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Masculine Case

American men have a one in five chance of getting prostate cancer. The good news: there are more treatment choices than ever. The bad: even doctors can't agree on which works best. Here's what you need to know

Clyde Anderson knew exactly what he didn't want when his doctor told him in February 1997 that he had prostate cancer. Anderson, an insurance executive from Gulf Breeze, Florida, had watched several friends do battle with the disease. Two had died, and most of the others had ended up impotent, incontinent, or both as a result of the treatments they chose.

"My doctor offered radical prostatectomy, or prostate removal surgery, and external radiation—the only two treatments available locally and the two most invasive," remembers Anderson, who was 67 when the diagnosis was made. "He called radical prostatectomy 'the gold standard,' but said that because I'd had previous surgery for an enlarged prostate, it would likely cause impotence. Besides, I'd watched friends go through hell with surgery. I knew if there was another way to fight this, I wanted to try it."

There is. In fact, thanks to research done in the past decade, there are so many different ways of treating prostate cancer—the most frequently diagnosed cancer in men over the age of 50—that neither doctors nor patients agree on which one is the best. With the baby-boomer generation now past middle age, and with well-known prostate cancer survivors speaking out (including former Senator Bob Dole; General H. Norman Schwarzkopf; junk-bond king Michael Milken; and Simon & Schuster editor-in-chief Michael Korda), the debate has become, as Intel Corporation chairman and prostate cancer survivor Andy Grove, has put it, "one of the raging controversies of contemporary medicine."

But finding a doctor who is willing and experienced enough to perform the procedure you want is a challenge. Particularly with newer methods, success rates rise and fall with the skills of the physician—skills that can make the difference between ending up impotent, wearing a diaper, or having diarrhea for the rest of your life.

"It's complicated," says Dr. Adam Raben, the radiation oncologist whom Anderson finally chose. "There are three categories of prostate cancer—favorable, intermediate, and high risk—and different management options in each category. When patients come to me, I say, 'The good news is that you have options; the bad news is that you have options.' The choice comes down to quality of life, side effects, and psychology. Some people say, 'I've got to know that when I go to bed my cancer is in a jar of formaldehyde—and not inside me.' Other people say, 'I'd rather die with cancer than have a miserable quality of life. I want to go singing and dancing.'"

Here are the four main prostate cancer treatments, as well as newer versions, some of which are still thought to be controversial. For men who are over the age of 70, and those in such poor health that their life expectancy is limited, there's also the age-old approach commonly referred to as "watchful waiting": Do nothing except keep a close eye on the tumor, and bank on the fact that prostate cancer cells are among the slowest growing of all cancers.


Radical Prostatectomy

This is the scorched-earth approach to treating prostate cancer that is contained within the prostate gland: It involves the removal of the prostate gland, the seminal vesicles (which produce some of the fluid for semen), and often the pelvic lymph nodes.

"There's no better way to cure contained cancer—or cancer that hasn't spread beyond the prostate gland—than total surgical removal," says Dr. Patrick Walsh, director of the top-flight urology department at The Johns Hopkins Hospital in Baltimore and pioneer of anatomical radical prostatectomy. The figures bear him out: With radical prostatectomy, local recurrence occurs in less than 10 percent of patients whose cancer hasn't spread beyond the prostate. For patients 40 to 65, who aren't as likely to outlive their cancers, that makes it highly recommendable.

Dr. Mitchell C. Benson, director of urologic oncology at the J. Bentley Squier Urological Clinic at Columbia-Presbyterian Medical Center in New York, agrees. "Like breast cancer patients who opt for radical mastectomy, men who choose radical prostatectomy often say they do so—despite other options—because they 'want the whole thing out,'" Dr. Benson says. "They're looking for a cure, but also for peace of mind. In the hands of a top doctor, surgical removal of the entire gland has been shown to have the most successful recovery and survival rates over ten years. But I would also point out that the results of radiation seed implantation therapy, which so far has been given only to a very select group of patients with minimal disease, may prove to be the same as surgery six to seven years from now. Whether this will translate into equivalent therapy for patients with localized prostate cancer remains unknown."

But some doctors, such as Dr. Fred Lee, a radiologist-prostatic oncologist who heads the Crittenton Prostate Center in Rochester, Michigan, say that radical prostatectomy is on its way out. "Radical prostatectomy is due to decline, just like radical mastectomy," Dr. Lee explains. Other, less invasive procedures, he says, will take its place, just as lumpectomy has done for breast cancer treatment.

In the short term, the negative aspects of radical prostatectomy are the same as those of any major surgery: You must undergo general or spinal anesthesia, take pain medication for several days, stay in the hospital for at least two to four days, and avoid strenuous activity and sports for six weeks. In addition, you will have to wear a catheter for up to three weeks, during which time regular activity is severely restricted, and you may suffer side effects such as bowel problems, which can be long-term, and soreness in the area of the incisions, although this normally subsides after several weeks.

In the long term, infertility is a given because the vas deferens must be severed during surgery. Impotence is also a serious risk: In a number of studies, roughly half the men who had a radical prostatectomy became impotent because the nerves that assure erections weren't kept intact during the surgery; even those who remained potent reported at least "a partial deficit," as one study delicately puts it. Another possible long-term effect is incontinence, though urinary control often returns, to some degree, over time.


The Newer Option: Anatomical Radical Prostatectomy

Since the early 1980s some doctors have practiced this new surgical technique, also known as "nerve-sparing" surgery. With it, the surgeon removes the prostate gland, but leaves intact the bundles of nerves that control continence and erection. The advantage, according to a 13-year study completed at The Johns Hopkins Hospital, where the technique was developed by Dr. Walsh, is that it significantly reduces the risk of incontinence and impotence without compromising success rates. That's not to say that it's fail-safe: Some patients still experience impotence, incontinence, and other side effects. And even when potency does return, a process that can take months, orgasms will be "dry," though one still experiences sexual pleasure and climax.


Cryosurgery

Cryosurgery is regarded as the most controversial of the prostate cancer treatments. It's been used successfully in dermatology and gynecology for precancerous tissue removal, and only now is being used to treat prostate cancer. Success depends greatly on the skill and experience of the surgeon. There are no 10-year—or even five-year—results available. But, states Dr. Lee, "four-year data remains very promising." According to Dr. Benson, "Complications are higher. It's less invasive, but not necessarily safer." Dr. Raben puts it even more strongly: "It's still investigational and not considered a standard approach as of yet."

During cryosurgery the cryosurgeon uses ultrasound to guide the insertion of five to eight tiny metal tubes called cryoprobes through the skin near the anus and into the prostate gland. The cryoprobes transport argon gas or liquid nitrogen, both of which are kept at -190 degrees C. When the argon or nitrogen arrives it freezes and kills cancerous and normal cells, ideally leaving the adjacent organs undamaged.

Although it's called "surgery" and the patient is placed under general or spinal anesthesia, cryosurgery requires only small incisions and results in little blood loss. Most patients are in the hospital for a day or two, and recovery takes a couple of weeks, not months, as with radical prostatectomy. It is also one of the few primary treatment options that can be repeated.

One of the main risks of this procedure is that it may freeze the urethra, although protected by a warming sleeve during the process, as well. If this occurs, the urethra may take months to heal. Another risk is that frozen, dead tissue may slough off and block the urethra, which could require additional surgery to correct. (Dr. Lee—a cryosurgery pioneer—estimates that of the 10 to 15 percent of his patients who suffer from tissue blockage, half must undergo follow-up surgery.) The rectum also may be frozen in the process, possibly causing serious injury. "But this occurs mainly in those patients who have had previous radiation," says Dr. Lee.

Other possible complications—incontinence and impotence. Howard Bubel, a retired Air Force colonel in Fairfax, Virginia, who opted for cryosurgery with Dr. Lee in 1995, considers the procedure a success when it comes to the treatment of his cancer. But in terms of potency, Bubel says, "Cryosurgery did me in."


Hormone Therapy

Hormone therapy alone is normally used only for patients with a short life expectancy. As Dr. Benson says, "It's not recommended as a definitive form of treatment because it doesn't cure cancer."

Hormone therapy works by controlling the body's testosterone levels, since testosterone can stimulate the development of prostate cancer. There are two ways to do this: surgically remove the testicles, which produce testosterone, or take a drug or hormone that suppresses testosterone production. Aside from being one of the most expensive forms of treatment—the monthly or quarterly shots cost thousands of dollars annually and have to be continued for life—hormone therapy comes with its own variety of side effects. These range from hot flashes and swollen breasts to weight gain and escalated risk of osteoporosis. Loss of libido is usually a given. ("And for some guys, it never comes back," says Dr. Raben.) Impotence is also extremely likely.


The Newer Option: Short-term Hormone Therapy Combined With Other Treatments

Normally, short-term hormone therapy is used to prevent the progression of cancer while a patient decides on another treatment, or after a treatment if there's evidence that the cancer has spread. "Three or four years ago, radiation oncologists would ask, 'When should we do hormone therapy?' " says Dr. Raben. "Now, it's 'When shouldn't we use hormones?' Accumulated data shows that combining hormones with radiation makes the radiation more effective for two reasons: Hormone therapy kills some cancer on its own, and it may make other prostate cancer cells more sensitive to radiation. So we usually give it before radiation, during, and a little after."

Even with short-term therapy, however, side effects can be severe. Howard Bubel embarked on a six-month hormone therapy course before he had cryosurgery. Bubel—who was 57 at the time—began losing hair from his chest, underarms, arms, and legs. "I had hot flashes about every two minutes," Bubel says. "A lot of guys don't have them as severely, but in my case they seemed to be constant. It was horrible."

As Dr. Raben puts it: "If you have hormone therapy for three months, your potency comes back about eighty percent of the time. But if you're on it for more than three months, potency rates drop to about fifty percent."


Radiation Therapy

This procedure has usually been recommended for patients over 65 because it is less invasive than surgery. Some doctors say it is a valid option for younger men as well. "Surgeons in general feel that radiation therapy is not a good option for younger patients," says Dr. Raben, "but with the success rates today, that doesn't appear to be the case."

The most common radiation treatment is external beam two-dimensional (2D) radiation, during which a linear accelerator outside the body targets the prostate gland, sending finely focused radiation beams to the tumor. Treatment lasts seven to eight weeks (versus four to five hours for surgery), and short-term side effects can be traumatic. Diarrhea and irritated intestines are par for the course for several months, and sometimes last permanently. Urinary flow may be obstructed, and rectal problems may occur. Fatigue is also a problem in some patients as the treatment progresses. Although impotence is not usually a problem in the short term, it may occur over time or even after treatment has ceased because of radiation's cumulative effect. Perhaps the biggest problem is that external radiation damages healthy cells as it kills cancer cells, though normal cells may repair themselves.


The Newer Option: Three-dimensional (3D) Conformal External Radiation

Three-dimensional (3D) conformal radiation is a more precise type of external radiation. It targets the prostate gland from multiple vantage points, allowing the radiation oncologist to deliver a potentially higher, more effective dose of radiation with less risk to the bladder and rectum. Statistics on patients at Memorial Sloan-Kettering Cancer Center and at Fox Chase Cancer Center in Philadelphia, where the technique was pioneered, show 85 percent success rates for low-risk patients who received high doses of 3D radiation. Also encouraging are the minimal side effects, though with 3D, too, impotence may occur over time. "It's about as well tolerated as any treatment I've seen," says Dr. Raben. "No diarrhea and no incontinence. It's state-of-the-art. Side effects with two-dimensional radiation are a different story."


The Newer Option: Brachytherapy

There are two types of brachytherapy—a form of three-dimensional internal radiation. With the first type, commonly referred to as "the smart bomb," catheters are inserted into the prostate for 24 hours, each delivering three initial doses of 500 to 600 rads of radiation. Then an additional 4,500 to 5,000 rads of external radiation are delivered over the next four to five weeks. This is the treatment that Andy Grove chose. "The smart bomb is computer-planned therapy, so you can optimize the dose," says Dr. Raben. "It's extremely well tolerated." With the second type, referred to as "permanent seed implants," tiny radioactive isotopes, or "seeds," made of iodine or palladium are planted inside the prostate, where they give off continuous low doses of radiation over several months. According to Dr. Raben, permanent seed implants are a good choice if potency is a patient's primary concern. They are also convenient: Implantation is usually an outpatient procedure that takes one day, and recovery time often lasts just a few days. Some suggest that success rates appear to be as good as with three-dimensional external radiation and radical prostatectomy for favorable-risk disease: A new report released, though not yet published at presstime, by Northwest Hospital in Seattle states that 66 percent of patients with early-stage prostate cancer who received brachytherapy remained disease-free after 10 years and maintained low PSA levels (see An Ounce of Prevention). Nevertheless, some doctors and medical organizations still feel there isn't enough long-term data to warrant recommending the procedure.

There are also risks. "Despite good planning, the placement of radioactive sources into the prostate requires technical skills and experience on the part of the radiation oncologist and urologist, both of which come more into play," says Dr. Raben. He also says overall side effects—particularly urinary burning and frequency—can be greater with permanent seed therapy than with "the smart bomb" in the first three to six months, but that 90 percent of the time these side effects subsequently subside.

Permanent seed implants are what Clyde Anderson chose with Dr. Raben, who performed the procedure. "It didn't hurt at all," says Anderson. "I arrived at the hospital around eight o'clock in the morning, had the procedure at eleven with general anesthesia. I was fully awake by two o'clock, and left the hospital late that afternoon. I felt only slight discomfort, and that went away after a couple of days. Since then, nothing."

In retrospect, Anderson is very happy with the choice he made. Three months after the treatment, Anderson's initial 6.3 PSA score—which put him squarely in the favorable-risk cancer category—had dropped to 0.9, which puts him out of the woods. Now, one year later, Anderson reports that all his bodily functions have returned to normal. "I feel very fortunate—and happy that I kept perusing information until I found a treatment that was the best thing for me," Anderson says. "It pays to be the kind of guy who doesn't take no for an answer."


Anatomy Lesson

Located just below the bladder and in front of the rectum, the prostate is one of the primary male reproductive glands. The size of a walnut, it wraps around the urethra (the tube that carries urine from the bladder through the penis) and manufactures the sperm-carrying fluid for semen. When a man climaxes, muscular contractions squeeze the semen from the prostate into the urethra, causing him to ejaculate.

While prostate cancer is caused by a malignant tumor that usually begins forming in the outer part of the gland, there are two other prostate conditions which many men over the age of 40 experience: benign prostatic hyperplasia (BPH), an enlargement of the prostate, and prostatitis, an inflammation of the prostate generally caused by a bacterial infection. Though neither is cancerous, they both cause urinary problems.


Numbers Theory

The risk of getting prostate cancer is definitely connected to age: More than 75 percent of patients diagnosed with it are over 65. But it's also connected to other factors as well. African American men are 66 percent more likely to get it than their white counterparts. A man whose father, son, or brother has had prostate cancer is at double the risk—five to six times the risk if three such relatives have been affected. There's even evidence that men may be more at risk if close female relatives have had breast cancer. A study published in January suggests that men with a high blood level of a hormone called insulinlike growth factor-1 (IGF-1) have a risk that is four times higher than normal. Here is the American Cancer Society's U.S. estimates for 1998.

Prostate Cancer
New Cases Diagnosed: 184,500
Deaths: 39,200

Breast Cancer (women)
New Cases Diagnosed: 178,700
Deaths: 43,500

Lung Cancer (men)
New Cases Diagnosed: 91,400
Deaths: 93,100

Colon and Rectum Cancer (men)
New Cases Diagnosed: 64,600
Deaths: 27,900


How Viagra Helps

In late March the Food and Drug Administration approved Viagra (sildenafil citrate), the first oral pill to treat male impotence. The decision was a groundbreaking event for prostate cancer survivors, for whom impotence is frequently a given. Taken before intercourse, Viagra works by enhancing the effects of nitric oxide, a chemical that the body normally releases in response to sexual stimulation, and which allows blood to enter the penis and make it erect.

According to the FDA, Viagra proved effective in approximately 70 percent of the men who participated in the drug's clinical trials. Side effects are fairly mild: headaches, flushing, indigestion, stuffy nose, urinary tract infection, diarrhea, and in a small percentage of cases, a temporary bluish tinge to vision or increased sensitivity to light. But there can also be serious dangers: Men who take medicines that contain nitrates, such as nitroglycerin, cannot take Viagra because the combination can lower their blood pressure too much, which can lead to serious complications.


Clear Vision

Color Doppler is the latest step in the race to detect small, curable prostate cancers. The Doppler works in the same way that television weather maps do—only instead of highlighting thundershowers it highlights tumors. Proponents, such as Dr. Fred Lee, say it is a significant improvement over standard black-and-white transrectal ultrasounds, which are more difficult to read. By highlighting probable cancerous cells in color, the Doppler allows more accurate diagnosis and precise placement of needles for biopsy.

"It lit up my cancer like a carnival," says Howard Bubel, who opted for cryosurgery. Comparing the Doppler image and the transrectal ultrasound, makes the Doppler's superiority clear.


An Ounce of Prevention

Between 1989 and 1993, prostate cancer incidence rates jumped 50 percent—far more than those of any other cancer. Researchers believe that the increase is largely due to the use of better and more widespread detection methods.Catching prostate cancer early makes a big difference: The five-year relative survival rate for patients whose tumors are diagnosed while still localized is 99 percent.Aside from an annual digital rectal exam (DRE), medical organizations recommend that men between the ages of 40 and 50 start having an annual PSA (prostate-specific antigen) test, a blood exam that measures levels of PSA. While PSA is produced by both healthy and cancerous prostate cells, malignant cells produce more.

But the PSA test, which became available in 1990, is controversial. First, it has a false-negative rate: 30 to 40 percent of patients with early-stage prostate cancer have a normal PSA. Second, it has a false-positive rate: One-third to one-half of men with BPH, a non-cancerous prostate ailment, but no prostate cancer will have an elevated PSA. However if results are high, many men feel compelled to take immediate, drastic action—even though it may be better to wait and repeat the test.

"The first thing that I tell men who have just been diagnosed is, 'Don't panic—you're going to live for a long while,'" says Dr. Kenneth Goldberg, a urologist and director of the Male Health Institute near Dallas. "But for the most part, they hear the word cancer and they want it out of there," he adds.


Risk Analysis

A doctor establishes that a patient has prostate cancer through elevated PSA levels in the blood and a series of biopsies, which are performed during a transrectal ultrasound (TRUS). The biopsy samples are graded by a pathologist according to how closely they resemble normal cells: The more they differ, the more aggressive the cancer is likely to be. The most commonly used grading system is the Gleason Grade, in which cells closest to normal are scored at two and those most divergent at 10.

Once it's been established that a patient has prostate cancer, doctors perform a variety of tests to determine just how invasive the cancer is. These include Computed Tomography (CT) scans, a computer interpretation of x-rays that shows if the cancer appears to have spread to the lymph nodes; a bone scan, which illustrates whether it has spread to the bones; and chest x-rays that show if it has spread to the lungs.

Using the results of these tests, doctors define the cancer's stage in order to determine treatment. Traditionally, staging goes from Stage A (cancer cells are in the prostate but haven't yet formed a tumor) to Stage D2 (the cancer has spread to lymph nodes far from the prostate, or to the bones). Another staging system, called Tumor, Nodes, Metastasis (TNM), divides cancer spread into more specific categories: T1 or T2 for cancer still confined to the prostate, to N+ or M+ for cancer that has spread aggressively.

Doctors combine the test scores in various ways and weigh them differently—there's no neat equation. With all the tests, however, the lower the score the better. Here's a general guideline to the various grading systems.

PSA Level
FAVORABLE RISK: Less than 10
INTERMEDIATE RISK: Less than 20
HIGH RISK: Above 20

Gleason Grade
FAVORABLE RISK: 5 or below
INTERMEDIATE RISK: 6 or 7
HIGH RISK: 8 to 10

Clinical Stage of Cancer
FAVORABLE RISK: T2a or below
INTERMEDIATE RISK: T2b
HIGH RISK: T2c or above

Number of Positive Biopsies
FAVORABLE RISK: 1
INTERMEDIATE RISK: 2 or 3
HIGH RISK: 5 or 6


Top Docs

Dr. Mitchell C. Benson
Director, Urologic Oncology
J. Bentley Squier Urological Clinic
Columbia-Presbyterian Medical Center
161 Fort Washington Avenue
New York, NY 10032
212-305-5201
Urologic oncologist.

Dr. John Blasko
Seattle Prostate Institute
1101 Madison Street Suite 1101
Seattle, WA 98104
206-215-2480
Radiation oncologist. Expert in seed implant therapy.

Dr. William J. Catalona
Washington University School of Medicine
4960 Children's Place
St. Louis, MO 63110
314-362-8200
Urologist. Expert in anatomical radical prostatectomy.

Dr. Zvi Fuks
Memorial Sloan-Kettering Cancer Center
1275 York Avenue
New York, NY 10021
212-639-5868
Radiation oncologist. Expert in 3D external-beam therapy.

Dr. Kenneth Goldberg Medical Director Male Health Institute
400 West LBJ FWY, Suite 360
Irving, TX 75063
972-751-6253
Urologist.

Dr. Stuart Holden
Tower Urology Medical Group
8631 West Third Street Suite 915E
Los Angeles, CA 90048
310-854-9898
Urologist.

Dr. Fred Lee
Crittenton Prostate Center
1101 West University Drive
Rochester, MI 48307
248-652-5611
Radiologist-prostatic oncologist and prostate cancer survivor. Expert in cryosurgery.

Dr. Gary Onik
104 Long Branch Road
Winter Park, FL 32792
800-330-9997
Interventional radiologist and cryosurgeon.

Dr. Adam Raben
Chairman, Radiation Oncology
Monmouth Medical Center
300 Second Avenue
Long Branch, NJ 07740
732-923-6890
Radiation oncologist.

Dr. Peter T. Scardino
Memorial Sloan-Kettering Cancer Center
1275 York Avenue
New York, NY 10021
212-639-8193
Urologist and surgeon. Expert in early detection and surgical treatment of prostate cancer.

Dr. Howard Scher
Memorial Sloan-Kettering Cancer Center
1275 York Avenue
New York, NY 10021
212-639-7585
Oncologist. Oversees Memorial's new prostate cancer therapies.

Dr. Patrick Walsh
Director, Department of Urology
James Buchanan Brady Urological Institute
The Johns Hopkins Hospital
Marburg Building, Room #134
600 North Wolfe Street
Baltimore, MD 21287-2101
410-955-6707
Surgeon. Developed anatomical radical prostatectomy.


Help Lines

AMERICAN CANCER SOCIETY 800-227-2345; www.cancer.org
AMERICAN FOUNDATION FOR UROLOGIC DISEASE (A.F.U.D.) 800-242-2383
CANCER INFORMATION CENTER, NATIONAL CANCER INSTITUTE 800-422-6237; http://rex.nci.nih.gov
NATIONAL COALITION FOR CANCER SURVIVORSHIP 888-650-9127; www.canceradvocacy.org
PATIENT ADVOCATES FOR ADVANCED CANCER TREATMENTS, INC. (PAACT) 616-453-1477; www.osz.com/paact
US TOO INTERNATIONAL, INC., PROSTATE CANCER SURVIVOR SUPPORT GROUP 800-808-7866; www.ustoo.com

Rosemary Ellis wrote about liposuction in the November/December 1997 Healthy, Wellthy & Wise.