Two Thirds Done

Thoughts and experiences of an eighty one year old Wild Duck.

Avram Miller by the sea
EN | IT

587 posts since 2006

Tag: prostate cancer

  • Biden physicians failed him, in my opinion

    Biden physicians failed him, in my opinion
    I assumed that President Biden had his PSA checked while in office, but I now realize that he may not have. The guidelines were changed in 2018. Under the new recommendations, PSA screening is not advised for men aged 70 or older. Biden was 78 when he became president in 2021.

    His office says he has not been screened since 2014, when he was 72. It typically takes about 10–15 years for a non-aggressive form of prostate cancer to reach stage four (Biden’s current status). In aggressive cases—determined by the Gleason score—it can happen in just 2–5 years.

    The current guidelines for PSA testing need to be rethought. The guidelines, I fear, were a reaction to the over-diagnosis and over-treatment of early-stage prostate cancer. About 18% of men will be diagnosed with prostate cancer. It is generally a slow-growing cancer, and its incidence increases with age. Some suggest that your percent chance of having prostate cancer roughly equals your age. Most men will die with prostate cancer, not from it. But some will die from it. I hope Biden will not be one.

    My own experience with being overly treated

    When I was treated for prostate cancer in 1996, it was definitely being over treated. I had a PSA of 4.8 and a Gleason score of 6. I should never have been treated—and today, I likely wouldn’t be, at least not initially.

    These days, a PSA level like mine would likely be monitored to track its rate of increase—assuming the elevation is actually due to cancer and not caused by something else. If the PSA continued to rise, a biopsy would eventually be performed. That would determine cancer is present and how aggressive it was. If it isn’t aggressive, a technique called active surveillance would be used: a combination of PSA tests and periodic biopsies every few years. This approach avoids aggressive treatment like prostate removal or radiation in most cases.

    The idea of not testing men over 70 makes little sense to me. Half of men over 70 are expected to live to at least 85. With continued improvements in healthcare and lifestyle, I suspect that life expectancy will continue to rise.

    Precise recommendations based on the person not the population

    The current recommendations regarding PSA testing are designed for the general population. I would have expected that Biden, given his access to top-tier medical advice, would have received more personalized recommendations. For example, it is generally not advised to have a colonoscopy after age 75—but these guidelines also emphasize factoring in projected life expectancy. Being in excellent health myself, I had a colonoscopy at age 79. I may not have another one—my next would be at 89—but we’ll see how I’m doing then.

    The invation of the Prostate Snatchers

    I wrote in 2010 about the aggressive  treatment of prostate cancer which I suspect the lead to the current recommendations.

    Invasion of the Prostate Snatchers

  • Biden: Prostate Cancer Stage Four-How is this possible

    Joe Biden has been diagnosed with stage four prostate cancer which has spread to his bones. I am, of course, sorry to hear this. Biden has been through a lot in his life, including the death of a wife and two of his four children, as well as having one son who struggled with drug addiction.

    I am a survivor of prostate cancer. I was diagnosed in 1996 and treated with a then-new radiation therapy called brachytherapy. In my case, about sixty radioactive seeds were implanted in my prostate. I experienced what is known as a PSA bounce. PSA is a blood marker that, when elevated, can indicate prostate cancer. In rare cases, PSA can rise temporarily after treatment—this phenomenon, now well known, was not yet recognized at the time. As a result, my doctors believed that my cancer had metastasized. There I was, in my early 50s, potentially facing a death sentence. Fortunately, it turned out well for me. In the process, I learned a lot about prostate cancer. I even became a board member of the Prostate Cancer Foundation, which was started by Mike Milken.

    I find it hard to imagine that Biden and his physicians were unaware of his prostate cancer for some time. If they were, there was no public disclosure. While most prostate cancers are not deadly, about 15% will metastasize. But if detected early and treated, the risk is extremely small.

    My guess is that Biden had prostate cancer for some time and it was not disclosed—possibly even before his first presidential term. It likely spread to his bones a few years ago but did not cause symptoms until recently.

    Something about this situation just doesn’t make sense to me. You don’t end up with a Gleason score of 9 (10 is the highest) without many years of rising PSA levels. I find it hard to believe his routine physicals did not include this simple blood test. To be fair, It’s possible that Biden decided not to have the PSA test done. Many men as they get older make the decision not to have this test. But of course, they are not the president of the United Staes.

    He will be treated with hormone therapy, which typically produces a remission that lasts 3–5 years. However, it often causes side effects such as cognitive decline and fatigue. There are other treatments available once hormone therapy stops working, which can add a few more years of survival.

    Biden was already having difficulty functioning full-time. He appears to have some cognitive issues that were not acknowledged publicly but were evident in his appearances. Hormone therapy could have made this much worse. My guess is that he would have had to resign had he continued his run for president and won.

  • Formerly, the Former Avram Miller

    Turning 80

    Turning 80 last month was not easy for me. I used to be the youngest person | in the room. Now I am the oldest. Once, I was a child prodigy. Now I am an elderly man who gets seats offered to him when he rides the metro. 

    Frankly, I am struggling to deal with my age and the issues related to it. It is mostly psychological but not completely.

    In 1999, I left Intel, where I was Vice President of Corporate Business Development and the co-founder of Intel Capital. I am best known for these roles, as well as being a key driver in establishing the residential broadband infrastructure that became so instrumental in creating today’s consumer internet.  I did important work which was valued then; this is now.  We are entering into a period of increased longevity.   The percent of people over the age of 80 in the USA has increased from 2.3% in 1980 to 3.7 in 2020, a more than 60% increase. This increase is expect to continue.  I don’t want to forecast much into the future because we do not know what kind of advances will be made in health care.  But most of us are not prepared for life after 80.  Also, most people that age have health problems that impact there lives.  Less than 25% are still 100% fit.  I fall into that category at least for now.  For most of my life, i was focused on the future including my own future.  Now I need to live in the present.  That is where I am struggling.  If I could just focus on the present without concern about the future.  My present is really very good.  I live well and have an amazing relationship with my wife.   

    My past is disappearing 

    At its height, Intel was one of the top ten companies in the world. That is when I walked out. When I resigned, the market cap of the company was about $250 billion. It would grow to almost $500 billion at its peak a year later. Since I thought that Intel had some room for appreciation, I hedged my stock and sold it right at the peak. In 2003, Forbes placed me in the 8th position on its Midas List of the top venture investors.

    My decision to leave Intel was based on several factors. Not only did I not see a continuing role for myself, but I also had serious concerns about Intel’s future, which sadly proved to be correct. I  no longer wanted to work for a company. I wanted to be on my own. I wanted to see what I could accomplish without Intel at my back. 

    In 1996, I was diagnosed with prostate cancer. It was treated using a new technique called brachytherapy (using radioactive seeds that are implanted directly into the prostate). I chose that method on the advice of Andy Grove, who did the same thing a year before me. Unfortunately, I had a reaction that was later identified as a PSA bounce, a phenomenon not recognized until several years after my treatment. It occurred in younger men (prostate cancer affects men as they age, and a 51-year-old like me was considered a young man). Instead of my PSA (the marker for prostate cancer) going down, it started to go up. It looked like my cancer had metastasized. My doctor said, “Well, at least it’s not going up quickly,” and then, of course, it started going up quickly. It was a very stressful time for me, to say the least.  A number of doctors told me that it had metastasized.  One even said that I probably had 5-10 years to enjoy my life. 

    It was then that I decided I would think about my future assuming that I only had ten years more to live. Prior to the cancer, I had been planning on starting a private equity firm with my friend Dave Roux of Oracle, but that no longer fit into my ten-year “rule.” He went on to found Silver Lake Partners. I became a limited partner.

    I was just 54 years old when I left Intel. With my experience and successful track record at Intel Capital, it would have been natural to start a venture capital firm, but I never actually thought of myself as a venture capitalist. Rather, I thought of myself as an activist strategist, and I wanted to help a few companies develop their strategic plans. Fortunately, I was financially comfortable and did not have to be concerned about adding to my wealth. I served on a number of boards, advised investment banking firms, and invested in early-stage companies for my own account. For instance, I put together much of the first round of Oura Ring. But slowly, I began to lose interest in business. I also realized that much of my standing in the world of technology was associated with Intel and its success. I remember thinking that the half-life of a technology strategist was about a year. The result is less than 1% after ten years.

    It was then that I started to jokingly refer to myself as “The Former Avram Miller.” For the longest time, I could explain that I had been an executive at Intel and founded its very successful venture arm, Intel Capital and people would be impressed.  Now, Intel is seen as a failing company. Intel Capital is a shadow of what it was in my time and is in the process of being spun out as a separate entity with a new name. A big part of my identity has  been eroded.

    From a ten year horizon to a five year horizon

    Fortunately, I am in good physical and mental health. But at my age, how long will this continue? So now I have revised the time horizon for decisions. I make life decisions assuming I have only five years. When I had a horizon of ten years, I felt that I had a lot of time to make things happen, but with five years, I have my doubts.

    I no longer want to be on boards, and it is unlikely that any board would want me at this age. I am happy to advise entrepreneurs, but this results in at most a few hours of engagement a week.

    I am still able to keep up with the key developments in technology. I have returned to my first career, which was in medical science. But I want  to transition to something I can do all by myself. I wrote a memoir called The Flight of a Wild Duck, which was published in 2022. It took three years and was, all in all, a good experience. I am considering writing another book, but perhaps this time it will be a work of fiction. I like the idea of creating something out of nothing. It was what I did when I was programing computer and composing music.

    But right now, I feel lost. Saying this probably makes some people uncomfortable. I guess you are not supposed to say that kind of thing. However, I have always been able to share my feelings, and I think it may be valuable to others who are having some of the same experiences.

    The depressing state of the world

    To make things even more complex, the world situation is creating a great deal of instability and uncertainty, which is also impacting me like so many. We moved out of Israel just before the Oct. 7th war. We traveled for a while before moving to Amsterdam while we thought about where we would want to settle longer term. Eventually, we decided to move to Italy, where we are now living. We are studying Italian. This will be my fourth language. I am hoping I will love it.  I was never able to master my third language, Hebrew.  

    We do not age uniformly

    Health is a consideration. Our bodies do not age uniformly. So while I may look sixty-five to some, I know that my hearing and sight are not sixty-five. I struggle to see my  computer screen as I write this post. I have trouble understanding people in noisy environments. I have arthritis in my hands, which makes it difficult for me to play the piano with the same level of energy as in the past. At some point, I will probably have one or more chronic diseases and have to spend a lot of time dealing with that. This is not something to look forward to.

    When I see people my age whom I have not seen in a while, I am stunned by how they look. The beautiful girl that I met and loved when she was 16 is now a senior citizen.  My oldest son is older than I was when I left Intel. Three of my four grandsons are adults. Every year, a few friends die. Many just disappear. Perhaps they are struggling with some of the same things that confront me now.

    I need some reprograming

    For the first time in my life, I have bouts of depression. If I say anything about this, people start worrying about me because of the suicide that runs in my family. But I think it is better to own up to it. I hope it does not get worse.  

    Still, I am adventurous. We have traveled to twelve countries in the last year. I guess most my age would not just pick up and move to a different country which I have now done three times in the last ten years and each with a different language.  

    Fortunately, I am married to the most amazing woman, Deborah. She is my joy and blessing and more than enough reason to stay alive.

  • Invasion of the Prostate Snatchers

    Listening to a discussion of Prostate Cancer on Science Friday and especially the comments of Mark C. Scholz who wrote a book with the provocative title of “The Invasion of the Prostate Snatchers”  felt it was time once again to make a plea for men not to rush to be treated. At the age of 51 some 14 years ago,  it was determined that i had prostate cancer.  I have written a bit about my experiences here and here.  At that time, I believed that there was a high probability that if I was not treated, I would die of prostate cancer.  I choose radiation because it appeared to have better result with respect to side effects especially impotence (which was for me frankly a big  concern ).  My procedure went as expected.  I was able to continue to work during the weeks I received radiation.  There were a few months where my bladder which received some radiation was irritated and I had to pee all the time (I am still traumatized by the few times I was trapped and could not get to a toilet fast enough like the time I  had to pee into a water bottle while I was stuck in a traffic jam).  But realizing that I was now sterile (I of course already had three wonderful children) and that I  could no longer ejaculate had an effect on my psyche.  Then things appeared to go bad and instead of my PSA going down it went up.

    After almost two years, it looked like I had metastasized  prostate cancer which is pretty much death sentence.  But it turns out that it was a false alarm.   The PSA levels started going down and the last time I checked they  were at a level the indicated that I had no longer active prostate cancer (while you can no for sure that you have prostate cancer, you can never know you do not).  Now 14 years later, I can say that I do not have any significant effects other than the ones already mentioned.  An after all, I am 65 and now more concerned that I might fart during a massage then worried that I would get an unintended erection.  But the bottom line is I should have done Watchful Waiting which means just monitoring PSA levels and having a biopsy ever year or two.    If I understand the statistic well, 28% of men over 60 have prostate cancer.  Of these, 3% of men will die of prostate cancer if untreated.  This is an argument for not doing a PSA test since you only have a 3%  but I believe in information.  But then if you do have prostate cancer, you have a 10% chance of dying from it.  But this includes men that clearly have an aggressive form of the disease.    I would guess that for someone like me who had a non aggressive version, the probably might be less than 3%.  I could have waited years or maybe for the rest of my life and never had the procedure.  However, when I explain this to men who have been recently diagnosed, they always opt for treatment.  Frankly, most of these men would do better by losing some weight, going to the gym and reducing a bit of stress.  But then who would keep the urologist  in business.

    A review of the book mentioned above can be read here.

  • It is not the PSA test that is a problem but what one does with the results

    Please forgive me for writing about this again. There has a been a lot of discussion recently about the effectives and wiseness of giving men PSA tests. I often say that I had PSA disease. From the time I was 50 (15 years ago), I had been getting regular PSA test as was the recommendation at the time. It was the view then that at PSA of under 4 was good but PSA’s above 4 were of potential concern. This was a pretty simple minded way to look at things. There are many factors that influence PSA such as weight, infections and just ones nature. My PSA was 4.1. My doctor suggested we wait a year and see what happen. We did it again a year later  and my PSA was 4.3. She then suggested I have a biopsy. So I went to a urologist. He said to me there was a 25% chance that they would find cancer. I was pretty sensitive to the issue of Prostate Cancer since Andy Grove with whom I had a lot of contact at Intel had been treated a year earlier for Prostate Cancer and wrote an cover article in Fortune that got a lot of attention. With one chance in four that I would have cancer , it seemed smart to find out. I had the biopsy (not a lot of fun) and waited for the results. The doctor scheduled the appointment for the end of a day. I did not think much about that at the time but later realized that was so he could spend some more time with me when he told me that I had indeed had Prostate Cancer and had a Gleason score of 6 (3+3). I won’t go into what the Gleason score is. You can read about it here. My score was not very high. That combined with my rather low PSA score of 4.3 meant that I had about an 80% chance that my cancer was confined to my prostate and had not spread. So like most urologist at the time, he recommend that I have my prosate removed. The idea was that if the cancer had not escaped from the prostate and you removed the prostate that you could not die of prostate cancer. I think the same logic is applied to breast cancer and ovaries (in women with high risk). Of course, I might have some side effect like not being able to have an erection (I was a single man or 51 years), urinary or even worse elimination problems. There were alternatives and I choose the same method as Andy Grove. I had a combination of internal (seed) and external beam radiation. The side effects are better in general and definitely in my case. What we now know (and maybe we knew then) was that most men who have Prostate Cancer do not die of it. They die with it. We also believe that there are many kinds of Prostate Cancer and the most are not life threatening. What should have been done in my case. We should have just do what is called watch and wait. We should have checked the PSA every year or even every six months to monitor the rate of increase. We might have done a biopsy ever year or two. I think there is a good chance that now at the age of 65, I would still have had my prostate. PSA tests are cheap. I understand that they only cost about nine dollars to perform (of course the labs charge more for them). It is important to monitor the PSA. If you have a PSA of lets say 10 and a Gleason score of 8 or more, you need to do something. But Urologist make a lot of money by taking out Prostates and they will play to the uncertain. I often have contact with men that have recently been diagnosed with Prostate Cancer. In cases similar to mine I suggest that they wait. Sadly none have.

  • The effectiveness of PSA Testing

    There was an interesting editiorial in the NYT today.  As a man who was treated for Prostate cancer  over 12  years ago, I often said that I had PSA disease.  The problem in my opinion is not having PSA tests done. It is what happens after the results come back positive.   The PSA test can provide a lot of value in determining if someone has prostate cancer and to a certain extent how aggressive  that cancer may be particularly if the PSA is monitored over a period of time.  The rate of change of PSA is an important indicator.  The problem is that when a PSA is above a certain level (they were using 4.0 when I had my first PSA done at the age of 50 years), the next step is often a Biopsy to determine if there is cancer and to grade the Cancer. This is where the problem really comes into play.  If cancer is detected (and the older you are the better chance that you will have some amount of prostate cancer), the next step is for the doctor to recommend ways for you to treat it. Top of the list is surgery followed by radiation of some time.  My doctors do not really treat the possibility of what is called “watchful waiting” especially if you are young.  Doctors  do not want to take the chance that you, their patient, may be one of the people that have an aggressive form of the disease.  The idea is that if the cancer is found early and the prostate removed or totally cooked with radiation, then you can no longer get prostate cancer.  But even that is not always true.  There is not just one kind of prostate cancer.  Many prostate cancers grow very slowly and many never spread beyond the prostate (it has to do that to become dangerous).  Frankly, I wish I never had treated my prostate cancer (I had radiation) but watched and waited (by monitoring the PSA and maybe having a biopsy ever few years) but at the age of 51 no doctor would have recommended that approach.

    The good news is that i am pretty sure within ten years we will be able to determine of a man has an aggressive form of the disease or one that can be left alone which would be most cases.  I also think we will find ways to deal more effectively with advanced prostate cancer which will mean that the cost of taking the risk will be reduced.