Remembering Robbie Robertson — and Understanding Prostate Cancer

What was said

Robbie Robertson was the guitarist and chief songwriter of The Band, and later a film composer. The Guardian reported that he died in Los Angeles on Wednesday, August 9, 2023, at the age of 80.

His management said he "had suffered from a long illness." His manager of 34 years, Jared Levine, wrote that Robertson "was surrounded by his family at the time of his death."

The family did not release a diagnosis, and this page will not assign one. What follows is an explanation of prostate cancer, which is worth understanding on its own terms, because almost nothing about it works the way people assume.

Where the prostate is, and what it does

The prostate is a walnut-sized gland below the bladder in men. The urethra, the tube that carries urine out, runs straight through it. The gland makes fluid that forms part of semen.

That anatomy explains two things. It explains why prostate problems cause urinary symptoms. And it explains why treating the gland can affect both urinary control and sexual function.

The symptoms are usually not cancer

This point is important and often missed. The National Cancer Institute (NCI) lists the urinary symptoms of local prostate growth: a weaker stream, urgency, hesitancy, waking at night to urinate, and a sense of not emptying fully.

NCI then says something plainly. These symptoms "are nonspecific and more indicative of benign prostatic hyperplasia than cancer." Benign prostatic hyperplasia is simple age-related enlargement of the gland. It is extremely common and is not cancer.

Early prostate cancer usually causes no symptoms at all.

When to raise it

See a clinician for:

• A urinary stream that has clearly weakened, or getting up more than twice a night to urinate
• Blood in the urine or the semen
• New, persistent bone pain, especially in the lower back, hips, or ribs
• Weight loss you did not intend

Go to an emergency department for a complete inability to pass urine. Also go immediately for back pain together with new leg weakness, numbness, or loss of bladder or bowel control. That combination can mean pressure on the spinal cord and is time-critical.

Raise the subject of PSA testing earlier than average if you are Black, or if your father or brother had prostate cancer, or if BRCA2 runs in your family. Prostate cancer death rates are higher in non-Hispanic Black men, according to SEER, the federal cancer surveillance program.

The PSA test, described honestly

Prostate-specific antigen is a protein made by the prostate and measured in blood. Its appeal is obvious: it needs only a blood sample, and it returns a number.

Its limits are just as real. PSA rises with benign enlargement, with infection, and with age, so a raised result frequently means no cancer. NCI notes a "gray zone" between 2.5 and 4.0 ng/mL where interpretation is genuinely unclear.

On whether screening saves lives, NCI is unusually blunt. It records the magnitude of the mortality benefit as "uncertain," and states that results from randomized trials are inconsistent.

On harms, NCI is not uncertain at all. It states that "based on solid evidence, screening with PSA and/or DRE results in overdiagnosis of prostate cancers and detection of some prostate cancers that would never have caused significant clinical problems."

Biopsies themselves carry risk. NCI lists fever, pain, blood in semen or urine, urinary infection, and rarely sepsis.

None of this means do not get tested. It means the test deserves a conversation rather than a reflex.

Grade Group: the number that matters most

If cancer is found, a pathologist grades it. The older Gleason system adds the two most common growth patterns, each scored 1 to 5, to give a total.

Because that produced confusing scores, it was translated into Grade Groups 1 to 5. NCI sets them out:

• Grade Group 1: Gleason 6 or less
• Grade Group 2: Gleason 7, written as 3+4
• Grade Group 3: Gleason 7, written as 4+3
• Grade Group 4: Gleason 8
• Grade Group 5: Gleason 9 or 10

Note that both Grade Group 2 and Grade Group 3 are "Gleason 7." The order of the two numbers matters, because the first is the dominant pattern. This is why Grade Group is now the more useful term.

Not every prostate cancer needs treating

Active surveillance means monitoring a low-risk cancer with repeat PSA tests, examinations, imaging, and biopsies, and treating only if it shows signs of progressing.

That sounds alarming. The evidence behind it is not. Many prostate cancers grow so slowly that they never threaten the man who has them, and NCI notes that even after spread to distant organs, some men have indolent courses lasting many years.

The problem is that no test reliably separates the dangerous cancers from the harmless ones at the outset. NCI points out that PSA level and PSA rate of change both classify men poorly at every cutoff studied.

What treatment costs

This is the arithmetic on the other side of the ledger, and NCI states it clearly. Between 20% and 70% of men who had no problems before radical prostatectomy or external-beam radiation "will have reduced sexual function and/or urinary problems."

A direct comparison sharpens it. NCI reports that radical prostatectomy was associated with more urinary incontinence than radiation, 9.6% against 3.5%, and more impotence, 80% against 62%. Radiation was associated with slightly greater declines in bowel function.

These are permanent changes for many men. They are the reason "just take it out" is not automatically the right answer.

The numbers

About 333,830 new prostate cancers and 36,320 deaths are expected in the US in 2026. Those yearly counts are American Cancer Society projections, which SEER reprints. NCI's own registry measurements, covering men diagnosed from 2016 to 2022, put five-year relative survival across all stages at 98.2%. Median age at diagnosis is 68.

By stage, survival over that same period is 100.0% for localized disease, 100.0% for regional disease, and 40.1% for distant disease. Localized cases make up 69% of diagnoses, regional 14%, and distant 9%.

Those first two figures are not typos. They reflect how slowly most of these cancers behave. The 40.1% figure is the one that shows why the distinction between low-risk and high-risk disease matters so much.

All of these are group statistics drawn from a national registry. They describe populations, not people.

Sources

• https://www.cancer.gov/types/prostate/hp/prostate-screening-pdq
• https://www.cancer.gov/types/prostate/hp/prostate-treatment-pdq
• https://seer.cancer.gov/statfacts/html/prost.html
• https://www.theguardian.com/music/2023/aug/09/robbie-robertson-band-dead-age-80
• https://www.theguardian.com/music/2023/aug/10/robbie-robertson-obituary