Was the prostate cancer not as serious as originally reported?

Michael Milken's Prostate Cancer Severity: An Evidence-Based Assessment

Based on the available medical evidence, it appears that many prostate cancers, including potentially Michael Milken's case, are less serious than initially reported, as the vast majority of prostate cancer is slow-growing and does not cause death. 1

Understanding Prostate Cancer Risk Stratification

• Prostate cancer is the most common nonskin cancer in men in the US, but despite its high incidence, the mortality rate is relatively low 2
• Approximately 75% of patients present with cancer localized to the prostate, which is associated with a 5-year survival rate of nearly 100% 2
• Risk stratification incorporates life expectancy, tumor grade (Gleason score), tumor size, and PSA level to determine appropriate treatment approaches 2

Natural History of Untreated Prostate Cancer

• In a long-term cohort study with 10-year follow-up of untreated early-stage prostate cancer, only 8.5% of patients died from prostate cancer, while 85% died from other causes 3
• The 10-year disease-specific survival rate for untreated early prostate cancer was 86.8%, even in patients who would have met criteria for radical prostatectomy 3
• Another study of untreated prostate cancer patients found disease-specific 10-year survival was 89% in the organ-confined disease group 4

Overdiagnosis and Overtreatment Concerns

• The PSA test often does not distinguish between serious cancer and non-serious cancer, leading to potential overdiagnosis 1
• In patients treated from 2000 to 2002, the rate of overtreatment (treatment in low-risk patients) was estimated to be about 55% 1
• Despite the low mortality risk for many prostate cancers, about 94% of patients with localized prostate cancer choose treatment 1

Treatment Decision-Making

• Clinical guidelines recommend that treatment decisions be based on cancer stage and grade, PSA level, and comorbidity-adjusted life expectancy 1
• Active surveillance is a reasonable option for low-risk and very low-risk patients 1
• Radical prostatectomy or external beam radiation therapy is recommended for higher-risk patients 1

Treatment Side Effects

• Treatment is associated with significant side effects, including:
  • Urinary incontinence (11% increased risk with radical prostatectomy) 1
  • Erectile dysfunction (37% increased risk with radical prostatectomy) 1
  • Bowel dysfunction 1
• These side effects must be weighed against the potential benefits, especially in low-risk disease 1

Shared Decision-Making

• Given the potential for overtreatment and treatment-related side effects, shared decision-making is crucial 1, 5
• Patients should be informed that the vast majority of prostate cancer is slow-growing and does not cause death 1
• The small potential benefit of prostate cancer intervention must be weighed against the significant potential harms 1

Implications for High-Profile Cases

• High-profile cases of prostate cancer, such as Michael Milken's, may receive aggressive treatment despite potentially having low-risk disease 1
• The perception of prostate cancer severity is often influenced by the dramatic nature of the diagnosis rather than the actual risk of mortality 1
• Without specific clinical details about Milken's case (Gleason score, PSA level, tumor stage), it's impossible to definitively assess his individual risk, but population-level data suggests many prostate cancers are less serious than initially perceived 1, 3