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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 couldn’t agree more - well said.
FWIW, I am not aware that PC tends to *cause* low testosterone but there is apparently a view that sometimes low testosterone *accompanies* some more aggressive PC, the opposite of the usual expectations. I suppose if a hungry cancer is "eating" all your testosterone that could be causal ... but I do not know that you can find that (yet) in the standard guidelines.
Biological systems tend to have extreme complexities and a huge spectrum of possible scenarios. Our science has advanced tremendously over the past 75 years or so - only to find the more we know, the more questions we have.
I've recently had some experience with these kinds of cases, tools, and ambiguities on a totally different topic, dental procedures. SMH. There too procedures have advanced tremendously in just the past twenty years but there is room for plenty more!
@carbcounter
\\ I am not aware that PC tends to *cause* low testosterone but there is apparently a view that sometimes low testosterone *accompanies* some more aggressive PC, the opposite of the usual expectations. I suppose if a hungry cancer is "eating" all your testosterone that could be causal ... but I do not know that you can find that (yet) in the standard guidelines.
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This is a very interesting thought: "Does a tumor consume testosterone, causing it to drop?"
I read that cancer cells themselves (separately) produce testosterone, and if this is true, then an increase in testosterone levels indicates the activity of these cells, while a decrease in testosterone indicates the opposite—there are fewer of these cells, they are inactive, and they have disappeared. Is my logical reasoning incorrect?
Note that everything revolves around testosterone, but I think the issue is much more complex. There are cases where, even with low testosterone levels, PSA still rises, and vice versa, even with average testosterone levels, PSA falls. The relationship between testosterone and PSA is nonlinear and is possibly described by a very complex differential equation. This suggests that there's more to life than just testosterone, in other words, other factors (other hormones, body characteristics, blood characteristics, immune system characteristics, various nutrients consumed with food, various environmental factors, and much more).
What if I have a benign adenoma along with my cancer, which leads to a slight increase in testosterone?
Many people talk about the dangers of alcohol, so why do so many oncologists know that red wine before meals can be beneficial for those with cancer? I've heard real stories of people who lived far from cities, in nature, drinking wine, breathing fresh air, and their results were much better.
Great topic, the author is simply brilliant!
I studied mathematics and I think cancer is complicated precisely because the body is a complex system with many variables. Taking them all into account isn't enough; you need to understand their dynamics, how they interact, and the cause-and-effect relationships. And even that may not be enough.
The strategy is to take into account the maximum number of available factors and analyze statistics taking into account probability theory, but the situation is sometimes such that they are trying to make money off of us.
@denis76 per Google there are some rare cancers that are known to produce mass quantities of testosterone, but I don't see anything to say there is anything more general than that.
I did find this:
https://corporate.dukehealth.org/news/study-solves-testosterones-paradoxical-effects-prostate-cancer.
... which if I read it correctly, suggests that the problems may be caused in the first place by low testosterone, making it sound like ADT is exactly the wrong thing to do. Is this possible? Is it likely? Is it true in selected cases? I guess research continues.
@carbcounter interesting-thanks!
@hanscasteels
We are from Canada. Husband diagnosed in April last year. Everything you said has been our experience too.
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I'm shocked and completely baffled. Thank you for the article. Is there a scientific basis for it, not just general statements?
All our doctors unanimously say that survival prognosis depends on testosterone. The lower your testosterone levels, the longer you'll live; the higher your testosterone levels, the shorter your life expectancy. This is all included in all standards and all clinical guidelines, and everyone is treated the same (reducing testosterone levels as much as possible).
The article says the opposite: that in advanced stages, we should aim not to lower, but rather to increase testosterone levels! By the way, my doctor mentioned cases where PSA levels still rise even with low testosterone, but for most people, PSA doesn't rise even with low testosterone. What about statistics?
My PSA just dropped to 0, and resistance hasn't developed yet. I have Gleason 9, so the risk is high. I may not live to see a revision of this treatment paradigm for those in advanced stages, and I'll simply be sent to my grave. It turns out that sometimes you have to go all in and go against the doctors' wishes, but how can you go against what's written in the consultation documents? Going by trial and error? It's very risky!
I used to think about taking three Erleada tablets instead of four and getting ADT injections every three months instead of every month, but the doctors said that would open the floodgates for cancer and kill me.
I'm certainly not a doctor, but I think the transition to a phase of cancer resistance will kill me, and the possible solution to their situation is "like a seesaw, avoid cancer resistance at all costs."
One scenario is when billions of cells are sensitive to ADT, and the second scenario is when billions of cells are insensitive to ADT. Maybe this is the key principle of survival strategy. Sometimes I think that the manufacturers of expensive drugs favor the second option because they are essentially on the side of We're making a profit, and if we reverse the treatment strategy (which doesn't actually require expensive treatment, but just simple testosterone injections), it will impact the pharmaceutical industry's stakeholders.
I want to live. But I don't want the fight for life to be like a lottery just because someone wants to make money! Maybe I'm wrong.
@denis76
I only started looking at PC in detail a few weeks ago on behalf of a friend who is going through this, and I had some troubles with the stories he told me about treatment, and I wanted to understand better. But I've been through this kind of research before on my own behalf for several other conditions. The "truth" is always complex and changing.
In every area I've looked the science, treatments, and results are much better now than fifty years ago. However in none of them has anyone found a "magic bullet" that is a quick and painless cure for everyone.
As far as PC and ADT and testosterone, it's clear from reading on this message board that there is a wide spectrum of medical scenarios. It is an easy and almost certain idea that science, treatments, and results will continue to evolve over the next fifty years involving new examination techniques, probably gene-based treatment selection, genes from you and genes from your cancer, perhaps new medicines that can better target the cancer itself, perhaps real cures for at least some cases. However that's in some future universe. What you have to do today is go with the best practices, keep an eye on things to minimize mistakes, and be glad it's not fifty years earlier.
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