no matter the outcome of a particular choice, I made the best possible decision. That knowledge that I have thought my decisions through carefully is what is really important—and may be more important than the decision itself.
I am in charge. Not my doctor. They need to be consulted and their opinions and ideas should carry weight as I make my decisions. But I never forget: it is my life, my today, and my future. I have made the best possible, fully educated decisions that makes sense for me, with the focus on long life.
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5 ReactionsUnfortunately, you can never know if your decision was the ‘right one’. My first RO told me there IS NO right one - ever!
And it’s impossible NOT to second guess everything you do. As Kevin points out, these should be shared decisions between you and your doctors. Their job is to explain the condition, their ideas for how to treat that condition and finally, to explain in terms you can understand, the whys and hows.
After that, you make your best decision ( a guess really) and go with it. If you do this stepwise and logically you’ll have no regrets.
Phil
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3 ReactionsI trust a decision far more when it's forged in the heat of real dialogue—where disagreement isn’t treated as insubordination and questions aren’t met with the intellectual equivalent of a tranquilizer dart. There’s something deeply suspect about decisions handed down from on high, cloaked in dogma, and enforced with the subtle menace of “discussion closed.” That’s not reasoned leadership; that’s authoritarian cosplay. If a decision can’t survive being questioned, it was never robust to begin with. And if I’m told to shut up and comply, don’t expect me to believe—only to obey. And that, frankly, is the surest way to breed quiet contempt.
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1 ReactionGeez, who the f*** is treating you, Joseph Stalin’s grandson? You need a new team, Hans…
Phil
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1 ReactionSo sorry : (, did not want to scare you Phil and I am almost sure that in your case it is just a "wrong blip" on a radar ! Yes, bones can have some uptake specially when there is some old scar tissue or inflammation present. And it is just as you said easily zapped out - just local R to that spot and it will be gone. But I am sure it is nothing. I was reading about SUV uptake just this morning. It says if is below 2 or around it is most probably benign. I just wanted to suggest that if it is making you nervous to perhaps ask for one more pair of eyes to look at it.
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1 ReactionNo, don’t worry about scaring me. The old me would have been all over that blip, almost hysterically; but now it’s more like “OK, whatever….” because PCa throws a lot of curveballs and you strike out a LOT when you think you know what’s coming at you.
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1 ReactionI had my 1st PSA test 25 years ago, was diagnosed with PCa 13 years ago, had proton radiation treatments 4 years ago, and now am monitoring my PSA (which varies between 0.35-0.55).
Instead of the term “aggressively,” my observation and experience is that PCa should be treated “appropriately.”
“Aggressive” treatment may in fact be overkill, depending on the circumstances. (To paraphrase from Shakespeare’s Henry IV, Part One, "Caution is preferable to rash bravery.”)
As a retired computer scientist, I’m accustomed to taking measured, calculated approaches to problem solving. For me, solving this prostate cancer issue was no different. After thoroughly evaluating all options, my protocol was SpaceOAR Vue, six months (two 3-month injections) of Eligard, and 28 sessions of proton beam radiation. This protocol was “appropriate” for my diagnosis.
It may very well be that “Aggressive is not the same as intelligent.” However, “appropriately” is certainly always the same as “intelligently.”
Yes, a PSA of 1.0 is almost always unremarkable, and warrants 6-month monitoring. Since (in normal circumstances) PSA levels are tied to testosterone levels, and it’s known that testosterone levels have a diurnal variation (testosterone fluctuates throughout the day, with higher levels in the morning and lower levels in the afternoon) PSA levels may fluctuate diurnally as well.
Another characteristic of my computer science background is that I try not to overthink things; I follow the numbers. I often use the concept of Occam’s Razor (basically, don’t over-complicate things).
Following the PSA, monitoring PSA doubling time, if it continues to rise, monitoring PSA Density, and if still concerned having a liquid biopsy may be warranted. MRI results and 2nd opinions on any test/scan requiring an interpretation. Much can be observed and diagnosed before jumping to a conclusion.
“So we hit it with everything we had.” The question always to be asked prior to treatment is “Is the treatment “appropriate” given the diagnosis?” Is a sledgehammer necessary? Or will a ballpeen hammer get the job done?
When a PSMA PET scan shows uptake in just a few areas, that’s considered oligometastatic - yes to all: clinical certainty, definitive, suggestive,…..and problematic. There are “appropriate” treatments for oligometastatic PCa. (Another important consideration is the PET scan result prior to the treatment decision.) That helps determine “appropriateness” of treatment.
Yes, always formulate a strategy before deploying firepower. (Just like in the military.) That’s where medical self-advocacy and shared decision-making enter the picture.
Personalized diagnostics are already available - genomic, genetic, liquid biopsies, PSMA PET, non-PSMA PET, immunological tests, and more - leading to strategic, data-driven, individualized care.
We just have to ask for them.
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8 ReactionsThis is a valuable discussion.It is difficult to make optimum decisions under stress. As pointed out, researching and understanding all the opportunities for testing that will provide the maximum number of datapoints in existential decision making is a minimum. Second opinions by centers of excellence should be availed of. If there is significant divergence of treatment plan get a third opinion , after all one would typically get 3 quotes for a house remodel. Even if the first quote looks excellent and is ultimately chosen the other two quotes can often throw out extra details which lead to modification of the specified work.
My mother was scared of our childhood doctor so medical care did not figure largely in my childhood. I have always been sceptical and challenging about medical pronouncements. Consequently upon my diagnosis of very aggressive prostate cancer ( Gleason 9 and Decipher 0.99) I became a prostate cancer researcher taking deep dives into the available research. Rightly or wrongly I feel this has helped me assess the value of some treatment options or at least put them in a benefit/risk context. Ironically, even though I am communicating this in a forum , forums can be less than objective , where individuals have a vested interest in the treatment decisions they have made.
Looking back on my journey, I would have appreciated a blueprint or decision tree which would have guided me as to the different tests to request at the optimum time on the various possible routes.
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