As a teen, Daniel Flora saw.first hand what cancer and cancer treatment can do. Now, as an oncologist, he is determined to find a ”kinder, gentler way.” Dr. Flora writes a kinder and gentler Substack newsletter, Curative - Rethinking Cancer Care. He talks about diet, exercise, and all those things we talk as prostate cancer patients, and ask our doctors about, Dr. Flora gave me permission to reprint this newsletter. Check out his blog.—HW)

By Daniel Flora, MD, PharmD

"To most physicians, my illness is a routine incident in their rounds. To me, it’s the crisis of my life. I would feel better if I had a doctor who at least perceived this incongruity."
— Anatole Broyard

There is no routine cancer care. Each cancer diagnosis is a breaking point in someone’s life. As oncologists, we owe it to our patients to remember that every time, with every person.

Dear [Patient],

If you are reading this, it means we are meeting at a moment that may feel overwhelming, uncertain, and life-changing. I want you to know at the start that everything you are feeling is normal. There is no wrong way to face this kind of cancer news. I have seen these emotions many times in the patients I care for, and I have felt them personally within my own family. You are not alone in this cancer journey, and you do not have to walk this path without support.

One of the most important things early on is finding solid ground. We may not be able to control every part of what lies ahead, but we can control how we start. We can build a foundation of good information, honest conversations, and a personalized treatment plan that is built around you as a person, not just around the disease. If I could offer you a map for the road ahead, this is what I would want it to include.

Building Trust Through Listening

Building trust is not an extra step in cancer care. It is the foundation for every decision we make together. From the beginning, I want to understand what matters to you. Not just your medical history, but your goals, your worries, and what you hope your life can look like during and after cancer treatment. Listening carefully helps me make better recommendations. Just as importantly, it makes sure you are part of every decision. Trust is built over time through honest conversations and respect, and it is something I take seriously from the very first meeting. If at any point you do not feel like you are being heard, I want you to tell me. Sometimes it is hard to know what to ask or how to say it, and that is okay. We will work through it together. What matters most is that you feel seen, understood, and part of the treatment plan every step of the way.

Taking the Time to Explain Your Diagnosis

Cancer is not one disease. It is many different diseases, each with its own causes and behavior. Part of building the right plan is learning as much as we can about what is driving the cancer in your body. Understanding the type of cancer you have, the stage it is at, and any biological factors that might affect treatment helps us make smarter and more personalized decisions together.

Building a Plan That Respects Your Goals

Whenever we are building a treatment plan, there are important questions we should be asking together:

• What are the goals of treatment? Are we aiming for cure, to prolong life, or to improve symptoms?

• What are the risks and benefits, and what does a survival benefit actually mean for you?

• What side effects could I expect, and how can we manage them?

• Are there clinical trials that could give you access to innovative therapies?

• Are there steps you can take with nutrition, exercise, sleep, or stress management that could strengthen your body and mind for what lies ahead?

I want you to know that it is not only okay to ask these questions. It is encouraged. Empowered patients often have better experiences, and in many cases, better outcomes. Understanding what to expect, how we will monitor your progress, how we will manage side effects, and what we will do if the plan needs to change is part of building a real partnership. Staying mentally and emotionally strong is part of this work as well, and I will do everything I can to support you. Whether that is through referrals to counseling, support groups, or simply making sure we check in often, my goal is to help you stay connected and resilient through whatever lies ahead.

Treatment is not something that happens to you. It is something we build thoughtfully and carefully together, based on clear goals, honest conversations, and respect for what matters most in your life.

Personalizing Treatment Through Molecular Testing

Your treatment will be personalized. I offer molecular testing (sometimes called NGS) to every patient when it is appropriate because understanding the biology of your specific cancer helps guide everything that comes next. Molecular testing allows us to look for root causes, such as specific changes in the cancer's DNA that are helping it grow. Knowing that information can sometimes open up options for targeted treatments or immunotherapy that would not be available otherwise. This is part of what I call Oncology 2.0, a more thoughtful and personalized way of practicing medicine that focuses on treating each patient based on their unique biology.

Encouraging Thoughtful Second Opinions

Sometimes another perspective helps confirm that we are on the right path. Other times, it can sharpen or even improve the plan we are building. I fully support second opinions whenever they might bring clarity, confidence, or new ideas to consider. This is not about questioning what we are doing. It is about making sure that you feel fully informed and supported at every step. If you would ever like another opinion, I can help you find someone with expertise so that you do not have to do this alone. Let me know if this is something you are interested in, and we will make it happen. Good cancer care is thoughtful, collaborative, and open-minded, and second opinions are often a valuable part of that process.

(Dr. Daniel Flora)

Considering Clinical Trials Early

Clinical trials are often misunderstood as something to consider only after standard options have been tried. In reality, some of the most promising therapies are available through clinical trials offered at the very beginning of care. From the start, I will be thinking about whether there are any trials that could be a good fit for you. If there is something that could offer a meaningful benefit, we will talk about it early so you have the opportunity to consider it when it matters most. Trials are never mandatory. They are simply one more way we work to give you the best options, built around your specific situation.

Caring for the Whole Person, Not Just the Cancer

Cancer touches every part of life, not just the body. It can affect sleep, appetite, energy, relationships, and how you experience the world around you. Good care means paying attention to all of these things, not just the disease itself. I will spend time talking with you about each of these areas, with a focus on personalized recommendations, including nutrition guidance and exercise prescriptions tailored to your situation. We will also talk about ways to support your emotional health and stay connected to the people and activities that matter most. These are not small details. They are part of how you heal and part of how you stay strong through treatment and beyond.

Why I Believe in Oncology 2.0

The treatments we choose must meet a high standard. They must be effective, improving survival and quality of life in real patients. They must be safe, studied properly, with risks and benefits we understand clearly. They must be tolerable, allowing you to live, not just endure. And they must not be cost-prohibitive, because good care should not come at the cost of the life you have built.

There is real progress happening every year. New trials, new approvals, new ways of putting patients first in how we think about treatment. We are not where we want to be for every cancer yet, but step by step, discovery by discovery, we are moving closer.

“True knowledge is to know the extent of one’s ignorance."
— Rudolf Virchow

Cancer humbles me every day. I will never claim to have every answer, and no good oncologist should. But what I can promise is that honesty and compassion will always come first. Listening carefully, explaining clearly, and walking this road with you will always be at the center of how I practice.

Finding Trusted Information

It can be tempting to search endlessly online, but not everything you read will help you. Some sources stir up fear or offer false hope. I encourage you to stick with trusted places like the National Cancer Institute, the American Cancer Society, or major academic centers. If you find something online that raises questions, bring it to me. We will sort through it together and make sure you have the clearest, most accurate information possible.

Being Careful with Miracle Claims

You may also hear about diets, supplements, or alternative cures that claim to treat cancer. I understand why these stories are appealing. Hope is powerful. But real breakthroughs in cancer treatment are not hidden. They are studied carefully, tested openly, and made available so more people can benefit. If something truly worked, it would already be part of standard care. I would be using it for my own family. I am always open to hearing what you are reading or considering, but I will also be honest about what is proven, what is promising, and what still needs more study.

Moving Forward Together

There is no perfect roadmap for what lies ahead. There will be victories and setbacks, hard days and good ones. What matters is that you will not be walking it alone. You have a team beside you, and you have a voice that matters in every decision we make. My commitment is to listen carefully, to explain thoughtfully, to plan personally, and to walk this road with you, not ahead of you.

We move forward together, one step at a time, with honesty, compassion, and hope.

Sincerely
Dan Flora, MD

Come to the ASPI webinar June 28: Cracking the Code on Pathology Reports—Helping Patients Navigate Medicalese to Get Better Health Results

Most patients have a hard time deciphering pathology reports they get after prostate biopsies. At the same time, many are puzzled with their Gleason score.

Cathryn J. Lapedis, MD, MPH, a Clinical Assistant Professor of Pathology at Michigan Medicine in Ann Arbor, has found in her research that patient-centered reports can help patients understand the reports.

She will be the featured speaker at the ASPI webinar from noon to 1:30 p.m. on Saturday, June 28.

Please register for the meeting here.

Lapedis was the lead author of a recent study in JAMA that found a 93% comprehension of patient-centered pathology reports compared with 39% of those who read a report from the University of Michigan and 56% reading a pathology report from the Veterans Administration.

She also looked at how these patients interpreted Gleason scores: 84% reading specially prepared patient-centric reports understood their scores vs 48% for the university group and 40% for the VA group.

She has fellowship training in medical renal and gastrointestinal pathology. Her research centers on rethinking the way pathology results are communicated to patients and the healthcare system. She completed an in-depth analysis of key stakeholders’ attitudes towards patient-pathologist interactions, and is currently piloting early interventions in patient-centered pathology communications.

Please send questions in advance to: contactus@aspatients.org

BidenWatch

By Howard Wolinsky

The diagnosis of Gleason 9 prostate cancer in former President Joe Biden spotlighting prostate cancer, the most common solid tumor in American men.

Here’s some news:

—Biden says he is being treated. The ex-president gave an update after delivering a Memorial Day speech. The Washington Post reports that Biden said“we’re going to be able to beat this,” adding that he has started taking medications and is working with a leading surgeon.

“The prognosis is good. We’re working on everything. It’s moving along, and I feel good. All the folks are very optimistic,” Biden, 82.

“It’s all a matter of taking a pill, one particular pill for the next six weeks and then another one,” Biden added. “The expectation is we’re going to be able to beat this. There’s no — it’s not in any organ, my bones are strong, it hadn’t penetrated.”

His office announced May 18 that he was diagnosed with a Gleason 9 cancer that had spread to his bones.

—Dr. Laurence Klotz, famed urologist from the University of Toronto, shares some views about cancers like Biden’s with the CBC.

He said patients with metastatic prostate cancer live "roughly twice as long now as they did 10 or 15 years ago, which is really a significant achievement."

"The disease can be controlled, often for a long time — but a cure is generally not in the cards," Klotz told Dr. Brian Goldman, host of CBC podcast The Dose.

"You have some patients who may live 10 or 15 years despite having metastatic disease. And unfortunately, you have others where the disease progresses very rapidly, despite all these new therapeutic advances, and the patient can sometimes die within a year,” Klotz said.

—Rick Davis, a PCa survivor and founder of the AnCan support platform, said the reports on Biden raised questions abiout Biden’s care:

1. Either he's not been put on Orgovyx, or he's not on doublet therapy. Either way, someone's not treating him correctly.

2. Why the heck is a urologist treating him for metastatic disease. Didn't anyone mention a GU med onc should be running his care.

3. This 'world-class surgeon' has to be in his 70's. No wonder he's not getting Orgovyx.

What the heck is going on?

This is truly a bunch of horse [manure] - especially when it makes it appear OK for urologic oncologists to treat advanced prostate cancer.

Is there no responsible medical practitioner who can talk to Biden and navigate him properly.

Don’t miss your PSA screening—your life may depend upon it

By Howard Wolinsky

Men who consistently miss prostate cancer screening appointments face a disproportionately higher risk of dying from the disease, according to a 20-year follow-up data from the European Randomized Study of Screening for Prostate Cancer (ERSPC).

Renal and Urology News reported from an oral presentation at the European Association of Urologists annual meeting in March in Madrid that there were 161,380 men aged 55-69 years recruited from seven centers. The group included 72,460 men randomly invited to screening. Of these, 12,401 (17%) were non-attenders and skipped every appointment. This group had a 45% higher risk of dying from prostate cancer compared with those who attended screening appointments, said Renée C.A. Leenen, MD, of Erasmus MC Cancer Institute, Erasmus University Medical Center Rotterdam in The Netherlands. Compared with a control group (88,920 men who were never invited to screening), men who attended screening appointments had a significant 23% lower risk of dying from prostate cancer.

Non-attenders had a significant 39% higher risk of death from the disease.

“The effect of screening on prostate cancer-specific mortality for men who actually attend screening has been underestimated,” Leenen said.

William Catalona, MD, professor of urology at Northwestern University in Chicago , who promoted the idea of PSA screening in the 1990s, told the magazine: “I believe that suffering and death from prostate cancer could be reduced even more by starting screening younger, using more frequent screening intervals, and more careful monitoring of men with rising PSA levels.”