As an early stage prostate cancer patient who is trying to make a practical decision about my own best course of treatment, I was disappointed by Dr. Scardino's new book, not so much because of its readability or the general advice that he offers, but because of the recent medical data and information about prostate cancer treatments other than surgery which he either doesn't provide or doesn't discuss in great detail. There are several other recent books on prostate cancer that in my opinion seem to provide a somewhat more comprehensive and balanced picture of the pros and cons for those of us who are concerned about making these difficult treatment decisions.
Dr. Scardino has a reputation for being one of the best surgeons in the country, and as you might expect since that is his particular specialty, he generally encourages surgery (radical prostatectomy) for the treatment of early stage prostate cancer. He summarizes the advantages and disadvantages as he sees them for each type of treatment, but for the most part, he doesn't offer much to balance his opinions with the published peer-reviewed data available from specialties other than his own and especially studies that might contradict or qualify his point of view. He offers only a limited sampling of the results with modern radiation therapy, although he does refer to some of the research done by several of his colleagues in the radiation oncology department at his own medical center, Memorial Sloan-Kettering, where emphasis appears to be focused primarily on the new Intensity Modulated Radiation Therapy (IMRT) -- which Dr. Scardino rates as the best type of radiation therapy currently available, better even than the more widely used radioactive seed implants (brachytherapy).
There are a number of examples that seem to me to be serious omissions in Dr. Scardino's book, but I'll mention just one that I found disturbing. One study that Dr. Scardino cites without reporting the specific data prompts him to assert that medical studies have shown surgery or external radiation to be superior to seed implants for the treatment of intermediate and high risk patients (those with high Gleason scores and/or high PSAs). Dr. Scardino's footnote refers to a study by Dr. D'Amico et al at Harvard Medical School published in 1998 (JAMA). But Dr. Scardino doesn't mention that there have been numerous studies since that time widely reported in the press that have shown exactly the opposite to be true -- studies that demonstrate progress with the seed implants in recent years appears to have made that form of radiation therapy superior to surgery, especially for intermediate and high risk patients.
Relying on only one outdated study, Dr. Scardino chooses not to discuss the more recent 10- and 12-year results reported by many established radiation therapists like Drs. Blasko, Grimm, Ragde, Merrick, Dattoli, Stock, Stone, Critz and others who are using seed implants, often in combination with IMRT or conformal radiation. In direct contradiction to what Dr. Scardino tells us, they report that seed implantation carries a much lower risk of serious complications like sexual dysfunction and urinary incontinence than radical prostatectomies. They may or may not be right, but these are issues that at least might have been addressed in the book even if Dr. Scardino is critical of those favorable results obtained by doctors using seed implants.
According to his own published research, Dr. Scardino has a success rate of 75% with surgery, but that is less than or only comparable to the results being reported by a large number of radiation oncology groups, including all of those mentioned above. In a controversial field where so many doctors disagree, the most serious challenge we face as patients is deciding which treatment among the competing options is best for us. Because there are no randomized controlled studies that directly compare the primary treatments like surgery and radiation, all that doctors and patients can do is compare the results that have been published by the very best physicians with each treatment (while keeping in mind, as Dr. Scardino cautions us, that the results of our own doctors may not come close to those being reported by the best physicians in the field).
I'm not a medical doctor, and I haven't made up my mind yet, though I'm obviously reluctant to jump into surgery when there appears to be equal or better options. There are some recent books from physicians specializing in radiation and oncology that offer a very different picture, in particular, Dr. Michael Dattoli's Surviving Prostate Cancer Without Surgery which just came out (by a radiation oncologist formerly at Memorial Sloan-Kettering), and the slightly less up to date Prostate Cancer Treatment Book by Dr. Peter Grimm that came out a couple years ago from several of the other doctors in this field. Both of those books make a more thorough effort to compare the data and treatments and they report very different results than does Dr. Scardino on both survival rates and complication rates.
It's not easy, but I think there is no alternative for patients but to be sure to learn as much as we can about all the points of view, and then to use our own judgment to decide for ourselves what is best for us. A totally fair presentation of the facts may not be possible with the different specialties biased one way or another. In fairness, as Dr. Scardino suggests in his book, we need to consider the source when we weigh the statistics and opinions of others. But we also need to be given all of the most recent data. It's unfortunate that no single book provides us with the second and third opinions that would cover the whole range of treatments. One would like to see these specialists debate the issues under one cover. That book has yet to be written.