COLUMN ONE : The Disease Men Try to Ignore : Awareness of prostate cancer has lagged, as have research funds. But a new openness and better treatments raise chances of stopping it without the feared side effects.

By THOMAS H. MAUGH II

Jan. 2, 1995 12 AM PT

TIMES MEDICAL WRITER

Norman Schwarzkopf’s prostate cancer almost wasn’t detected. “When you are a general, the doctors don’t tend to do a thorough digital rectal exam,” says the leader of America’s Gulf War forces.

Even though he had none of the symptoms, Schwarzkopf had been doing a lot of reading about prostate cancer. So, during a hospital visit for a different purpose, he asked a urologist to do a more thorough exam. The doctor felt a tiny lump.

In May, after a biopsy indicated cancer, Schwarzkopf had so-called nerve-sparing surgery that removed the tumor while avoiding the two problems that most torment men facing prostate cancer: incontinence and impotence. Today, says the 60-year-old retired Army general, “I feel like a million dollars. . . . Everything is absolutely, totally back to normal.”

Schwarzkopf’s experiences are typical of both the problems that can hamper detection and the promise offered by quick diagnosis and new treatments in defeating a disease that, among cancers, is second in prevalence only to skin tumors.

A new blood test has the capability to detect prostate cancer before it has metastasized, and new surgical and radiation treatments can halt the tumor without debilitating side effects. “If it is detected early, you can be cured, and you can also have a normal life,” said Dr. Patrick Walsh of Johns Hopkins University in Baltimore.

Despite the advances, however, prostate cancer remains a devastating disease. Approximately one in nine men will develop prostate cancer, a risk slightly greater than a woman has of developing breast cancer. This year, about 200,000 American men will develop it and 38,000 will die from it.

Part of the problem can be traced to the disease’s image. Although it is more common than breast cancer, relatively few men are familiar with prostate cancer and fewer still are willing to undergo screening. Men simply do not want to think about it, experts say. And unlike with breast cancer and other diseases, only recently have celebrity spokesmen begun talking about prostate problems.

“There’s been no Betty Ford (breast cancer), no John Wayne (lung cancer) . . . , “ Walsh said.

That situation is changing. In addition to Schwarzkopf, former pro quarterbacks Johnny Unitas and Len Dawson have spoken out about their experiences, as have Sen. Bob Dole (R-Kan.) and retired Sen. Alan Cranston (D-Calif.).

Also, prostate cancer was reported as the cause of death for actors Bill Bixby and Don Ameche, rock musician Frank Zappa and entertainment mogul Steve Ross.

Nonetheless, in terms of public awareness, “We’re 20 years behind the women,” said Bill Whitmore of Boston, co-founder of one of the first prostate cancer support groups, US TOO.

As a result, research support has lagged. Funds for study of breast cancer, which strikes about 180,000 American women annually and kills 46,000, will total $262.9 million this year, or about 13.5% of the National Institutes of Health research budget. Research on prostate cancer will total $55 million, about 3% of the budget.

“There is no question that breast cancer is important, but prostate cancer also deserves some funding,” said Dr. E. David Crawford of the University of Colorado, chairman of the National Prostate Education Council, organized to encourage men to undergo screening.

The reasons for the disparities seem all too clear to many men. “Anything associated with sexual organs or the natural processes of elimination, men tend to be squeamish talking about it,” said Hank Porterfield of US TOO.

Even William Martin, who wrote “My Prostate and Me” about his experiences with cancer, admits to reservations. “The first time a journalist asked me about my sex life, I thought, ‘Hey, that’s awful personal,’ ” said Martin, a sociologist at Rice University in Houston.

“That’s one of the reasons the disease is so dangerous. Men not only don’t want to talk about it, they don’t even want to think about it.”

That reluctance is layered atop a more fundamental disregard for physicians. “Men grow up learning it’s unmanly to make too much out of any health problems,” according to Dr. Abraham Morgantaler, author of “The Male Body.”

As a consequence, women visit doctors more often, are hospitalized more often and undergo more operations, according to figures compiled by the U.S. Department of Health and Human Services. Two out of every three health care dollars are spent on women.

Slowly, however, men are becoming more open about their bodies and their health. Schwarzkopf said he sought more extensive screening as “reassurance.” Now, he said, “I’m damn glad I did what I did and I advise every friend that I have, if you are over 50, go in and have (the tests) and look the urologist in the eye and say, ‘Take all the time you need.’ ”

Doctors like Crawford are increasing efforts to educate men about health options and men are creating support groups similar to those for breast cancer.

Five years ago, according to the American Foundation for Urologic Disease Inc., there was only one, rather informal prostate cancer support group, located on Cape Cod. Today, there are 315 throughout the country, and they are becoming more vocal. A New England network of about three dozen groups, for example, helped persuade Massachusetts lawmakers to appropriate $1 million for prostate cancer information in 1995.

The prostate is a walnut-sized gland that sits beneath the bladder and surrounds the urethra, through which urine is eliminated. Its main function is to produce a nutrient solution for sperm that becomes part of the semen.

The cause of prostate cancer is unknown, but genetics play a major role. A man whose father had the disease has double the normal risk of developing it. Those who have two or more family members with the disease have five times the normal risk.

Most of the symptoms involve difficulties in urination. Unfortunately, they arise only after the tumor is no longer readily curable. That is why physicians stress the need for periodic examinations. In most cases, symptoms are caused by benign prostate enlargement, a painful but not life-threatening disorder in which swelling of the gland closes off the urethra. About 300,000 men in the United States each year undergo surgery to treat the benign form.

The digital rectal exam is the standard screening test, in which a urologist manually examines the prostate, feeling for lumps. However, more than 40% of the tumors detected in this manner have already metastasized.

Because of this problem, many physicians have hailed the introduction of the PSA test, which detects a protein called prostate specific antigen in blood. “This is the most important thing that has happened in prostate cancer research in the last five years,” said Dr. Timothy Wilson of the City of Hope National Medical Center in Duarte.

Although low levels of PSA are normally present in the blood, above-normal levels often indicate a tumor. When both PSA and rectal exams are used, the percentage of tumors that have metastasized before detection is reduced to 10% to 15%, according to Wilson.

Some critics have charged that the PSA test produces too many false positives. Colorado’s Crawford argues that this does not invalidate the test as a screening tool. While only 45% of men who have a high PSA value and an abnormal result in a digital rectal exam actually have a tumor, he said, “that’s two times the number of those who have an abnormal mammogram and actually have cancer, and mammograms are considered highly useful,” Crawford said.

Because of the value of screening, many researchers were outraged by the appearance of an unusual report in the Journal of the American Medical Assn. this fall that advised most men against prostate screening.

Dr. Murray D. Krahn and colleagues from the University of Toronto reported that screening men only once extended life span only marginally, and led to treatment-induced “reductions in quality of life,” including incontinence and impotence.

Some researchers have questioned the value of PSA detection in screening because the test has not been available long enough to show that it extends life span. However, Krahn’s report was the first to actually argue against it.

Critics charge that he failed to recognize improvements in life span resulting from recent advances in treatment and overemphasized the negative aspects of treatment.

“The JAMA study cannot be applied to the average prostate cancer patient,” argued Dr. William J. Catalona of the Washington University School of Medicine in St. Louis. “The study misleads the public because its conclusions are based on old information that grossly underestimates the lethal potential of prostate cancer.”

The Krahn study, in effect, “is making an assumption that you’re better off dead than impotent and, personally, I’d rather be alive and impotent than dead,” said Dr. Ralph deVere White of the UC Davis Medical Center.

When a cancer is discovered, the choice of therapy depends on how advanced the tumor is. If the cancer has not metastasized, the best treatment is a radical prostatectomy, in which the gland is removed. As a cure, it is “the gold standard” to which all other procedures must be compared, Wilson said. About 100,000 men have their prostates removed each year in the United States.

Surgery is also a major source of the side effects that were once the bane of men with prostate cancer. Until a few years ago, at least 15% of surgery patients became incontinent and virtually all lost sexual function.

That situation was changed by Walsh--called the “Michelangelo of prostate surgery” by Johns Hopkins colleague Donald Coffey--who devised a technique that drastically reduced blood loss. “I think everyone would admit that the operation used to be performed in a pool of blood” that made it impossible for surgeons to see what they were doing, Walsh said.

He also discovered ways to remove the prostate without damaging the nerves that control erectile tissue. This is the procedure that Schwarzkopf underwent.

Today, 2% of men ages 50 to 70 who undergo the Walsh procedure experience incontinence and 25% suffer loss of sexual function. (Even in those cases, Walsh said, a prosthesis can help.) In that age group, 95% have no recurrence of cancer within the first year. Recently, Walsh reported a four-year disease-free rate of 76%.

The second most common therapy is radiation, which is chosen by patients who cannot or do not want to be hospitalized for surgery or in whom the tumor is inoperable. A beam of radiation is directed at the tumor daily for six to eight weeks in an attempt to kill malignant cells.

A recent study showed a 27-month survival rate of 72% for those treated with radiation, but most studies have found a five-year survival rate of about 20%. And there are more side effects than with conventional surgery. About 3% of patients become incontinent and more than half become impotent. Many patients also develop painful radiation burns of the mucosa lining the rectum, as well as fatigue, diarrhea and painful and frequent urination.

Physicians have high hopes for two newer techniques--cryosurgery and radioactive seed implants. In the former, surgeons use a liquid-nitrogen-cooled probe to freeze tumor cells, killing them instantly. In the latter, rice-grain-sized pellets of radioactive isotopes are implanted in the tumor to kill it with localized radiation.

Both can be performed with only an overnight hospital stay, or on an outpatient basis. They are substantially cheaper than conventional surgery and the patient can return to work more quickly.

Cryosurgery can have “tremendous advantages” because it is much easier than conventional surgery, said Dr. Kenneth P. Ramming of the John Wayne Cancer Institute in Santa Monica. In the 55 cases he has treated, he said, he has seen no instances of incontinence or impotence and no recurrence of the tumor. He cautioned, however, that he has no long-term follow-up data on his cases, because his first patient had the treatment just 14 months ago.

But not everyone gets such good results, Wilson said. He noted that “some centers are reporting impotence rates of 30% to 80%” and incontinence rates as high as 30% among cryosurgery prostate patients. “This is something that should not be done in the community at this point, only in a research setting,” he said.

Radioactive seed implants also look promising. In a recent study, Dr. John C. Blasko and colleagues at the Northwest Tumor Institute in Seattle reported that 93% of patients treated with the seeds were disease-free after 37 months. The impotency rate was about 10%, incontinence about 1%.

“Our research shows that . . . seed implantation may be as effective as radical prostatectomy and external radiation, but without their cost, inconvenience or likelihood of side effects,” Blasko said.

The final option is simply to do nothing--a choice known as watchful waiting. By and large, prostate cancer progresses slowly. If a patient is elderly and in poor health or has some other disease with a relatively short life expectancy, most experts agree, he will get little benefit from treatment.

The problem, Wilson said, is where to draw the line. And there are no hard and fast rules. “You might find a healthy 80-year-old with 10 to 15 years of life expectancy who deserves aggressive treatment, or a 60-year-old with severe heart disease who doesn’t,” he said. One complicating factor is that some prostate cancers progress rapidly, but physicians have no way to identify them.

One sign of aggressiveness is metastasis, and researchers at Columbia-Presbyterian Medical Center in New York City earlier this year announced a new blood test to detect metastasis earlier. The test uses a new genetic engineering technology called PCR--the same technique used in genetic fingerprinting and a host of other applications--to identify prostate cells in the bloodstream.

If prostate cells are present, the tumor has begun metastasizing and should be removed immediately, said Dr. Carl Olsson of Columbia. If there are no cells present, it is still confined to the prostate and watchful waiting is called for. “Routine use of the assay could conceivably spare 25% to 30% of (prostate patients) from surgery,” he said.

Dr. Gary R. Pasternack of Johns Hopkins has developed a more direct test of aggressiveness. He looks for the presence of a genetic marker called pp32 in cells obtained from the tumor in a biopsy. If the marker is present, the tumor is aggressive and should be treated as such. If it is not, the tumor is the slow-growing type, he said, and watchful waiting is indicated.

Schwarzkopf learned about all these options on his own. He also talked to two close friends who had undergone prostatectomies. “Quite frankly, they both said it was no big deal, that there was no need to be concerned, “ he said.

Today, he said, “I have completely resumed my former lifestyle. In July, I spent two weeks in Alaska standing in rivers salmon fishing. In August, I was . . . (hunting) in Africa. I feel great.”

COLUMN ONE : The Disease Men Try to Ignore : Awareness of prostate cancer has lagged, as have research funds. But a new openness and better treatments raise chances of stopping it without the feared side effects.

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