Biutiful (2010) and Advanced Prostate Cancer

Uxbal survives in the margins of the city. He takes a cut from Senegalese street vendors and from Chinese labourers making counterfeit goods in a basement. He pays off the police. He earns extra money as a medium, carrying messages from the newly dead to their families.

He is raising Ana and Mateo largely alone. Their mother, Marambra, is bipolar, drinking, and not a carer anyone can rely on.

Blood in his urine sends him for tests. He is told he has prostate cancer that has already spread, and that he has months. He starts chemotherapy, then abandons it on the advice of a healer, Bea, who gives him two black stones to leave for his children.

His attempts to do good keep misfiring. Cheap gas heaters he buys to keep the Chinese workers warm kill them overnight through carbon monoxide poisoning. He tries to secure his children's future by leaving his savings with Ige, a Senegalese widow.

Weakening, incontinent and bleeding, he gives Ana his father's ring, tells her what he can manage, and dies beside her. A last scene reunites him with his own young father in a snowfield.

The ending is discussed below.

The physical honesty here is rare. Uxbal passes blood, wears incontinence pads and vomits, and none of it is softened or shot tastefully at a distance.

That matters because incontinence and bleeding are among the symptoms people are least willing to mention, to their families or to their doctors. A film that says them out loud does a small useful thing.

His drift from chemotherapy to a healer is also recognisable. People do stop treatment when it makes them feel worse and cannot cure them. That is not stupidity or superstition; it is a rational response to a bad trade, made without anyone sitting down and explaining what the trade actually was.

The last weeks are right too. The world shrinks. The urgent questions become practical: money, guardianship, who will have the children. Uxbal is not frightened of dying so much as of leaving two children unprotected, and that is where most parents' fear actually sits.

The film's real subject is what a diagnosis does to someone with no margin.

There is no sick pay. There is no family to fall back on. There is a health system he can technically use and cannot really use, because stopping work is not an option and appointments are during working hours.

This is worth naming plainly, because it is not only a Barcelona problem. Late diagnosis clusters in people with insecure work, insecure housing and insecure immigration status, and the reasons are logistical before they are medical. Uxbal is not neglecting himself. He is doing the arithmetic of a man who cannot afford a Tuesday morning.

Here the film simplifies badly. He is given chemotherapy and then nothing.

Prostate cancer that has spread is normally treated first with hormone therapy, also called androgen deprivation therapy, because male hormones drive the cancer's growth. NCI lists the options for stage IV disease as hormone therapy, hormone therapy combined with chemotherapy, bisphosphonate therapy, external radiation, and alpha emitter radiation therapy, which is used when the cancer has reached bone. None of this is mentioned.

The timeline is compressed too. Uxbal is diagnosed with advanced disease and dies within roughly two months, staying mobile and negotiating deals almost to the end. Advanced prostate cancer in bone usually brings pain and fatigue that would have stopped him far earlier.

And the film never asks how the disease got this far unnoticed, which leaves the impression that prostate cancer simply appears at a terminal stage.

Early prostate cancer usually causes nothing at all. NCI notes that in the United States about one man in eight will be diagnosed with it at some point.

When early symptoms do appear, NCI lists:

• Trouble starting the flow of urine.
• Frequent urination, especially at night.
• Trouble emptying the bladder completely.
• A weak or stop-and-go flow.

All of those are caused far more often by benign prostatic hyperplasia, a non-cancerous enlargement of the prostate that is very common with age.

For more advanced disease, NCI lists pain in the back, hips or pelvis that does not go away, and the symptoms of anaemia: breathlessness, tiredness, a fast heartbeat, dizziness or pale skin. The CDC's symptom list also includes pain or burning when passing urine, painful ejaculation, and blood in the urine or semen, which is what sends Uxbal to the doctor.

Blood in the urine has many causes, most of them not cancer. It is never something to watch and wait on.

Prostate cancer can be screened for with a PSA blood test, but the US Preventive Services Task Force deliberately declines to recommend it for everyone.

For men aged 55 to 69 it is a grade C recommendation, which means the decision should be an individual one made after a conversation about benefits and harms. The benefit is a modest reduction in deaths from prostate cancer and in cancer spreading. The harms are false positives, complications from biopsy, and finding slow-growing cancers that would never have caused any trouble, then treating them at the cost of incontinence or erectile dysfunction.

For men aged 70 and over the Task Force recommends against PSA screening, a grade D. It notes that the harms are greater in this group.

The Task Force also says the balance should be weighed with family history and race in mind, and points clinicians to separate guidance on higher-risk groups, including African American men and men with a father or brother who had prostate cancer. Those men are usually advised to have the conversation earlier.

One distinction does the most work here. Screening means testing when nothing is wrong. If you have symptoms, you are not being screened, and none of the arguments above apply. Get assessed.

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Biutiful is a punishing film and an honest one about the body. It is unreliable about treatment, and it should not be read as a picture of what happens after a diagnosis of advanced prostate cancer.

Its most transferable insight is not medical. A cancer diagnosis lands on top of whatever life a person already has, and a life with no slack in it has nowhere to put one.

If you are passing blood, or if urinary symptoms have changed and stayed changed, that is not a screening question and it is not something to sit on. See possible warning signs and screening.

This page discusses Biutiful for education. It is not medical advice, and nothing here is a judgement of anyone's real medical care. Spotted an error? Please email corrections@cancerexplained.org.