Al Roker’s Forecast: Rising PSA, Radical Prostatectomy On Horizon

By Howard Wolinsky and Mark Lichty

We were stunned on November 6 when beloved NBC weatherman Al Roker revealed on the Today Show that he had been diagnosed with prostate cancer and would be undergoing surgery in a few weeks. Our hearts go out to him and his family,

“It’s a good-news, bad-news kind of thing,” Roker, 66, explained on-air. “The good news is, we caught it early. The not-great news is that it’s a little aggressive. So I’m taking some time off to take care of this.”

We know when such news is reported that the public will seek help in large numbers. In this case, many men, especially Black men, will be undergoing PSA (prostate-specific antigen) tests to see if they have signs of prostate cancer. You don’t have to be a weatherman to know that many men likely will be diagnosed with prostate cancer. We want to be sure they know that radical surgery isn’t their only choice.

As men with 25 years of experience with Active Surveillance of prostate cancer between us, we considered the information Roker offered on-air and had some questions:

— Did Roker have a second opinion on the diagnosis? He gave no indication he did. But everyone who gets this diagnosis is wise to get a second or even a third opinion to be sure they are satisfied with the diagnosis. Mistakes can be made that result in overdiagnosis and overtreatment,

— No rush. Roker said he plans to undergo surgery in a couple of weeks and get it over. This is slow-growing cancer. You can take your time, get your bearings, and make sure you are making the best choice.

— Just how aggressive? Roker said the cancer was “a little aggressive.” What does that mean?

We wondered what his Gleason score was. The Gleason score is the grade pathologists give to these cancers. The range is from 3+3=6 for low risk, 3+4=7 for “favorable” intermediate-risk, 4+3+7 for “unfavorable” intermediate risk, and 4+4 on up for the most aggressive cancers.

We asked Roker on his Facebook page for his Gleason score. We are waiting for an answer.

Our educated guess is that he is either a 3+4 or a 4+3.

If he were a 4+3, doctors likely would urge him to remove the gland. Roker said he did consider but rejected focal therapy to remove the gland partially and radiation.

— Genomic and genetic testing? These tests can be used to help determine how aggressive a cancer is. We don’t know if Roker underwent this testing. We expect Roker did.

— Did he consider active surveillance? We don’t know if Roker was a candidate for active surveillance. He was scheduled. for surgery at Memorial Sloan Kettering Cancer Center in New York. Memorial has an active surveillance program so Roker likely was offered this option if he was a candidate.

Dr. Vincent Laudone, Roker’s surgeon, said the weatherman’s cancer “appears somewhat limited or confined to the prostate” but given that it’s aggressive, the decision was made to remove the prostate. Roker was home on November 12 after undergoing the radical surgery.

These days, most men with low-risk prostate cancer, like us, and some with favorable intermediate-risk prostate cancer opt for active surveillance rather than a radical prostatectomy. Until a few years ago, radicals were the most common choice. They often caused side effects such as urinary incontinence and impotence. We know men who are angry and depressed because they saw the best surgeon they could find and ended up in diapers and with no libido because of surgical damage.

Protocols vary. But AS involves regular testing of levels of prostate-specific antigen to determine if the cancer is becoming more aggressive, mpMRI scans, digital rectal exams, and other tests.

— What about diet and exercise? These factors play an important role in an AS program.

Roker’s case is complicated by his African ancestry.

It is well established that Black men in the United States, Canada, and the Caribbean of West African descent are diagnosed more often and die at higher rates from prostate cancer than their white counterparts.

Hence, some of these men and their doctors have believed that Black men are not candidates for active surveillance. So Black men didn’t get a chance to follow a less invasive path.

Three days before Roker’s news came out, a study appeared in the Journal of the American Medical Association that refuted these views on low-risk Black men and active surveillance.

“It was once thought that active surveillance was not safe for Black men because of a perception that prostate cancer was inherently more aggressive in this population, which led to unnecessary treatments and side effects, such as urinary incontinence, erectile dysfunction and bowel problems for Black men,” Brent S. Rose, MD, assistant professor of radiation oncology at University of California, San Diego, told Healio. “However, our study showed that Black men who underwent active surveillance instead of immediate treatment were not more likely to have their cancer spread or to die of the disease.”

Again, we don’t know if Roker could have qualified for active surveillance. Clearly, many other Black men do but are discouraged from following this path.

Al Roker is a popular figure in America. Many men will follow his lead. In England, the National Health Service was flooded recently with requests for screening after two celebrities there went public with their prostate cancer stories.

Our hope is that men will weigh all options, including AS.

There have been few (we know of only two) celebrities who have opted for active surveillance and talked about it. Many have opted for radical prostatectomies — probably more than needed to.

AS needs a “poster child.”

Maybe someday, another celebrity will follow the AS path and let the world know so they can help other men from being damaged needlessly at the hands of prostate surgeons.

Fair skies lie ahead for men of all races who choose AS if diagnosed with low- or favorable intermediate-risk prostate cancer if they choose active surveillance.

Clip (above) from the New York Times article about Roker points to another article about AS and Wolinsky: “Before Prostate, Surgery, Consider Active Surveillance: https://www.nytimes.com/2020/03/02/well/live/before-prostate-surgery-consider-active-surveillance.html

Mark Lichty and Howard Wolinsky are co-founders of Active Surveillance Patients International (aspatients.org). Lichty is chairman of the organization. Wolinsky is a moderator of the Active Surveillance Virtual Support Group from AnCan (ancan.org) and Us Too International (ustoo.org). Contact Wolinsky at howard.wolinsky@gmail.com

This commentary represents the personal views of the authors