Book Reviews

"A fascinating journey through the complexities of US healthcare, insurance, and prostate cancer. Where screening is discouraged and treatment options all come with unacceptable side effects. Well researched, but easy to read. As a survivor and physician, I could appreciate both sides of Murray's dilemma." --James Thomson, M.D.

"The diagnosis of prostate cancer is a frightening one. Even as a health care provider, it is difficult to keep up with the ever-changing research and recommendations for diagnosis and management of this all too common disease. Prostate Cancer: Sheep or Wolf? does a fabulous job of discussing both the mainstream and the cutting-edge options, and will be immensely helpful to many men as they investigate the alternatives." --Michael J. Hilts, M.D.

"Today, buffeted by hard marketing, hype and misleading guidance, a diagnosis of prostate cancer is one of toughest life events many men will face. Neither promoting or demonising any particular approach, this thoroughly-researched and referenced book will be a valuable resource for men, whether they are at the point of considering screening or have already received a diagnosis of prostate cancer. However, Wadsworth's engaging narrative style and use of charming illustrations makes it a delight to read." --Dr Carole Wyatt, MBBCh (UK)

"Mr. Wadsworth has written a very personal account of his ongoing battle with Prostate cancer. Although not a treatise on treatment of Prostate cancer it does contain and demonstrate several actions that I, as a Physician treating various cancers, feel are important to all patients.

First - Patients must be involved in their care decisions. Although there are Cancer treatment guidelines (such as, cancer treatment is not "one size fits all"! Mr. Wadsworth demonstrates this very well.

Second - Physical fitness and physical activity are important aspects of treatment. Fitness will allow better tolerance of treatment. Maintaining focus on overall health and not on the cancer will improve one's mental outlook. Again, this is well demonstrated by Mr. Wadsworth.

Third - Occupy your mind with something besides the cancer. This is demonstrated by selecting RV options, planning travels, and restoring an old boat.

Again, all cancers and all cancer patients are unique but this book does provide examples of how to accept and deal with a cancer diagnosis sadly common to many men." --Jack Walzel, M.D.
"This is not only a very informative book, but is also exceptionally easy to read - I completed it in one sitting. The author refers to low-risk cancers as 'sheep' and high-risk cancers as 'wolves'. These analogies not only reflect the tameness, or otherwise, of those animals, but the degree to which one (the sheep) remains in the enclosure (the prostate gland) whilst the other (the wolf) is able to roam beyond this confine.

The book highlights the importance of multidisciplinary meetings, which are obligatory in cancer management in the NHS. This allows a second review not only of the histopathology, but also a second interpretation of the multiparametric MRI (mpMRI). If the histopathology suggests a lower grade tumour than does the MRI, repeat targeted biopsies are required.

The patient's wishes are also represented by the Clinical Nurse Specialist so that a management plan can be formulated with the surgeon and oncologist that will be acceptable to the patient.

Blind biopsies are no longer performed (without prior mpMRI) in men under the age of 70, unless the PSA level is so high as to indicate metastatic disease, often confirmed by a radionuclide bone scan, the initial imaging modality in such unfortunate cases. Even men over the age of 70 with lower PSAs are increasingly being offered an initial MRI prior to biopsy.

Another point that is worth noting is that active surveillance(AS) does not simply refer to serial PSAs. AS also involves repeat mpMRIs +/-repeat biopsies at 12-18 month intervals.

The author has illustrated the minefield that is the management of intermediate risk prostate cancer. The degree of risk that an individual's cancer poses is a crucial assessment for determining the level of morbidity (incontinence/impotence) that that individual should be prepared to accept. Ina young patient this becomes more acutely focussed and is a major dilemma for the patient but also a major headache for the healthcare professionals charged with recommending the most appropriate management.

In conclusion, this book is a must-read for those worried about their PSA result and for those who have recently been diagnosed with prostate cancer." --Dr Eryl A Thomas, MRCP, FRCR Consultant radiologist (retired) James Paget University Hospitals NHS Foundation Trust, England

Sheep or Wolf

There are many confusing realities with prostate cancer.

A man facing unfavorable screening results may in fact not have cancer, as Andrew came to find out. At the opposite extreme a man’s cancer may have been undetected until it was too late, so only palliative care was warranted, as Joe faced. Or the cancer may not warrant treatment for a variety of reasons, such as apparent low risk, so medically supervised monitoring is the strategy, as for Peter. On the other hand, the cancer threat may warrant treatment, despite the reality of serious and permanent side effects. But as for George, who now wears man diapers for his incontinence, he did not know how serious his cancer threat was. He just knew he had prostate cancer and was afraid of it.
To simplify the process and to understand my cancer’s aggressiveness, I sought to answer the question—was my cancer a sheep or a wolf? As many prostate cancers are known to spread slowly, recognizing it as a sheep would mean that it was slower moving and not that aggressive. Depending on one’s age and overall health, with a “sheep” cancer, one may never experience symptoms, may never need treatment and may well die from something else.
To understand local cancer and metastasis better, I thought of my prostate gland as “the barn,” the area surrounding the gland as the “barnyard,” and the blood vessels outside of the barnyard and the lymphatic system as the “highway” to metastasis, incurable disease. Using that analogy made it easier for me to comprehend the diagnostic and treatment challenges I faced.
If the sheep were in the barn, time would be on my side. Time to research and consider various treatment methods, giving me a very good chance for a cure. If the sheep were already in the barnyard, I would have less time to consider treatment options, but still a good chance for a cure. If the sheep were out on the highway, there would be no cure.
If I had a wolf, no matter the location, I would need to make my decisions very quickly. If still in the barn, it seemed reasonable a cure was possible. If the wolf was in the barnyard, maybe a cure was possible. But if the wolf was out on the highway, as with a sheep, there would be no cure, and life expectancy might have been precariously short.
Although it may seem to be a simple concept and question as to if one has a sheep or a wolf cancer, it took me nearly a year to reach my conclusions and to make my decision for treatment.