Treating Prostate Cancer
Maybe he lost his nerve, maybe he lost his lead, maybe it was the split with his wife. We’ve all got a favorite explanation for New York Mayor Rudolph Giuliani’s abrupt withdrawal from the U.S. Senate race. But the reason Giuliani himself has given--his health--cannot be easily dismissed.
Recently diagnosed with prostate cancer, the mayor now faces an agonizing, almost certainly life-changing, calculation about treatment. And he’s hardly the only one.
Every year, some 180,000 men learn they have the disease, and about 32,000 men die of it, usually after the age of 70. The diagnosis itself hits most men like a kick to the groin--and that’s exactly where the disease strikes. The apricot-sized prostate gland is located right behind the genitals, where it makes the fluid that nourishes sperm cells. And treating (i.e., attacking) a cancer in the prostate seems nothing short of emasculation.
It doesn’t help much to learn that most prostate tumors are very slow growing or that most men die with prostate cancer and not of it. In about 3% of all men, the cancer causes a painful, often lingering death, making it the No. 2 cancer killer among men, after lung cancer.
And here’s the cruel punch line: Doctors can’t tell for sure which prostate cancers are killers. They simply don’t have enough scientifically valid research studies to guide their predictions as they do, for example, with breast cancer.
Doctors diagnose prostate cancer by measuring blood levels of a protein called prostate-specific antigen, or PSA. Doctors consider PSA readings below 4 to be normal, between 4 and 10 to be slightly elevated, and above 10 to be highly elevated and solid evidence of cancer. Urologists then examine biopsies taken from the prostate and rate them on a 10-point scale, called the Gleason scale, according to how deformed the cells look. From these two scores, doctors make an educated guess about how the cancer will behave. But it’s a guess all the same.
“We’ve gotten very good at telling men whether they have the cancer,” says Dr. Paul Nutting, a Denver family physician who has served on a national panel to evaluate prostate cancer treatment and now edits the Journal of Family Practice. “But we still don’t know how to answer the big question: What do you do once you’ve got it? That is ultimately up to the patient--the man himself--to decide. A good doctor will lay out all the options.”
Those options are not at all pleasant. You can have the gland cut out, a major operation called radical prostatectomy, which leaves about 6% of men incontinent and at least 30% impotent. In 85% to 90% of cases, doctors say, the surgery removes all traces of cancer. But in the other 10% to 15% of patients, the cancer recurs, and it’s not clear how much the surgery helped, if at all.
Another way to attack the cancer is by zapping the prostate with radiation, either from an external beam, or from radioactive seeds that are implanted in the gland. Both treatments can cause urinary problems, and sometimes impotence. Like surgery, radiation therapy may leave some cancer.
A third option is to live with the cancer, hoping it doesn’t spread and managing it with drug therapies, some of which are still experimental.
The most popular choice is surgery. About one in three men decide--often quickly--to have their prostates cut out.
“Once you learn you’ve got cancer, it’s very hard to do nothing,” says Claus Roehrborn, a urologist at the University of Texas Southwestern Medical School in Dallas. “You want it out, and you may not want to listen to all the other alternatives.”
The ideal candidate for surgery, most doctors now agree, is a healthy man in his 50s or early 60s whose cancer is confined to the prostate and looks aggressive under the microscope. Men like Michael Tortosa, for example, a San Diego therapist who was diagnosed with a prostate tumor three years ago, at age 45.
“I decided to have the surgery pretty quickly,” Tortosa says. “I’m healthy, I run half-marathons, I expect to live a lot more years, and I just couldn’t bear the thought that this cancer would be growing inside me.”
Men nearing 70, or in poor health, are usually poor surgery candidates, urologists say. They run high complication risks while under the knife, and that’s why a good doctor will urge radiation treatment as an alternative. About 30% of patients try some form of radiation therapy, and most are men with significant detectable cancer whose life expectancy is not much longer than 10 years.
“Radiation is not quite as good as surgery at eliminating the cancer,” says Paul Lange, chairman of the department of urology at the University of Washington in Seattle. “But it’s easier on the patient and better at preserving potency.”
It’s not so easy, of course, as leaving the prostate alone. Urologists call this option “watchful waiting,” and some say it’s worth considering for men in their late 60s or older who have cancers with modest PSAs (from 4 to 10) and Gleason scores of around 5 or 6. The risk of waiting is that the cancer may escape the prostate and spread quickly, foreclosing any opportunity to try other treatment. The more likely benefit, says Roehrborn: a long, happy life without having to suffer the nasty complications of radiation or surgery.
“Many men are willing to choose watchful waiting when they hear about the complications of treatment, and they see the odds of dying of prostate cancer,” says Roehrborn, who himself is watching 50 such patients in Texas as part of a long-term study of watchful waiting. He checks PSA levels three times a year.
“So far, so good,” he says. “We have been watching this group for four years, and their PSAs have not changed much.” He says he would begin to worry if a man’s PSA doubled in any given year.
Curtis Minor, 63, a retired real estate appraiser in Simi Valley, began having his PSA checked every two months after being diagnosed with prostate cancer in 1998. At the time, his PSA was 7 and Gleason score 6--both elevated, but only modestly. Several doctors recommended surgery, but Minor had a heart condition and, at his age, thought that solution too extreme. He bided his time, and for about a year, his PSA held steady. Then, last year, it went up to 10, and then to 12.
That’s when he decided to try another treatment. He carefully studied the options: not only surgery and brachytherapy (seeds), but also cryotherapy, in which prostate specialists destroy the gland by freezing it.
“They all seemed like a lot of hell to go through,” Minor said, “and [that they] might not help me, if my cancer had spread.”
Instead, he tried something unusual: hormone therapy. Normally reserved for men in the final, deadly stages of prostate cancer, hormone therapy is a drug regimen that suppresses the body’s production of testosterone, which fuels prostate cancer growth.
“It took me awhile to figure it out,” Minor says, “but I finally learned that some men were trying this as a primary treatment, not as a last resort.”
Depriving a man of this hormone has its costs; hot flashes are common, as are sleep problems--and libido almost always disappears. But some patients, like Minor, tolerate the side effects well. And in about 85% of patients, hormone therapy knocks the PSA below 1: in effect, starving the cancer cells, reversing tumor growth.
For how long? That’s the rub with hormone therapy. Often the drugs suppress cancer growth for a couple of years. Then the cancer rallies, rendering the drugs useless. That’s why researchers are now experimenting with other anti-cancer agents to fill in once the hormone therapy no longer works.
Dr. Eric Small, an oncologist at UC San Francisco, has gotten good responses from patients with hormone-resistant cancer by giving them drugs used in traditional chemotherapy.
“Our sense is that we are extending life,” he says. “The PSAs are coming down by 50% to 70%, which we know is correlated with longer survival, better quality of life, and slower moving cancer. We are not quite ready for prime time, in terms of replacing prostate surgery as a treatment. But we are getting good results, these drugs are well tolerated, and these are things patients should be aware of.”
And that is the message prostate cancer survivors would give Giuliani: Study your options before making a decision.
“A surgeon is going to recommend surgery, a radiologist will recommend radiation, a plumber’s going to want to do plumbing,” says Tortosa, the San Diego therapist. “All I would say is make sure you learn all you can about what treatments are out there, and make sure you’re the one making the decision, based on what’s best for you. This is a decision you have to live with for the rest of your life.”
