A man's tough choice

Special to The Times

The biopsy was positive. Don Cozza felt a wave of disappointment rush over him. He had been certain the test would show that he didn't have prostate cancer after all.

Cozza listened as his urologist described two options that were suitable for his cancer, which had not spread beyond the prostate and was likely to respond well to treatment: surgery or radiation. When Cozza, 54, told his wife that his doctor was leaning toward surgery, she urged him to seek a second opinion from a radiation oncologist. "He gave me a more encouraging view of side effects as far as radiation goes," says Cozza, of Port Hueneme.

Both doctors made compelling arguments for the type of therapy they perform, leaving Cozza confused in the face of a daunting decision: What is the best way to treat prostate cancer?

Doctors in the United States will diagnose about 230,000 men with the disease this year. About 8 in 10 of those men, like Cozza, will have their disease detected in the early, highly treatable stage. Although early-stage prostate cancer is rarely fatal, choosing from the various ways to treat the disease often heightens a man's anxiety.

"Patients feel like they're in a free fall," says Dr. Mark Kawachi, director of the prostate cancer center at City of Hope Hospital in Duarte. "There are so many options, so many treatments."

Doctors say that a paucity of research comparing the effectiveness of various treatment options is one reason for the confusion. Another problem, some doctors say, is the relative lack of cooperation among the various specialists who treat prostate cancer.

That list of options seems to grow each week. Kawachi, for example, is pioneering the use of minimally invasive robotic technology to remove prostates. And UCLA researchers are refining a relatively new technique called cryotherapy, which freezes prostate cancer cells. Others are studying whether ultrasound can be used to treat prostate tumors.

And the most commonly recommended treatments for prostate cancer each have variations men must ponder. The treatment known as radical prostatectomy, in which a urologist surgically removes the cancerous prostate, is the most common procedure. However, some doctors offer so-called nerve-sparing surgery, which reportedly reduces the risk of erectile dysfunction and other side effects of surgery. Radiation oncologists, meanwhile, zap tumors with brachytherapy (radioactive seeds implanted in the prostate) and external beam radiation (X-rays delivered from outside the body). A patient who opts for radiation treatment must also decide whether to seek out a clinic that performs "conformal" radiation, which allows for higher doses, or proton beam therapy, which bombards the prostate with atoms.

And chemotherapy and hormone therapy, which are not usually recommended for men with early-stage cancer, are used for those with more advanced forms of the disease.

Because prostate cancer is often slow growing, a minority of men choose not to be treated at all (so-called watchful waiting) unless blood tests suggest that the tumor is becoming more aggressive. However, here's what really confounds men who opt for therapy: Early-stage prostate cancer is unusual, compared with other forms of cancer, because no one knows the best way to treat it. "When you see a patient with kidney or bladder cancer, you tell them, 'This is what you need,' " says Dr. Arie Belldegrun, chief of urologic oncology at UCLA's Jonsson Cancer Center. "With a prostate cancer patient, it's very hard to know what to tell him."

The problem arises from a lack of hard data. Traditionally, urologists and radiation oncologists have not collaborated on studies to determine which therapy is best suited for given patients, based on the nature of their tumors or their age, for example.

Women with breast cancer face fewer treatment decisions because there has simply been more research, says Kawachi. He believes the available knowledge to assist men in making decisions about treating prostate cancer is about 10 years behind research on breast cancer treatments. "At this point with breast cancer, [treatment options] seem relatively clean and straightforward," says Kawachi. "Prostate cancer is only now entering that realm."

Despite the lack of evidence showing the superiority of one approach over another, physicians who treat prostate cancer often tilt in favor of the techniques they perform. A 2000 survey published in the Journal of the American Medical Assn. found that 93% of urologists would advise a man with early prostate cancer to have surgery, while 72% of radiation oncologists would say that radiation is just as effective.

"It can be bewildering for patients," says the study's lead author, Dr. Michael J. Barry of Massachusetts General Hospital in Boston. "I think they are being presented with all the options by physicians. But the emphasis on the options may be different, depending on who they see."

Perhaps it is human nature for physicians to think their specialty is superior. But it's also clear that treating prostate cancer is big business for hospitals and physicians.

"It's a tremendous source of referrals and a tremendous source of revenue," says Dr. Stuart Holden, director of the prostate cancer center at Cedars-Sinai Medical Center in Los Angeles. Indeed, the national bill for the most common form of prostate cancer treatment -- the conventional prostatectomy -- was $1.4 billion in 2002, according to the Agency for Healthcare Research and Quality.

As a result, prostate cancer doctors compete for patients. "There are clearly turf issues," says Dr. Louis Potters, medical director of the New York Prostate Institute in Oceanside, N.Y., who specializes in brachytherapy. Potters recently completed a 12-year study showing an 81% survival rate among more than 1,400 men with prostate cancer who were treated with radioactive seeds. Yet he thinks too few urologists encourage men with the disease to consider brachytherapy. "Patients should be informed that it's an option," says Potters.

Though the 81% figure may sound impressive, it's important to note that Potters' study results match widely cited survival statistics for all three major forms of treatment for prostate cancer.

In other words, regardless which therapy a man chooses, he has at least an 80% chance of surviving five years. These estimates come from studies that followed men who had undergone one form of therapy. Doctors cannot claim that a given technique is more likely to cure a man based on scientific evidence, since head-to-head comparisons have never been conducted.

Hearing that all treatments are equally effective, many men use criteria besides just survival rates to choose a therapy. Some believe only surgery will definitively eliminate their risk for recurrence. Others like the convenience of brachytherapy, since the procedure takes less than an hour and patients resume normal activities in a day or two. Surgery, by comparison, requires at least a few nights in the hospital and up to three weeks of recuperation at home. External beam radiation entails daily visits to a clinic for up to 10 weeks.

Other men choose a therapy based on its risk of side effects. But making sense of the statistics can be tricky. For example, erectile dysfunction (ED) is the most common side effect of treatment for early prostate cancer -- and arguably the one men fear most.

While some prominent surgeons claim that up to three-quarters of their patients who have prostatectomies remain potent, most physicians tell patients the risk is much higher, on the order of 60% or more. In one group of men studied, 93% had ED following prostate surgery.

Since removing the prostate can damage nerves necessary to produce an erection, the surgeon's talent is a critical factor in determining whether a man remains potent. But skill with a scalpel does not explain the wide variance in the reported incidence of ED, says Dr. James A. Talcott, a medical oncologist at Massachusetts General who studies quality of life among men with prostate cancer.

Talcott says that men report much higher rates of impotence when filling out questionnaires than in interviews with their physicians.

He suspects that when doctors actually ask patients that question in person, the men probably underreport their problems with impotence. That may be because some men are reluctant to appear ungrateful to the doctor they credit with saving their life, Talcott says.

What's more, some surveys ask men specific questions such as, "Do you have unassisted erections adequate for vaginal penetration?" Other surveys simply inquire whether a man is bothered by problems with potency.

"The patient might think, 'Not being potent is kind of a drag, but I know next year I'll be good as new,' " says Talcott, in which case the man might report that potency isn't a problem. Similar discrepancies arise when researchers gather data about incontinence and bowel problems, both common among men who undergo surgery or radiation for prostate cancer.

The American Urological Assn. is drafting standard definitions of the various side effects associated with prostate cancer. "We're also trying to get a better handle on these complications and how often they occur," says Dr. Brantley Thrasher, an AUA spokesman.

Men who are confused by conflicting claims may want to consult with a medical oncologist, says Dr. Peter R. Carroll, chair of the urology department at UC San Francisco.

Many large hospitals now have full-service prostate cancer centers, in which men see both a urologist and a radiation oncologist, then meet with a medical oncologist, who helps patients choose a treatment.

Any discussion of treating early-stage prostate cancer should include the option of watchful waiting, says Carroll.

"I clearly think this disease is overtreated," he says.

In the not-too-distant future, improved screening techniques may be able to determine which men require aggressive treatment, or none at all, and even which therapy is the best choice.

At Cedars-Sinai, Holden heads a group developing a blood test designed to detect clusters of proteins that would indicate whether a tumor is fast growing or dormant, and offer clues about what treatment might work best.

For now, as more men become better informed about prostate cancer, some physicians are responding by spelling out all options and encouraging men to seek other views.

"The climate is changing," says Dr. Henry Z. Montes, of Radiation Oncology Centers of Ventura County in Oxnard. "We're in a transitional zone, where I see a fair number of patients getting a second opinion from a radiation oncologist as a consequence of a referral from a urologist."

Don Cozza, who consulted with Montes, planned to meet with a medical oncologist before making up his mind about what treatment to choose. Montes supports Cozza's choice, one way or another.

"I tell men, 'Never second-guess yourself,' " says Montes. "Whichever decision a patient makes is the right decision."

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The options

Men with prostate cancer must choose from an array of treatments, many of which have additional variations. Here are some of the primary options:

Therapy: Radical prostatectomy

Description: Prostate is surgically removed

Advantages: Thorough

Disadvantages: Possible erectile dysfunction; long recovery

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Therapy: Nerve-sparing surgery

Description: Avoids cutting nerve bundles

Advantages: Maintains sexual performance

Disadvantages: Not possible for everyone

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Therapy: Brachytherapy

Description: Radioactive seeds implanted in prostate

Advantages: Precise, quick recovery after procedure

Disadvantages: Discomfort; risk of incontinence, erectile dysfunction

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Therapy: External beam radiation

Description: X-rays delivered from outside body

Advantages: Avoids surgery

Disadvantages: Risk of diarrhea, painful urination, erectile dysfunction

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Therapy: Hormonal therapy

Description: Lowers production of testosterone

Advantages: Slows spread of disease

Disadvantages: Not a cure

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Therapy: Cryosurgery

Description: Uses liquid nitrogen to freeze and kill prostate cancer cells

Advantages: Quick procedure, one to two days recovery

Disadvantages: Can cause erectile dysfunction

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Therapy: Chemotherapy

Description: Uses anti-cancer drugs

Advantages: Kills cancer cells

Disadvantages: Can affect normal cells and cause nausea, tiredness, hair loss, low white cell count

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Source: Prostate.com. Graphics reporting by Joel Greenberg

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