Medical Dilemma: Prostate Cancer Numbers Are Soaring
No one needs to tell a woman, or a man, for that matter, what purpose breasts have or where to find them. But ask the average man or woman where the prostate gland is and most would be hard pressed to offer particulars. Sometimes women know that the older men in their lives have enlarged ones, while most men unpleasantly associate the organ with the snap ofthe latex glove their physician don when digitally probing an area they would rather forget.But prostate cancer is as deadly and prevalent a cancer -- actually more prevalent -- for men as breast cancer is for women. And though it gets much less attention, aesthetically, politically, and medically, the prostate and its problems are poised to take center stage.By some current estimates, one in five males born today will develop prostate cancer in their lifetimes. The figure for breast cancer is one in ten. The American Cancer Society estimates that 317,000 men will be diagnosed with prostate cancer this year -- far outdistancing the 184,000 women who will find out they have breast cancer. The estimate is that 41,400 men will die of prostate cancer this year, a number swiftly approaching the annual breast cancer toll of 44,300 deaths.But more dramatic than the incidence is the rate of escalation. Since 1985 there has been a 600 percent jump in new cases -- the fastest rise in cancer detection ever recorded. The largest proportion of the increase is due to the ever-growing use of a simple blood test called PSA, which measures an enzyme produced by the prostate gland.Many of these newly diagnosed cases are among well-known men who have gone public. In 1992, Bob Dole's prostate cancer was detected by a routine PSA test and he treated it by having his prostate removed. So many of his brethren in the nation's capital have been diagnosed with the disease that it leads one to wonder whether the perniciousness of American politics is a contributing factor. The list includes Washington Post columnist David Broder; syndicated political columnist Michael Novak; Alaska Senator Ted Stevens; Supreme Court Justice J. Paul Stevens; Washington D.C. Mayor Marion Barry and Hamilton Jordan, former aide to Jimmy Carter. Clearly this disease has no regard for the political spectrum -- on the right, it has struck Senator Jesse Helms and on the left, former Senator Alan Cranston.Other well-known men with the disease are Sidney Poitier, Robert Goulet, Jerry Lewis, Roger Moore and Buffalo Bills coach Marv Levy. General H. Norman Schwarzkopf, 61, and junk bond king Michael Milken, 49 -- both diagnosed in the last couple of years -- have become active in campaigns to raise public awareness.Almost all of these men as well as the authors of more than 10 recent books on prostate cancer are adamant in their insistence that every man over 50 -- and in higher risk groups, men over 40 -- get PSA tests annually. In the May issue of Forbes magazine, Intel CEO Andy Grove, recently diagnosed and treated with radiation, writes, "When I sit in meetings at work and look at groups of men who are my contemporaries, I want to shout at them, do you know what your PSA is?"In the book How I Survived Prostate Cancer...and So Can You (Health Education Literary Publisher, 1994), James Lewis Jr. urges wives to use any means they can to persuade their husbands to get tested, including, if necessary, instituting a no-test-no-sex policy.Because these men are so zealous, I found it curious that in a survey of about 10 men I know between the ages of 45 and 60, only two had ever been tested. In one case it was because the doctor recommended it; in another, it was because the man asked for it and the doctor grudgingly agreed. What's going on here? Are most family practitioners too busy, too careless, too ignorant to recommend a simple blood test that could potentially save so many lives?In fact, there is no consensus in the medical community on the issue of routine PSA testing. Currently two major cancer organizations take opposing views: The National Cancer Institute does not recommend routine PSA screening for otherwise healthy men; the American Cancer Society recommends that men over 40 who are African American (they have the highest rate in the world) or men with a family history be tested annually and all other men have yearly tests after the age of 50.But even primary care physicians who follow the American Cancer Society guidelines are not necessarily enthusiastic about it. When Mill Valley internist Larry Posner discusses the PSA test with his patients, he says, "The test may save your life or it may open a Pandora's box."The Prostate is a small and enigmatic organ. It is a muscular walnut-shaped gland about an inch-and-a-half long, loosely attached to the bottom of the bladder. The urethra, the tube which transports urine from the bladder, is threaded through it, like a string in a bead. The job of the prostate is to concoct a chemical brew that makes up part of the seminal fluid (prostate specific antigen is one of those chemicals). During ejaculation, the prostate's muscles contract and force this fluid into the urethra, adding to the semen produced by the seminal vesicles.For all that is known about prostatic secretions, the exact role the prostate plays in sexual function is still a mystery. From an evolutionary perspective, there doesn't seem to be much purpose for it after reproduction.Most male animals have a prostate, but only humans and dogs are prone to problems with it. Why not horses? Why not bulls? No one knows. Problems in this obscure little gland are astonishingly common and come in three varieties: prostatitis, benign prostatic hyperplasia (BPH) and prostate cancer.Prostatitis is simply an infection or inflammation of the prostate. There are bacterial and non-bacterial varieties, and acute and chronic cases. It is extremely common and may or may not be painful. A course of antibiotics may be prescribed or -- and this may be the only good news about prostate problems -- sometimes having lots of sex makes it better.In BPH, the prostate becomes enlarged, choking off the easy flow of urine through the urethra. Symptoms can include annoying frequency or great difficulty urinating. As many as three-quarters of all men will eventually have problems caused by BPH. Again, no one knows why. Along with baldness and unruly eyebrows, an expanding prostate just seems to be one of the unwelcome accompaniments of aging.It isn't believed that either of these two conditions cause cancer, but they do make its detection and treatment more problematic.Like BPH, prostate cancer is ubiquitous and associated with aging. If all men lived to be 90 years old, almost 100 percent would develop it. Autopsy studies reveal that 40 percent of men over 50 harbor tiny cancers in their prostates. Over 65, that number increases to 80 percent.Though prostate cancer is one of the most common cancers, in most cases it is also one of the slowest growing, taking three years or more to double in size. (Breast carcinomas often double in less than three months.) Because the majority of the cancers grow so slowly and because it is possible for a cancer to stay confined to the prostate indefinitely, most of the cancer's hosts die of something else first. But because the disease is so prevalent, the exceptions to this rule represent a lot of men. And as men live longer, these numbers will increase.Before the blood test, most cancers were picked up through digital rectal exams -- a procedure avoided by patients and doctors alike. Aside from the fact that too few were done the test was inadequate, because by the time a tumor is palpable it's been growing for quite awhile. As a result, more than half of all prostate cancers were discovered only after they had metastasized -- by which time it was usually too late to do much to prolong life. Such cancers frequently spread to the bones and death can be drawn-out and painful. Treatment for advanced cancer is usually palliative at best, and can include the removal of the testicles.THE PSA TEST was developed after researchers discovered in the seventies that mouse antibodies in a test tube react to the presence of a prostate specific antigen in human blood. The test, which began to be used extensively in 1988, meant that physicians now had a relatively easy way to assess what was going on in this heretofore elusive gland. But just as a thermometer reveals the existence of your fever but not the cause of it, an elevated PSA only indicates that something is wrong in the prostate without revealing the source of the problem. A PSA count of four or more (four nanograms of antigen per milliliter of blood) signals prostate trouble, but that trouble could be many things, including benign enlargement, infection or trauma. In older men, even having sex can cause the numbers to soar."The ideal tumor markers are the ones that are made by tumor cells and not by anything else," says Kaiser urologist Paul Alpert. "Since PSA is made both by prostate cells and prostate cancer cells, there's a tremendous overlap between normal and non-normal."There is a significant number of men with PSA's over four who don't have cancer," Alpert points out, "and there is a significant number of men who have PSA's under four who do." (General Schwartzkopf was one of them. His cancer was detected by a digital rectal exam after a PSA test of only 1.8. If you decide to have routine testing, it is strongly recommended that you do both.)If a man gets an elevated PSA score, the next step is to have more tests. These consist of transrectal ultrasound (a special probe is inserted into the rectum which enables the doctor to see the entire prostate) and needle biopsies performed by the urologist using transrectal ultrasound as a guide.A man who chooses to take a PSA test, says Alpert, should realize that he's essentially committing himself to the next step. "There's not much point in getting a PSA test unless, if your PSA is elevated, you're willing to follow it up with other testing which is fairly uncomfortable and fairly invasive."Once A Man Is Diagnosed with cancer, the issues he must sort through regarding treatment are vast and much too complex to detail here. In general, however, the patient, with his doctor's guidance, must consider the extent and aggressiveness of his tumor (this is estimated on the basis of further tests and a system of "grading" and "staging" tumors) and his current state of health and life expectancy.Treatment options include surgery, various forms of radiation, cryotherapy (freezing cancerous tissue), hormone therapy and "watchful waiting."The treatment most often selected is a radical prostatectomy. This is major surgery in which the prostate, the seminal vesicles and the lymph nodes around the prostate are removed. The urethra is then reconnected between the bladder and that portion of the urethra beyond the prostate. Since the widespread use of PSA testing, there has been a massive increase in the number of radical prostatectomies. In one early study of Medicare patients, the number of radical prostatectomies went from 2,600 in 1984to 16,000 in 1990.Thanks to advanced surgical techniques, radical prostatectomies are less harmful than they once were. Fewer men are left with sexual and urinary dysfunction, but the number of men who suffer serious side effects is still considerable. The actual figures are hard to pin down -- surveys of patients who have had the surgery relate much higher complication rates than what is reported by the treating doctors -- and the numbers range wildly from 2 percent to 65 percent, depending on the study.Whatever the actual statistics, most men are willing to risk complications if they believe that doing so will save their lives.Initially, the concern was that the PSA test would pick up large numbers of cancers that never would have caused problems -- doctors call these "indolent" cancers -- thus subjecting many men to needless surgery. But according to Alpert, current data suggests that this is not the case. "We undoubtedly remove these indolent cancers occasionally, but it's probably less than five percent." He bases that estimate on how much cancer is in the prostates they take out. "The good news is that the cancers we're picking up through screening seem to be the more aggressive ones." Peter Carroll, the chairman of the Department of Urology at U.C. San Francisco, concurs. "If you took out the prostates of every man over fifty, you'd find cancer in forty percent of them. But if you do PSA testing of one hundred men over the age of fifty, you don't find forty cases of prostate cancer. Instead, you find between two and eight percent in that age group. So most of the cancers PSA is picking up are not insignificant."So if most of the cancers detected early through PSA are ones that would eventually cause trouble, and most of those are removed, the cure rate must be going up. The belief has always been if you catch the tumors before they have spread beyond the prostate, the chances are much better that you will get a cure. But as the years go by, it appears that this is not necessarily so.If The Cancer is confined to the prostate at the time of the surgery, after it's removed, the PSA should go down to close to zero; no prostate, no prostate specific antigen. If it starts to rise again, it means that prostate cancer cells are still in the body and that they are proliferating. Post-surgical PSA tests are beginning to show that cancer appears much more frequently after a radical prostatectomy than doctors once thought. Apparently many cases that appear localized in the prostate aren't."Our batting average isn't very good with prostate cancer," says Alpert with considerable sadness. "Many of our treatments fail, both surgical and non-surgical, and turn out to be palliative. But that's not the way they were planned."Alpert's honesty is in stark contrast to the almost ebullient tone taken by urologists who are quoted in the many books on prostate cancer. The word "cure," at least in the case of early detection, is used liberally. (Time magazine reported that three days after Schwartzkop's surgery, one of his doctors said, "We have one hundred percent of your cancer in a jar.")Patrick Walsh, the urologist from Johns Hopkins who developed the current state-of-the-art, nerve-sparing radical prostatectomy, claims a high cure rate. Five years after surgery, only 15 percent of his patients show evidence of cancer recurrence. Ten years later, that number is 20 percent. Those "cure rates" are much better than what was reported before PSA testing. Other urologists do not report cure rates that high, but Walsh tends to operate only on men with very low PSA scores.Some concern exists about outcome numbers being affected by what medical researchers call "lead-time bias." If, on average, PSA detects a cancer five years earlier than a rectal exam would have and the patient dies 10 years after surgery, it looks, on paper, as if you've given him five or even 10 extra years of life. But you may only have extended the time between diagnosis and death. He dies when he would have anyway; he just lives more years without a prostate.The no-treatment course -- watchful waiting -- is selected by men who have been diagnosed with cancer but decide not to treat either because of their age or because their tumors are small and assessed as lower grade. (Some critics say too many men wait without watching. Ideally, men -- especially men under 70 -- who select this course should have regular PSA tests and rectal exams.) Doctors in Europe are partial to watchful waiting as a course of action, and many believe the U.S. propensity to treat so many men aggressively is nuts.Those who support watchful waiting point to a Swedish study that showed the 10-year survival rate among men who weren't treated was the same as the survival rate among men who were. This study has been criticized because the men were older -- average age 72 -- with small, slow-growing tumors.All studies comparing treatment to non-treatment have flaws of some kind, and a large well-run, randomized clinical trial -- thousands of people given surgery and an equal number left untreated -- has yet to be completed. The National Cancer Institute, however, is now conducting one called PIVOT (Prostate Cancer Intervention Versus Observation Trial). The study will monitor the progress over 15 years of two thousand prostate cancer patients in the Veterans' Administration hospital system, but results are 10 years away.Meanwhile, men will continue having to make critical treatment decisions without the backing of sound scientific evidence. In his new book, Man-to-Man: Surviving Prostate Cancer (Random House, 1996), Michael Korda writes vividly of the agony involved in the whether-to-treat-or-not-treat decision. "If I had the surgery, I risked spending the rest of my life with some degree of incontinence. I could undergo the surgery and still experience a recurrence of cancer, in which case I might be incontinent, impotent and wondering whether the surgery was really necessary -- whether I might have had ten, or fifteen, or twenty 'good' years left to me if I had simply elected to leave well enough alone."Given The Present Uncertainty, how does a man decide whether to be tested?Internist Larry Posner recommends that his patients over 50 have PSA tests (African-American men and those with family histories, after 40), but he cautions them that a positive test may open a whole set of difficult decisions that they will have to make with inadequate information to guide them. "I tell them that the treatment hasn't been proven to work and the side effects can be awesome." But he also informs them that he himself has had the test.Carroll says despite the fact that we still don't know whether improved detection will translate into improved survival, he recommends that men take it. "In my opinion, healthy, asymptomatic men benefit from PSA testing. My reading of the data that's available now is that testing is a benefit."Those who argue against screening say the evidence isn't good enough to support it wholesale, but it's not good enough to say it won't be of value either. Some of the opponents of screening may find in five or ten years they were way off the mark."He says the problem isn't the test; the problem is that men who are diagnosed are not offered the full spectrum of management options. "Once you've detected cancer, you have to assess the risk, the patient, the cancer volume and stage, and then you apply treatment selectively," Carroll says. "Not all men need to be treated. Currently at U.C., we're watching about 17 percent of the men who have been diagnosed." Carroll is incensed that anyone would recommend that the test not be available. "Can you imagine not offering mammography to women? It blows me away that men in this age group are not thought of as rational human beings who have the right to know whether they do or do not have prostate cancer."But for many men, no matter what the size of their tumors or the calculation of their potential life spans, once they know they have cancer, they want to do something. When Schwartzkopf was asked about why he decided to have surgery, he said, "I'm not a type B personality who knows I have cancer growing inside of me and can live with the knowledge. I go into a kung-fu attack position when I go through a door of a hospital." Many men, even older men, feel the same way. One of the negative aspects of PSA testing, according to David Lakes, a Kaiser oncologist, is the increasing number of older men -- some in their eighties -- who are deciding to treat their cancers aggressively. Even in the best of circumstances, older men are disproportionately likely to experience impotence and incontinence and live no longer than they would without surgery.In an article in the Journal of the American Medical Association, Murray D. Krahn, a urologist from the university of Toronto, writes that while he is opposed to widespread PSA testing, he believes the decision to be tested should be up to the individual. "You have to sort out how cancer phobic you are or how much you dislike medical treatment," he writes, adding, "I'm a very treatment-phobic person. I'd just as soon stay away from doctors."SIDEBAR ONEOther Factors: If You're A Man Over 50 You Are At Risk For Getting Prostate Cancer, But There Are Other Factors Which May Either Increase Your Risk Or Reduce ItFAMILY HISTORYHaving a close relative with prostate cancer places you at higher risk, and you can inherit the genetic predisposition from both sides of your family. Also, if your mother had breast cancer, you are at greater risk for prostate cancer.RACEIf you are an African-American man, you have a 37 percent greater chance of both getting prostate cancer and dying of it than any other group. GEOGRAPHYGlobally, a dramatic north-south pattern exists, with the highest area of prostate cancer in the north, the lowest in the south. The variable here is thought to be ultraviolet radiation. Vitamin D, activated in the body by sunlight, is known as a tumor inhibitor and may prevent or slow incidental prostate cancer.These findings might explain why black men in the U.S. have such high rates. People with dark skin absorb less sunlight and therefore have less vitamin D in their blood. In one study, blood levels of vitamin D in black men in Zaire were compared to blood levels of vitamin D in Zairian black men living in Belgium. The men still living in sun-soaked Zaire had significantly higher levels of vitamin D in their blood.ENVIRONMENTIncidental prostate cancer is found in 30 percent of men in every race and culture in the world, so what happens in that culture is critical. For example, very few Japanese men living in Japan die from prostate cancer. When Japanese men move to the U.S., their rate of symptomatic prostate cancer eventually escalates to the same level as American men. It appears that whatever initially causes cancer may be the same in all men. What differs is what causes the progression of cancer.DIETSeveral studies have found a relationship between saturated-fat intake and prostate cancer risk, but all saturated fat may not be equally culpable. One study conducted by the Harvard School of Public Health indicated that men who ate red meat five or more times per week were 2.5 times more likely to suffer from advanced prostate cancer than men who ate red meat once a week or less. Another study from the Harvard School of Public Health found that lycopene, the substance that gives tomatoes their red color, seems to both prevent and slow down the growth of prostate cancer. But in what form a man eats his tomatoes seems to be important. Fresh tomatoes (not tomato juice) and foods cooked with tomato sauce, such as pizza, were significantly related to lower risk of prostate cancer, with tomato sauce seeming to have the strongest association. The conclusion of the researchers was that the process of cooking and the addition of oil enhanced the "bioavailability" of lycopene.VASECTOMIESSome studies have shown an association between vasectomies and prostate cancer. But like so much other research in this area, the studies have major flaws.SEX HORMONESMen who are castrated before the age of 40 rarely get prostate cancer. Some studies show that men who start sex early in life are more prone to prostate cancer. Some studies show that men who keep having sex late in life are more immune.DRUGSOne hope on the horizon is Proscar, a drug currently used to treat prostate enlargement which has shown some promise in preventing prostate cancer. It works by thwarting the hormonal process that converts testosterone to a substance called DH -- the active form of male hormone in the prostate. The drug has few side effects and because it doesn't affect the levels of testosterone in the blood, it doesn't usually cause sexual dysfunction.In 1993, the National Cancer Institute initiated a study in which 18,000 healthy men, randomly divided into two groups -- one taking Proscar and one taking placebos -- will be followed for seven years. Peter Carroll says the data is not yet strong enough to recommend the drug to all men. But, he adds, even if it doesn't pan out for cancer prevention, it has some tantalizing other possibilities. "It may prove to have some effect on male pattern baldness."