The Curious Prostate Cancer Case of the Libyan Terrorist

Just over a year ago, Scottish authorities released Abdel Basset Ali al-Megrahi, the Libyan terrorist who killed 270 people on Pan Am flight 103 above Scotland in December 1988. Despite being sentenced to life imprisonment for his role in masterminding the deadly attack, his release was allowed on humanitarian grounds because he had advanced prostate cancer. Medical "experts" in the British prison system said that he had less than 3 months to live. On this advice, he was freed and returned to Libya so that he could die with his family members. However, he is still alive and well today, more than 9 months after he was predicted to die. Needless to say, the families of the 189 American victims are upset about this.

Without discussing the ethics of the decision to release al-Megrahi, or British Petroleum's alleged role in his release to secure oil contracts in Libya, I wanted to discuss some misconceptions surrounding advanced prostate cancer. The full medical records that resulted in his release have not been made public. However, based on the comments from Kenny MacAskill, the Scottish justice minister who freed him, and Dr. Andrew Fraser, the medical director of the Scottish prison system, I can make an educated guess about the status of his cancer. Because of the complexity of prostate cancer, even doctors can be confused by it. I think this is what occurred. From the doctors' comments made to the press, it appears that al-Megrahi had not started a recommended course of chemotherapy. If this is true, then the prediction of a three month life expectancy is far lower than it should be.

Prostate cancer advances through a series of stages. With the use of the PSA blood test as screening, most men are diagnosed in the localized stage. If caught in this window, the vast majority of men are cured of their cancer. This is what I prefer specially with the skills from open surgery and robotic laparoscopic skills, men are able to have an excellent sexual function and urinary continence, while they are cured of the prostate cancer. After treatment (or if it is not caught early) the cancer can return in rare cases, which we know because the PSA rises. At this point, however, the cancer needs the male hormone testosterone to grow. By shutting down testosterone with either medical or surgical castration, the growth of the prostate cancer can be suppressed. Eventually, however, the cancer will become resistant to the castration and start to grow again. At some point during the process from rising PSA to castrate-resistance, the cancer will escape from the prostate and go to other parts of the body, which is known as metastasis. Once patients are castrate-resistant, the only treatment is chemotherapy.

Given the grim prognosis that the Scottish authorities cited, it is likely that al-Megrahi had metastatic castrate-resistant prostate cancer. If he didn't, then the 3-month life expectancy was hugely underestimated. But assuming he did, the time from this diagnosis to death is often difficult to predict. On average, men receiving the chemotherapy he was recommended live 19 months after starting treatment. However, some men live 3 years or more.

In any event, it is clear that the 3 month life expectancy given as the rationale for his release was far too low. Hopefully the British authorities will comply with the request of the Senate Foreign Relations Committee to release the medical records so we can better analyze the data. If they do, I will be able to give a much more accurate commentary.

David B. Samadi, MD is the Chief of Robotics and Minimally Invasive Surgery at Mount Sinai School of Medicine in New York City. As a board-certified urologist and an oncologist specializing in the diagnosis and treatment of urologic diseases, kidney cancer, bladder cancer, and prostate cancer, he also specializes in many advanced minimally invasive treatments for prostate cancer, including laparoscopic radical prostatectomy and laparoscopic robotic radical prostatectomy. His Web site, Robotic Oncology, has been translated into six different languages and is one of the most popular urology sites on the Internet.