A hand places a letter sealed with a heart into an open ended mailbox, while another hand reaches into the back to take it.

With Love to Brett, My Unfortunate Son

Last updated: December 2022

Creedence Clearwater Revival recorded the hit “Fortunate Son” in the late 1960s. It is a Vietnam protest song, lamenting how some “fortunate” men could avoid military service altogether, while others less fortunate were forced to serve. Brett, you are my unfortunate son. You could be forced to serve in the prostate cancer battle, already experienced by your grandfather and me. I pray that never happens, but if so, knowledge is power.

Hopefully I can help empower you to break the family streak. But if you end up joining us, my wish is that your battle begins from a position of the greatest possible strength.

Prepare for the possibility

When I was 27 as you are today, prostate cancer (PC) was the last thing on my mind. It would still be 3+ years until your grandfather would be diagnosed, and with a healthy lifestyle, I thought I had nothing to worry about! But armed with knowledge, you won’t make that mistake.

The National Cancer Institute notes that the inherited risk of PC is as high as 60%. The CDC defines increased risk to be if "you have more than one first-degree relative (father, son, or brother) who had PC, including relatives in three generations on your mother’s or father’s side of the family."1,2

You’ve been dealt bad cards, but let’s play them as strongly as possible. Ask yourself, “if I ever get diagnosed, what would be ideal?” Hopefully you answer can be, "I caught it early, it is slow-growing, and it hasn’t spread. I can therefore leverage the latest treatments." Let’s chart that course. Today.

Genetic testing

Start by better understanding your genetics. In addition to PC, breast cancer is on your mother’s side. Those can be related, so delve into that. Start at “23 and me” or “Ancestry,” and the raw data from those tests can be used at other sites for more detailed reports. Check with your doctor about other tests, or even consult a geneticist. Find out what you can from your mother about her side of the family. Anything you learn can be addressed now, or lifestyle changes can be made.

Vasectomy

A 2020 study that looked at vasectomies suggested that "vasectomy is associated with a statistically significantly increased long-term risk of prostate cancer." Though the "absolute risk" following vasectomy is small (and the findings on this topic vary), I had a vasectomy at age 38. And 19 years later, my cancer was confirmed. Please keep this in mind if you ever consider a vasectomy.3

Testosterone treatments

When I was playing softball regularly, I often played with guys who supplemented their low T with injections. Invariably, it made them feel like new men! But PC feeds on testosterone. Though it might be enticing, please carefully weigh the pros and cons before undergoing testosterone therapy.

PSA testing

Please start getting PSA tests at age 40, if not earlier. The PSA test was critical to my diagnosis (see my article, “The Critical Role of The PSA Test”). Research last updated in 2022, as of my writing this, recommends PSA screenings for men with good general health from age 45 to 75, and further states, “it is reasonable to encourage even earlier screenings (at ages 40 to 45) in high-risk individuals."4

Please get annual physicals, and add the PSA to your bloodwork by age 40. If the doctor does not want to add it, find an online lab and order it yourself. Keep your results in a spreadsheet so that you can amass your PSA trajectory. My PSA trajectory was the only indicator I had of cancer.

Don’t fall into the PSA 4.0 trap

It is still commonly accepted that a PSA under 4.0 means that you are probably OK. That was not true for me: I never had a PSA greater than 4.0 when my cancer was active. Some research has suggested more specific age-specific PSA ranges, and that from age 40-49, it's good to note any result greater that 2.5. Understand too, that as you age, the ranges change.4

Thoughts on the DRE

Additionally, the screening process often involves the digital rectal examination (DRE). For me, the DRE never revealed any anomalies, nor did it contribute to my diagnosis.

The research I cited that was last updated in 2022 notes that "digital rectal examinations alone ... have a sensitivity and specificity of less than 60%, most likely due to inexperience and insufficient training, which is why DRE is not recommended to screen for prostate cancer without PSA testing." Please get your PSA tested regularly, and discuss with your doctor whether the DRE is even necessary.

Technological advancements

Advancements in prostate cancer treatment occur regularly. Please make an effort to stay abreast of such developments, and I will pass on anything that I find interesting. You can’t leverage the latest advancements if you don’t know what they are. Don’t rely on someone to tell you about the latest developments, for a variety of reasons, that won’t happen. As a high-risk patient, this is now your responsibility.

Brett, I am very sorry you are my unfortunate son. But there are many things you can do now to help break the family prostate cancer streak. One of the big keys is to gather data. Data turns into information, information drives knowledge, and knowledge is power. Another big key is regular early PSA testing, begun by age 40, if not before. Do these things as a regular part of your life now, and hopefully prostate cancer will not be part of your life later. I send my love.

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