Netflix’s ‘Grace and Frankie’ get a second opinion on their take on prostate cancer
By Howard Wolinsky and Mark Lichty
“Grace and Frankie,” the Emmy-nominated Netflix senior-centric comedy about love and life in the septuagenarian set, which includes the authors, has courageously has dealt with serious topics, such as divorce in old age, gay marriage, Alzheimer’s disease, and euthanasia, with deft and often humorous touches.
The show recently focused on a hot topic for elderly men and women (and men) who love them — cancer of the prostate, the finicky walnut-sized sexual gland that tends to become cancerous as men age. The program did not live up to its usual standards and did not use its pulpit to set men diagnosed with prostate cancer on the path to find the most appropriate care. They went for the laughs.
Prostate cancer is second only to skin cancer as the most common cancer in American men, according to the American Cancer Society (ACS). The ACS estimates that 192,000 new cases of prostate cancer will be diagnosed in 2020. And this cancer of a sexual gland is the second leading cause of cancer death, following lung cancer; 330,000 deaths are estimated in the U.S. in 2020.
About 70 percent of men in their 70s have prostate cancer though in most cases it has not been diagnosed. Most men live with prostate cancer and don’t die from it.
So prostate cancer is a perfect topic for the audience of “Grace and Frankie” and its sharp-witted writers led by producer Marta Kauffman, who also created “Friends.”
But as men with early-stage prostate and co-founders of Active Surveillance Patients International, an advocacy group, we feel Kauffman & Co. missed the mark with the episode entitled “The Funky Walnut,” a reference to the walnut-sized sex gland.
The set-up is Sol Bergstein (Sam Waterson) is a 75-year-old retired lawyer who left his wife Frankie (Lily Tomlin) for Robert Hanson (Martin Sheen), his law partner.
Sol’s urologist, Dr. Rogers (Elliott Gould), a world-weary, chain-smoking urologist, breaks the news — Sol has prostate cancer. ‘’We’ve caught it early, it’s indolent, so it’s slow-growing, which is terrific,” he said.
To those of us who have received this diagnosis, this actually is good news, though for most new patients, like Sol, and their partners, like Robert, it may seem like a death sentence at first.
Practical Robert, the hard-nosed lawyer, asked the doctor: “So what’s the game plan. What do we do now?”
Dr. Rogers responds: “Well, there’s surgery, but that can be risky anytime you go under. Then, afterward, with infections, yada, yada. Loss of sexual function. There’s radiation, that whole megillah.”
Then comes the bottom line: “Or we keep a good check on it, and you do whatever you want with no change at all,” said Rogers. He advises Sol that he is a healthy guy: “So I’d let it ride. It’s your walnut.”
This is a strategy known as active surveillance, following a man diagnosed with indolent prostate cancer with regular prostate-specific antigen blood SAMPLES and biopsies and often imaging of the prostate including MRIs.This approach spares most men from the risks of surgery and radiation. Yada, yada.
About 50% of American men choose this approach now compared with under 10 percent a decade ago. At some multidisciplinary clinics at major medical centers, such as MD Anderson Hospital and Massachusetts General, about 80% of these men opt for active surveillance.
A skeptical Robert said: “Do nothing?” He asks Dr. Rogers what he would recommend for an otherwise healthy man in his 50s or 60s. Surgery, the urologic surgeon, responds. “Absolutely.”
“The Funky Walnut” cracks at this point.
Robert concludes that what’s good for the younger men would be the best approach for a man in his mid-70s. Not so fast, counselor. You may think Sol’s life is in jeopardy if he does nothing but monitor his cancer. It’s not. If he goes on active surveillance, Sol will avoid the potential for side effects from surgery or radiation. Specifically, he will retain his sexual powers, avoid wearing adult diapers and avoid any bowel issues.
Robert doesn’t ask why the surgeon recommends surgery for the younger men. These days, unless they have been diagnosed with advanced prostate cancer, many younger men wouldn’t want to risk the life-altering side effects.
Active surveillance is not age-dependent, noted Brian Helfand, a urologist at NorthShoreHealthSystem in suburban Chicago. “AS is considered a viable option for young men. However, the ultimate goal of active surveillance may be different in younger men versus older men. Just based upon the time horizon, the goal of active surveillance in young men may be an intentional delay of treatment vs. in older men where the goal would be a total avoidance of treatment,” he said.
Robert, be aware: a surgeon who makes this recommendation may have a conflict of interest because he is paid by the surgical case rather than a salary.
And there’s more. Sol and Robert seem to have agreed on the surgery even before the visit to Dr. Rogers is even over, a matter of minutes. Sol, no need to be in a hurry with slow-growing cancer. An aggressive cancer is another story.
In the real world, we would urge Sol to slow down before rushing to book an OR appointment with Dr. Rogers. You have time.
Here’s our advice to Sol: Get a second opinion. Do your research by reading up on prostate cancer. Join a support group. Change your lifestyle by exercising and improving your diet. Your low-risk cancer may not be a target for surgery or radiation, but likely you are a good candidate for active surveillance.
The writers got it right when they had Dr. Rogers tell Sol: “The good news is at your age something else will probably kill you first.” That is good news.
There’s an old joke about the digital rectal exam, a procedure in which a single lubricated finger is inserted in the patient’s rectum in search of tumors. But in this case, the doctor inserts two fingers. The patient asks: “Why two fingers?” The doctor answers: “It’s always a good idea to get a second opinion.” It seems the same is true for TV scripts.
Howard Wolinsky, a Chicago-based medical journalist, and Mark Lichty, Stroudsburg, Pennsylvania attorney and businessman, are co-founders of Active Surveillance Patients International, an advocacy group for men with low-risk prostate cancer.
