Going Public
Harry Belafonte is appearing in Newport Beach in April. To sing? No, to talk about his prostate cancer.
Sen. Barbara Boxer (D-Calif.) dropped by UC Irvine in January. She doesn’t even have a prostate gland, but prostate cancer was her topic.
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.
“The first major meeting on prostate cancer was held in 1963,” says Donald F. Coffey, a professor of urology at Johns Hopkins University in Baltimore. “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 diagnoses, 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.”
But things have changed.
Prostate cancer, mainly associated with old age, is now known to start as early as age 20. It usually grows so slowly, however, that many more men die with prostate cancer than die of it.
Improved treatment has greatly reduced the side effects of 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 it 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.
This makes prostate cancer “the most complex cancer problem the nation is facing,” says Dr. Harmon Eyer, chief medical officer of the American Cancer Society.
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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 nourishes sperm and forms semen by producing a protein called PSA.
Cancer in the prostate is unique because it usually develops very slowly--so slowly that 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: A minority of 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 the serious side effects--incontinence, impotence and big medical bills--when you might not have needed treatment at all.
“Right now it’s all an odds game,” says Dr. Otis Brawley, an oncologist and epidemiologist at the National Cancer Institute.
“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 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 that by age 60, odds are about 50-50.
Dr. Wael Sakr, a pathologist at Wayne State University in Detroit, has since 1991 been examining the prostates of most men autopsied by local coroners. He found the first tiny lesions of cancer in a few men in their 20s and in about 30% of men in their 30s. Most of these cancers would never have progressed to a dangerous stage, he says.
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How Good Are the Tests?
Until the 1990s, they weren’t very good at all.
A physician would perform a rectal examination to feel whether the prostate was hard or misshapen.
But 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, a well publicized trial confirmed that elevated blood levels of PSA, the protein the prostate produces, indicated possible prostate cancer.
The PSA test now is common and costs between $50 and $90. Since the test’s general use, 70% of diagnosed cancers are caught before they have spread out of the prostate.
It is “the best marker we have now for any cancer,” Coffey says, but its marksmanship is mediocre. It misses many prostate cancers, and when its results are positive, about two-thirds of the time it’s a false alarm.
If the physician suspects cancer, the next step is taking tissue samples with a needle device. Any cancer tissue found is graded according to quantity and stage of development. The result is called the 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.
Coffey likens 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 Dr. 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.”
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How Good Is Treatment?
Between 1991 and 1995, the death rate from prostate cancer fell by 6.3%.
“These are huge numbers,” says Dr. Thomas A. Ahlering, a surgeon and chief of urology at the UC Irvine College of Medicine.
“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 surgeon’s problem has been, and remains, the prostate’s location so close to other vital body parts.
It rests against the nerves that control erection, which, if permanently damaged, leave the man impotent.
It also rests against the two ring-shaped muscles that pinch the urethra closed until it’s time to urinate. If one of these muscles is not preserved, the man loses control of urination.
New surgical techniques have reduced these side effects, but the techniques are difficult to master. Even the best surgeons feel as if they are defusing a bomb, Ahlering says.
Still, he estimates, good surgeons prevent incontinence in all but 5% to 15% of cases, depending on the patient’s age--the younger the better. Under ideal conditions, a man younger than 60 has an even chance of remaining potent after surgery, Ahlering 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.
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.
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 male hormones are reduced or eliminated, usually with drugs. This method does not cure the disease, but it sometimes achieves a spectacular and long-lasting remission.
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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.”
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The Male Anatomy
The prostate, about the size of a golf ball, is a male sex gland. It lies below the bladder, surrounding the upper part of the urethra.
Symptoms
Early prostate cancer often has no symptoms. The following symptoms, however, could indicate prostate cancer or a noncancerous condition called benign prostatic hyperplasia:
* Need to urinate frequently, especially at night.
* Difficulty starting or holding back urination.
* Inability to urinate.
* Weak or interrupted flow of urine.
* Painful or burning urination.
* Painful ejaculation.
* Blood in urine or semen.
* Frequent pain or stiffness in lower back, hips or upper thighs.
Source: American Cancer Society
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Resources
* American Cancer Society: (800) ACS-2345
* American Foundation for Urologic Disease: (800) 242-AFUD
* Cancer Information Service: (800) 4-CANCER
