state of the prostate

Harry Belafonte is coming to Orange County in April. To sing? No, to talk about his prostate cancer.

Michael Milken lectured here in August, but his topic was not junk bonds. He talked about his prostate cancer.

Sen. Barbara Boxer dropped by in January. She doesn’t even have a prostate gland, but prostate cancer was what she wanted to talk about.

After generations of being an unfit topic for polite conversation, this disease, the most common cancer and the No. 2 killer among American men, has finally become a hot topic. Now public figures are lining up to give their first-person accounts.

“For 30 years, no one ever called me about this,” says Donald F. Coffey, a professor of urology at Johns Hopkins University and one of the world’s foremost authorities on the prostate.

“The first major meeting on prostate cancer was held in 1963,” Coffey says. “The next one wasn’t until 1970. Can you believe that? And now there’s meetings every hour on the hour.”

Women, complaining that a male-dominated medical establishment had shortchanged them, rallied a decade ago and demanded more research into breast cancer. Now they are reaping the rewards--more sophisticated diagnosis, improved treatment and ongoing research into possible cures.

But if men were in charge all this time, why weren’t they funding research into the cancer that half of them have by age 60? It kills as many men as breast cancer kills women, yet until recently research grants were virtually nonexistent.

“Males just didn’t like to discuss that they have prostate problems,” Coffey says. “I have no idea why, but I think it’s for the same reason that males won’t stop and get directions when they’re lost. It’s got something to do with male ego or macho, whatever you want to call it.”

We can make some good guesses, however.

Prostate cancer has been diagnosed mainly in the elderly. Therefore, having prostate cancer confirmed you were old.

Treating prostate cancer meant you ran a risk of becoming incontinent. Only babies wet their pants.

And treating prostate cancer often left the man impotent. Enough said.

Beliefs have changed since then. Researchers now think prostate cancer starts early in a man’s life, perhaps in the 20s, and usually grows so slowly that many more men die with prostate cancer than die of it.

Improved treatment has greatly reduced incontinence and impotence.

And a blood test, though imperfect, now can warn of prostate cancer much earlier than before.

Now the American Cancer Society in California has enlisted boxer George Foreman to strike a manly pose on posters and proclaim, “Real men get it checked.”

But get it checked and what happens? You discover that among reputable physicians and researchers, there is disagreement over virtually everything about prostate cancer.

The blood test gives a lot of false alarms and usually fails to detect the smaller cancers.

If you do have cancer, it may be threatening your life. But it may be growing so slowly you’ll die of boredom before you have any cancer symptoms.

Surgery and/or radiation may save your life. Or they may leave you incontinent and impotent when treatment was unnecessary.

There is even disagreement about whether you should be tested at all. Some believe the psychological wear and tear of a prostate cancer diagnosis is worse than the threat from the disease itself.

Patients looking for definitive answers find that there are none. Many physicians instead give a patient an education about alternatives, then hand the decision back to him. You decide what to do.

“The side effects of treatment may be serious--that’s the issue,” says Dr. Thomas A. Ahlering, a surgeon and chief of urology at the UC Irvine College of Medicine. He has performed about 200 prostate surgeries and is in charge of training resident urologists at UCI.

“You’ve got this long period before this cancer really becomes a problem to you,” says Ahlering. “You have to prioritize. The psychological factor is a very important factor.”

Dr. Harmon Eyer, chief medical officer of the American Cancer Society, says he considers prostate cancer “the most complex cancer problem the nation is facing.

“It’s a very poorly understood issue of cause, screening, treatment. All of these things the public are poorly informed about.”

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The cause of all this trouble is a golf ball-size gland in the male abdomen. It lies near the bladder, where urine is stored, and near the seminal vesicles, where semen is stored. The urethra--the tube that carries both urine and semen out of the body--runs right through the prostate.

Until the 1970s, researchers were unsure of the prostate’s role. Now it’s generally agreed that the prostate is assigned the care and feeding of sperm.

Sperm are manufactured in the testicles, then deposited in the seminal vesicles, a halfway house where they wait in a thick, gelatin-like solution until called for duty. The prostate adds a fluid called prostate specific antigen (PSA) that both nourishes the sperm and thins the solution into easy-flowing semen. Sperm can’t leave home without it.

Cancer arises in the prostate the same way it appears anywhere else in the body, researchers believe. A series of changes in genes over many years produces a cell that ignores the usual rules. This renegade is now a cancer cell, which reproduces faster than normal cells and never stops.

These cells gather in colonies called tumors and compete with normal cells for space and nourishment. Eventually the cancer cells hog so much of the body’s nourishment and crowd out so many normal cells that vital parts of the body can no longer function.

The uniqueness of prostate cancer, however, is that usually this is a very slow process.

Cancers of the lung, liver, pancreas and brain spread so quickly they are almost never caught in time. In effect, a diagnosis is a death sentence.

But prostate cancer grows so slowly that researchers believe it can arise in middle age or earlier and never cause any symptoms during a normal life span.

That’s good news, but here’s the bad: Some prostate cancers are quick and aggressive. They can spread to the bones of the pelvis, lower spine and ribs, sometimes to the legs and arms, and cause a protracted and agonizing death. But there is no sure way to tell these quick cancers from the slow ones.

Just to be safe, why not attack all prostate cancers with surgery and/or radiation? Answer: Because you risk some serious side effects--incontinence, impotence and big medical bills--when you might not have needed treatment at all.

For some with prostate cancer, “an operation is not going to prolong his life but is going to make him more miserable,” says Dr. Otis Brawley, an oncologist and epidemiologist at the National Cancer Institute.

“Right now it’s all an odds game. If you are diagnosed with prostate cancer, you have a 25% chance of dying from it. I know what to do if we’re talking about a group of a thousand guys. I have no idea what to do with the one guy in front of me. No one knows the right thing for that one individual.”

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Who Gets Prostate Cancer?

About 10% of prostate cancer is inherited.

About one in five men at some point in his life will be found to have prostate cancer.

Black men seem more susceptible than white men. Latinos and Asians seem far less susceptible than whites. Still, for all men, prostate cancer is the most common cancer.

The rule of thumb is to take your age, subtract 10, and that’s your approximate chance of having prostate cancer at that moment. That means by age 60, odds for white men are about 50-50.

Since 1991, Dr. Wael Sakr, a pathologist at Wayne State University and the Karmanos Cancer Institute in Detroit, has been trying to discover at what age the first tiny lesions of prostate cancer appear.

Working with urologist Gabriell Haas, Sakr has sectioned and microscopically examined the prostates in most of the men autopsied by local coroners. Although his sample is not purely random, he believes his major findings are sound.

And surprising. “We found that the prevalence of these small, so-called latent cancers start at a young age. Our data indicate that among men in their 30s it’s been about 25% to 30%, perhaps even higher.”

Sakr says there are different ways to view this finding. It might be alarming that the cancer begins at such a young age, “but we know statistically that most of those who get it younger will probably not progress” to the cancer’s dangerous stages.

How Good Are the Tests?

Until the 1990s, they weren’t very good at all.

A physician would perform a rectal examination to feel the prostate, which lies against the front wall of the rectum. The physician was testing whether the prostate felt hard or misshapen.

The trouble was that cancer discovered by this method usually was at an advanced stage and difficult to treat. About 70% had already spread outside the prostate.

In 1989, however, William J. Catalona, a urologist at Washington University in St. Louis, ran a well-publicized trial of the blood test that measures PSA, the substance the prostate produces to nourish sperm and thin semen. His trial confirmed that a rising level of PSA in the blood could be an early warning sign of prostate cancer.

The PSA test, now in general use and locally costing between $50 and $90, “has its good and bad sides,” but it has turned out to be “the best marker we have now for any cancer,” Coffey says.

The good side is that since the test’s introduction, 70% of cancers are found before they have spread. This makes them much easier to treat.

The bad side is the test’s mediocre marksmanship. It misses diagnosing many prostate cancers. And when the result is positive, about two-thirds of the time it’s a false alarm. The elevated PSA is being caused not by cancer but by some other condition.

“There is no book that says if you have a PSA of this, then you do that,” Ahlering says. “It’s still very much up to the physician’s experience and judgment.”

If the test makes the physician suspicious, the next step is a needle biopsy. A tube inserted into the rectum sends six tiny needles into the prostate, withdrawing tissue samples in a few milliseconds. Then the tissue is examined under a microscope.

If cancer tissue is found, it is graded according to how much was found and how fast it’s growing. It’s given what pathologists call a Gleason score--2 being the least aggressive cancer, 10 being the most aggressive.

The extremes of the Gleason scale are fairly reliable indicators of how fast a cancer is growing. But most scores fall in the middle range, where it’s anybody’s guess.

There was a time when you could get a PSA test at a health fair or a table set up in the shopping mall. Since then, the American Cancer Society has backed away from its endorsement of mass screening. It now recommends men be tested by their physicians.

Last year, the federal U.S. Preventive Services Task Force and its Canadian counterpart recommended against mass screening.

Coffey likened the PSA test to a smoke alarm. “I’m just telling you if you have a smoke alarm going off in your house, you’d best check it out. If there’s a fire, I think the fire has to be put out.”

But what if the fire’s in the fireplace?

“The vast majority of men with prostate cancer don’t die of it,” says Gerald W. Chodak, a urologist and director of Weiss Memorial Hospital’s prostate center in Chicago.

“It’s not life-threatening to them, or they die of something else first. If they don’t understand the consequences of their test, they might find themselves on a railroad car they can’t get off.”

Chodak issues a two-page form to his patients listing the pros and cons of the PSA test, and patients must sign it before he’ll administer one. “No study has shown that screening reduces a man’s chances of dying or suffering from prostate cancer,” it states.

Catalona says that’s an unrealistic view. “Even if we were to plan those studies and do them today, there’s no way we could have that answer for 10 or 15 years. We would sacrifice a generation of men. That view in simply impractical.”

How Good Is Treatment?

In 1995, the estimated number of new prostate cancer cases was twice that in 1991. Yet the death rate had fallen by 6.3%.

“These are huge numbers,” Ahlering says. “We don’t know what’s responsible, but we just have to assume that PSA testing and therapy must be playing a role.”

Brawley of the National Cancer Institute says it’s too early to make that assumption.

The decrease “has varied by region,” Brawley says. “Connecticut has not screened and treated as aggressively as Washington. Connecticut also has a lower rate [of prostate removal surgery]. Yet both states have the same mortality rates for the same period.

“I actually think we are curing some people who need to be cured, but I don’t know that,” Brawley says.

Treatment may or may not be reducing deaths, but it is definitely reducing its own unpleasant side effects.

The problem with surgically removing the prostate is its location.

The valve that controls urination is a sphincter--a ring-shaped muscle that pinches the urethra closed until it’s time to urinate. It’s so close to the prostate that it’s virtually a part of it and can’t be spared.

The second, backup valve is very close to the prostate and requires extreme care to preserve. Lose that and you are incontinent.

The two nerves that control erection run right against the prostate. Any permanent damage to these nerves means impotence.

New surgical techniques introduced by Dr. Patrick Walsh, director of urology at Johns Hopkins University, were generally adopted by surgeons in the late 1980s and greatly reduced incontinence and impotence after prostate removal. The techniques are difficult to master, however, and even the best surgeons feel as if they are defusing a bomb, Ahlering says.

“Incontinence rates have dropped dramatically since the ‘80s. An honest appraisal of incontinence then was maybe 40% or 50%,” he says. “Now with a good surgeon, it’s between 5% and 15%, depending on your age--the younger the better. It’s our hope within the next five to 10 years we’ll have incontinence down for all patients under age 75 to 2% or 3%.”

Nowadays, under ideal conditions, a man under 60 years old has an even chance of remaining potent after surgery, Ahlering says. That too, is a great improvement, he says.

Radiation is another means of attacking cancer that has not yet spread from the prostate.

Usually it is administered by a machine outside the body, but radioactive “seeds” can be injected into the prostate near the cancer to kill it. The seeds remain in place and eventually lose their radioactivity. Radioactive rods can be inserted into the prostate and removed 48 hours later. These are relatively new treatment methods, and there is debate over their effectiveness.

If the cancer has spread outside the prostate, physicians generally turn to hormone therapy. The spread of prostate cancer is driven by male hormones, so to slow or stop its spread, male hormones are reduced or eliminated.

At one time this was done by removing the testicles, but nowadays the same effect can be achieved by drugs that block the testicles’ production of hormones.

This method does not cure the disease, but it sometimes achieves a spectacular and long-lasting remission.

A new method, cryoablation, uses liquid nitrogen injected into the prostate to freeze and kill cancer cells. The jury is still out on whether it is effective in the long run.

What Is Needed?

“What we need is some way to predict whether a patient’s prostate cancer is life-threatening,” Chodak says. “How fast is it going to grow? If it is going to take 10 years to develop and the man is already 75 years old, that makes it much easier to decide what to do.”

Coffey says research looks promising for such tests. An enzyme has been found in cancers but not in benign or normal tissues. “This could be a useful marker to tell cancers that might be on the march,” he says.

Another enzyme seems to protect against the genetic breakdown that leads to prostate cancer. It is absent in cancer cells but present in benign diseases. It, too, might be used as a marker.

And research into environmental factors such as diet is gathering steam, Coffey says. The fact that Asians have a low incidence of prostate cancer in Asia but a higher one in America shows that environment plays a factor, he says.

“We are getting underway in a big way,” Coffey says. “We’re far behind the research into breast cancer--I don’t know how far, but we’re struggling. There are ways to get at this disease; we’re just at too early a stage.

“There’s a lot of confusion and a lot of hype, and people taking strong positions, but there is some steady, good progress going on in this field.”