December is a festive time of year and I’d like to have a little fun by sharing with you a short one-act play about prostate cancer starring (as herself) Melinda Beck of the Wall Street Journal. Ms. Beck, the Health Journal columnist for the WSJ, does not know me—we’ve never spoken, never met. I know nothing about her other than what she has written in her column, and unless she reads The After Proton Blog she probably knows even less about me. So why cast her in this role?
I regularly search the web for information about prostate cancer and proton therapy, and her articles are often near the top of the list—above the fold, as they say. I can’t help noticing her consistently negative bias concerning proton. Either intentionally or unwittingly, she is hurting many who could benefit from the most advanced radiation therapy technique available—one that has helped me and many readers of this blog. For Beck, it’s just a topic for another article. It’s not personal.
My play starring Ms. Beck—I’ll take the liberty of calling her Mel—will be personal. I’ll assume she has a husband …
My play starring Ms. Beck—I’ll take the liberty of calling her Mel—will be personal. I’ll assume she has a husband whom I’ll call Mike because I know a disproportionate number of men named Mike who have had prostate cancer. Mike will need a urologist whom I’ll call Dr. Yoo (as in “yoo-rologist”).
I must emphasize that Mike and Dr. Yoo are fictitious characters and the conversation in the following script is completely imaginary.
A one-act play
Mel, Mike, and his urologist Dr. Yoo are sitting around a small round table in a brightly lit windowless room in Yoo’s office. Mike and Yoo are slowly sipping coffee from Styrofoam cups. Mel is gazing into her half-empty bottle of fresh spring water theoretically from somewhere in the vast mountains of North Carolina.
Yoo: Well, Mike, Mel, I suppose you can guess what I’m going to tell you.
Mel: Bad news, Doc?
Yoo: Mike’s biopsy was positive, and that’s never good news, but we’ve caught his prostate cancer early which is very good news.
Mel: Okay. We were prepared for that. Now what?
Yoo: Thankfully, at this stage you have options. Your most basic choice is whether to proactively treat Mike’s cancer now, or whether to watch how it develops with an active surveillance approach.
Mike: Mel and I have already discussed it and we’re not going to wait. So how do you suggest we treat my prostate cancer?
Yoo: Well, we could talk for hours about the many ways cancer is treated, but in the end it will probably be a choice between surgery and radiation. So let’s cut to the chase and compare those options, okay?
Mel: Okay. Sort it out for us. Tell me how you see it.
Yoo: All right. First of all, at this early stage both surgery and radiation can be very effective in treating the cancer, but there are differences.
Mel: Enlighten us.
Yoo: Surgery is surgery and as you know, even with a robotic approach it always involves cutting. And of course, the ultimate outcome depends heavily on the skill of the surgeon. If yours is a good one having a good day, the results can be good. The prostate can often be removed without significant damage to the sexual-function nerves around it, but Mike, there is no guarantee you’ll avoid erectile dysfunction, which is a significant risk with surgery. Urinary incontinence could also be an issue for you, and like any surgical procedure, a prostatectomy carries a risk of infection. But the cancer should be gone along with the prostate, unless some renegade cancer cells had already escaped.
Mel: Sounds lovely. What about radiation?
Yoo: No guarantees with radiation or any treatment, but there’s obviously no risk of surgery-type infection, and radiation is painless. Now, unlike surgery, radiation does allow treatment of a margin around the prostate in case some undetectable bad guys have escaped the capsule. And E.D. is less likely, as is incontinence. The results are generally good, and don’t depend on the skill of one person—there’s a team running the show.
Mike: I like the sound of that. I’m leaning …
Yoo: Now Mike, if you go that route you’ll have to decide between conventional X-ray radiation (IMRT) and proton radiation. The main difference is that the proton beam radiates substantially less healthy tissue than IMRT. Proton is lower intensity on the way to the prostate and has no exit impact at all on healthy tissue beyond the prostate. Protons do most of their damage at the target. IMRT behaves differently, radiating everything in its entire path. It’s at its maximum strength as it passes through healthy tissue on the way to the prostate, and continues radiating healthy tissue as it exits. So with proton you might reasonably expect a lower risk of side effects and radiation-related secondary cancers developing later. Time will tell.
Mike: Well, based on that it sounds like proton makes sense. Sign me up.
Mel: But Mike, I know you’ve read my articles and you know how I feel about this, don’t you? I’m just not sure proton is … I mean, I think I understand how you might be tempted to consider … but I really don’t …
Yoo: Mike, let me help Mel out here. I’ve read her columns and your wife does seem to have a surprisingly negative view of proton. I’ve been very interested in this and I’ve actually made a little list of phrases she’s used and quoted about proton. Would you like to hear that list?
Mike: Uh, I guess so. Mel?
Mel: I’d rather, uh, well if you … I mean, shouldn’t we just be discussing you, Mike? We really shouldn’t make this about my job. I try to keep work separate from my personal life. But, okay. Fine. Read the list.
Yoo: Okay. I have it right here. Here goes:
From Mels’ May 26, 2015 article:
uncertain future … insurers balk … expensive radiation treatment … uncertain market … dogged by a lack of evidence … millions of dollars in losses … no added long-term benefit … no guarantee of success … pricey, unproven treatment … could stimulate unnecessary demand
And a few from Dec. 13, 2012:
no long-term benefit over traditional radiation … far higher costs … has sparked an arms race among major medical centers … costly new technology … no proven advantage
And a couple more from back in April 7, 2009:
lack of evidence has been a particular issue for proton … no conclusive evidence that the added cost is justified
Mike: Mel? What about it?
Mel: Well like I said, those are just articles and it’s my job, but now we’re talking about you, Mike, so I’m not sure it’s fair to …
Mike: Okay, okay, but Mel, Dr. Yoo says proton radiates less healthy tissue than conventional IMRT. Is that true?
Mel: Well, yes, but …
Mike: Okay, and shouldn’t I want to avoiding radiating healthy tissue as much as possible?
Mel: Well of course, but you …
Mike: Because less radiation to healthy tissue can reduce my risk of side effects and secondary cancers, right?
Mel: I …
Yoo: Okay, guys. Why don’t you go home, do some research, talk to people, give this more thought and call me in the morning.
Mike: Sure, we’ll do that. We’re in this together, but I’m pretty well convinced I’ll go proton. So, Dr. Yoo, what’s my next step? Who do I call?
Yoo: Mike, I’ll make you a copy of my list of major U.S. proton therapy centers—more than a dozen. Contact a couple to request their application. And Mel, there will be some good information in those packets. Maybe it’ll help you with your future articles, hmm?
Beck’s abuse of power
As the Wall Street Journal’s Health Journal columnist, Melinda Beck sits on a high and powerful perch for influencing thought on proton therapy. Sadly, she doesn’t seem to like it much, and I’m not really sure why. Beck seems determined to flood the world with negative phrasing about proton. Sometimes they are her own words, sometimes they are her selection of quotes from others.
If Beck were the WSJ’s sports editor would she be critical of football fields roughly the size of a proton particle accelerator?
Her abundance of negativism about proton therapy’s place in the world’s arsenal of cancer weapons is sometimes subtle and therefore dangerous. One of her favorite negative innuendos involves size and cost. In more than one article she says “Proton … theoretically can target tumors more precisely. But it requires a particle accelerator roughly the size of a football field that typically costs about $180 million.” See how her use of “theoretically” and “but” set the tone? 
The precision of the proton beam is widely acknowledged, and the size and cost of a proton facility doesn’t diminish that fact. If Beck were the WSJ’s sports editor would she be critical of football fields roughly the size of a proton particle accelerator? Maybe, but they’re both just as big as they need to be.
Best wishes for Beck
I sincerely hope no man in Melissa Beck’s real family must ever hear a prostate cancer diagnosis. Furthermore, I hope there is never the need for a conversation like the imaginary one above. I hope Ms. Beck will remove the negative spin she places on proton therapy in future columns. She can report the same facts, but frame them more objectively. It’s not difficult, and she can refer to my earlier blog post in which I rewrote her May 26, 2015 article to demonstrate how to create a positive spin from the same set of facts.
My message for Melinda
Proton therapy was my choice for treating my prostate cancer diagnosed in 2010, largely for the reasons stated above. The same is true for many readers of The After Proton Blog. My message to Melinda Beck is that for us, this subject is not merely academic.
For us, it’s personal.
In the spirit of the holidays I would like to wish Melinda Beck and her family good cheer, good health, and greater objectivity in future columns discussing proton therapy. After all, protons are positive—she should be, too.
That’s my message for Melinda Beck. Please email your message to me here. Thanks!
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