The Case for Prostate Cancer Diagnostics & Treatments
Written By: Cassie Whyte
A few days ago, I had the pleasure of speaking with prominent Urologist, prostate cancer expert, and men’s health advocate, Dr. E David Crawford. Throughout his decades of experience, Dr. Crawford has dedicated himself to improving prostate cancer diagnostics and treatment, as well as educating students and the public alike about men’s health and its intersection with urology. As the third leading cause of death in men, prostate cancer remains relatively understudied and disregarded by health advocates. But Dr. Crawford maintains a positive attitude:
We’ve got to get away from the way we’ve been burying our heads in the sand with prostate cancer. It’s not that hard, really. Prostate cancer is the most common cancer in men, second leading cause of death. If we find it early, we can treat it, cure it, or control it…it’s pretty simple.
Having been devoted to the field of urology for the vast majority of his professional life, Dr. Crawford has been present for every stage of development, evolution, and regression, in terms of treating and containing advanced prostate cancer. He explains how prostate health awareness had a proclivity to lag behind other anticancer campaigns:
“It goes back many decades, dealing with so many patients who walked into my clinic with advanced, incurable prostate cancer. A couple of friends too.”
The nonprofit and advocacy realm regarding breast cancer, for instance, had been thoroughly solidified as a benevolent, preventative force by the 1970s. Dr. Crawford continues,
“There was a lot of interest among women and discussions about breast cancer, and we were way behind that. We didn’t see that. And that was very successful, the whole movement about early detection of breast cancer. We were really dragging.”
Luckily, a small group of illustrious healthcare professionals, such as Dr. Crawford, helped prostate cancer awareness catch some steam in popular discourse by collaborating with and incorporating public figures in the discussion. Dr. Crawford retells,
“There are a couple of well known men who got prostate cancer a couple of decades ago. I had the chance to work with a couple of them, General Norman Swartzcoff, General Powell…Bob Dole…and that generated a lot of interest too.”
Encouraging politicians, athletes, and celebrities to act as frontier educators is always a great way to animate the public; it also has an overwhelming effect on normalization and destigmatization, particularly regarding health issues that are otherwise perceived as embarrassing or marginalized. Prostate cancer, especially previous to the ubiquity and triumph of the Prostate-Specific Antigen test (PSA), is very much so one of those issues. The intrusiveness of the classic prostate exam proved a difficult obstacle for both professionals and patients to overcome:
“The way to diagnose prostate cancer back then…we didn’t have any mammograms. The only thing you’d do was a rectal exam. The acceptance of that was not terrific, as you can imagine.”
The introduction of the PSA was a transformative endeavor. Dr. Crawford remembers when the PSA was first approved, declaring that,
“The rectal exam, even when you felt something, it was usually more advanced…but then a sort of miraculous thing occurred: this blood test, PSA, came out. That was the game changer.”
Not only is the PSA less intrusive and thus less intimidating, but it is consistently more effective and advantageous. PSA is a protein produced by tissue in the prostate which can be either cancerous or noncancerous. The test measures the amount of this protein and detects abnormally high levels, subsequently indicating that a man may potentially have prostate cancer. An enlarged prostate and other related conditions can also increase PSA levels, but the test is a uniquely efficient means of eliminating those who are at very low risk. Dr. Crawford refers to this process as…
“Throwing out a large net, and catching the big fish.”
But the success of the increasing prevalence of PSA did not come without its own detriment. Due to the rapid and widespread implementation of PSA usage, coupled with an eagerness to learn more about prostate cancer,
“A lot of over-diagnosis and over-treatment occurred,”
says Dr. Crawford. He proclaims that this…
“Led to a number of organizations, and rightfully so, saying ‘Hey, we gotta put the brakes on this, we gotta stop the screening, because we’re doing more harm than good.’”
While PSA was revolutionary in detecting prostate cancer, it required a complementary tool that would distinguish which cancers necessitated treatment. Prostate cancer is unique in that it is somewhat inevitable in aging men:
“If you ripped prostates out of a hundred 90 year old men off the street, you’ll find 80% of them have prostate cancer.” And even more shocking is the fact that, “They don’t know about it, and they never will.” Because of this peculiar disposition, primary care physicians and urologists alike must be equipped with not only PSAs, but molecular markers, which help to isolate life-threatening cases of prostate cancer from less risky manifestations, or, as Dr. Crawford calls them, “toothless lions.”
After a steady pattern of over-diagnosis and over-treatment of prostate cancer, and the resulting pressure from organizations and stakeholders to minimize usage of the PSA screening. As Dr. Crawford articulates,
“We were over-treating people, and they were having side effects, and they didn’t need the treatment…we got together and said, we’re harming most people, let’s not do it. Then that blew up in everybody’s face, because prostate cancer, the advanced disease, it has started creeping back in and becoming very common again.”
Prevention and treatment of prostate cancer is, ultimately, a balancing act. Medical professionals and researchers must walk a very delicate line and avoid over-correction on either side. Luckily, Dr. Crawford maintains that there is a pathway to do so: PSA screening, molecular markers.
“It’s not that difficult, but we make it difficult,” he says.
Dr. Crawford also emphasizes the fundamental importance of taking personal preventative measures, such as prioritizing nutrition, fitness, and moderation. Moreover, men specifically have a detrimental tendency to disregard recommended health practices; they regularly skip annual checkups and fail to follow up with their primary care physicians, even when issues present.
Dr. Crawford recalls a comical, but incisive anecdote:
“I’ll tell you a story of a guy who came to see me a couple years ago. I said to him ‘Yes sir, why are you here?’ and he says ‘I don’t know.’ I say ‘What’s the problem’ and he says ‘Nothing.’ …I said ‘Who told you to come here?’ He says, ‘My wife!’ I said ‘Oh yeah, why did your wife send you here?’ He says, ‘She sent me to see you cause I get up to urinate 6 times a night. It doesn’t bother me, it bothers her!’ There’s something to be said about that.”
Men are socialized to pull themselves up by their bootstraps. Even concerning subjects as potentially fatal as their own well-being, seeking health care is sometimes framed or perceived as weakness. “Men tend to be somewhat stoic and say, ‘Oh nothings gonna harm me,’” says Dr. Crawford. But that conception is terribly misguided. And that very faulty reasoning is, perhaps, upstream of men’s falling behind in critical health metrics, such as the astonishingly disparate lifespan gender gap.
Throughout my conversation with Dr. Crawford, he was insistent on highlighting one question in particular: “How do you motivate people?” In other words, how do we, as medical professionals and advocates alike, consistently and persistently encourage people to proactively pursue their own health?
“Most people know you shouldn’t smoke, you shouldn’t drink too much, you should exercise…it’s hard to find anybody that argues with most of that, any of that. Except, we don’t do it,” he says.
Approaching one’s own health, as a comprehensive constellation of environmental factors and biological predisposition, can be extraordinarily intimidating. But knowing the facts regarding one’s family history, genetic risk factors, and psychological disposition provides a great infrastructure. As for health professionals and advocates, it can sometimes feel like a frustrating and impossible project; it all comes down to that aforementioned question: how do you motivate people?
Dr. Crawford provides a working answer:
“Well, everybody’s buttons are different. That’s where the art of medicine comes in, what turns some people on and what doesn’t. That’s where we need a team approach. For some people it’s their apple watch. For some people it’s, ‘Hey, if you don’t change your lifestyle, you’re not gonna live 10 years.’ It’s variable.”
This may seem like a pessimistic takeaway on the surface, but really, it is not. Health is less of a singular metric as it is a perpetual process of self-improvement, personal initiative, and medicinal intervention when necessary or beneficial. The good news is: we are all, at least to some extent, masters of our own well-being.
As for his closing advice, Dr. Crawford offers…