Options for screening and treating this disease are increasing. Here is what every man should know
RON SLAYMAKER, a university basketball of Kansas, exercises regularly, eats sensibly and doesn't smoke. At 59, he hadn't missed days of work because of illness in 36 years. Then a routine physical examination turned up a nodule on his prostate, the walnut-shaped gland beneath a man's bladder. A biopsy revealed it was cancer.
"I was shocked," says Slaymaker, who had no symptoms. Like most men, he didn't know that prostate cancer, at least in curable stages, rarely produces symptoms. Soon he found himself facing a bewildering array of treatment options. Worse, doctors differed widely in their recommendations.
Slaymaker was far from alone. This year hundreds of thousands of men will learn they have prostate cancer. Many of them will be at a loss about how to treat the disease. Their confusion---and that of many doctors---is only heightened by rapid medical advances in the field.
How can men and their families effectively deal with this dreaded malignancy? Here's the latest in medical knowledge.
Getting Accurate Screening
Detected early, prostate cancer is curable. That's because it usually grows slowly, taking years to develop. The problem, says Dr. Patrick C. Walsh, chief urologist at Johs Hopkins Hospital in Baltimore, is that "when a man has symptoms, it's probably too late."
Each year tens of thousands of sufferers die.
For this reason, doctors emphasize early screening. One method is the digital rectal exam (DRE). In this procedure, the doctor examines the rectum manually, feeling the prostate for uneveness, hardness and enlargement.
A serious drawback to the DRE is that it reaches only one side of the prostate. Phil Gunby, an editor at the Journal of the American Medical Association, understands well the possible consequences. In Gunby's case, the routine DRE failed to detect a tumor because it was on the gland's far side.
Luckily, he also underwent another form of screening that sometimes accompanies the DRE. This is a blood test that measures prostate-specific antigen (PSA), a protein given off by prostate tissue. In general, the higher PSA, the greater the cancer risk. A reading of 4 nanograms per milimeter is often used to trigger further evaluation. But since PSA readings rise as men grow older, many doctors adjust the cutoff for the man's age---for example, using a level of no more than 2.5 for a man in his 40s, 3.5 for a man in his 50s, 4.5 in his 60s and 6.5 in his 70s.
Often even more telling is the rate of change revealed by PSA tests. A rise in PSA is what alerted by PSA tests. A rise in PSA is what alerted physicians to Gunby's prostate tumor in 1995. His PSA reading had jumped from 2,6 to 6,8 in just two years. A biopsy showed cancer.
As with the DRE, the PSA "isn't a magic wand," Walsh says. Elevated PSA levels only signal something is amiss. Further evaluation is needed to determine if the cause is begin enlargement, cancer or infection. Dr. William Catalona, a urologic surgeon at Washington University School of Medicine in St. Louis, and colleagues are developing a second-generation PSA test to help distinguish between begin problems and cancer.
While PSA testing is fairly common, it is not foolproof. But as Dr. Howard Scher, chief of the genitourinary oncology service at Memorial Sloan-Kettering Cancer Center in New York City, says , "I've always felt that you're better off having the information and trying to use it intelligently as opposed to not having it at all."
The American Cancer Society recommends that men over 50 be tested annually. Since men with a family history of the disease are at greater risk, they should start testing in their 40s.
Gauging the Cancer's Spread
Different scales are used to estimate a prostate tumor's insasiveness. Once the cancer has spread, surgery probably won't be effective. But patients are advised not to make treatment decisions based solely on any one of these tests.
One measurement system, called TNM, has a scale ranging from T1a, the earliest-stage tumor, to T4, a tumor that often has spread into the bladder, sphincter, rectum and pelvic muscles.
Another scale, the Gleason score, measures the "grade" of tumor---what the cells look like. Cells with welldefined borders are generally less aggressive than those with irregular borders. The Gleason score is a bellshaped curve from two to ten, with higher numbers indicating more aggresive cancer. Most men are five, six or seven.
At Johns Hopkins, Walsh and Dr. Alan W. Partin have developed a way to take into account the Gleason score, PSA level and TNM staging to better gauge whether a tumor has spread. For example, if a man has a PSA less than four, a Gleason score of five and a T1a staging, he has 90-percent chance that his tumor is confined to the gland.
On the presumption that prostatecell DNA circulating in the blood shows that prostate cancer has spread, doctors are evaluating a new blood test called reverse transcriptase polymerase chain reaction (RT-PCR). "It can detect one prostate cancer cell in a million," says Dr. Aaron E. Katz of Manhattan's Columbia-Presbyterian Medical Center.
Examining DNA may also prove useful. Dr. Jeffrey S. Ross and colleagues at Albany Medical College in New York looked at DNA from cancerous prostate tissue and found that in cells with an "aneuploid" (jumbled) DNA pattern, the cancer was three times more likely to recur and up to twice as likely to spread beyond the prostate.
Choosing the Best Treatment
In 1987 Manny Hamelburg 47, was told he had prostate cancer. Although his father had also had the disease, Hamelburg says that he was "completely ignorant" about it. When his surgeon suggested radiation, he agreed.
Several years later the cancer returned, and Hamelburg requested surgery. He was stunned to be told he wasn't a candidate---his prior radiation treatment disqualified him. Radiating the prostate leaves it prone to developing fibroids and therefore difficult to remove surgically.
Hamelburg investigated his options and entered an experimental chemotherapy and hormone treatment program at National Institutes of Health in the U.S. Today, four years later, his cancer remains under control.
The lesson here: don't rush to choose your treatment. When detected early, slow-growing prostate cancer "is one disease that gives you plenty of time to make up your mind," argues urologist Ralph De Vere White of the University of California, Davis, School of Medicine and Medical Center.
Here are the options:
1. Surgery
The ideal candidate for surgical removal of the prostate---a radical prostatectomy---is a man whose cancer is confined to the gland, who has no other health problems that might compromise recovery from major surgery, and who can expect to live another ten years. Some surgeons won't operate on men over 70, since the operation may not significantly prolong their lives.
The benefit of surgery is that it can cure early-stage disease. The drawback is that the procedure may involve cutting the nerves to the prostate, resulting in impotence---a scenario that affects up to 75 percent of men. About six percent experience incontinence.
When the prostate is removed, surgeons also take out the seminal vesicles, which means sperm are no longer produced. On resuming sexual relations, men experience a "dry orgasm": the sensation is the same, but ejaculations stops. (Men who still wish to father children often store their sperm prior to surgery).
An operation perfected in the early 1980's by Walsh at Johns Hopkins reduces the risk of impotence by sparing the nerves. "Ninety percent of my patients in their 40s and 25 percent of men in their 70s recover their sexual function," says Walsh.
But men whose cancer is too extensive aren't candidates for nerve sparing surgery. Richard Howe of Houston, former president of Pennzoil, was rendered imporatnt after a standard radical prostatectomy. After noninvansive approaches didn't work, in May 1995 he had surgery to insert a penile implant, a device that allows a mechanical erection. "It's an expensive operation," Howe says, "And the recovery is similar to having a prostatectomy. But it does work. I've never had any second thoughts about it."
2. Radiation
Radiation is less invasive than surgery and there's no age barrier. Some men also have radiation after surgery when doctors believe the cancer may have spread outside the gland.
The most common type is external-beam radiation, a six-to seven-week course of treatment in which a daily dose of radiation is beamed through normal tissue to destroy cancer cells. While patients are still left sterile, impotence rates are about half as much of those following surgery.
Radiation, however, doesn't always cure prostate cancer. Studies find the disease eventually recurs in 30 to 90 percent of patients. And after radiation, surgery is no longer an option.
In a newer type of radiation, called brachytherapy, tiny radioactive "seeds" or pellets are inserted into the prostate. Unlike external-beam radiation, brachytherapy is a one-time event;a spinal block makes the procedure painless. Because the radiation is contained in the gland, there are fewer side effects. Only about 15 percent of patients experience impotence. Brachytherapy has a shorter track record than other therapies, but so far 60 to 80 percent of patients showed no signs of recurrence six years after treatment. Preliminary findings suggest it may be especially appropriate for older men.
George Berger's prostate cancer was diagnosed in May 1994. When the surgeon refused to operate because he was 71, Berger, a retired systems engineer, did a computer search for treatments available, and settled on brachytherapy. After the procedure, his PSA dropped from 11.6 to 0.2. "Sooner or later I may need additional treatment," Berger says, "But in the interim, the localized therapy has done well---and I'm neither incontinent nor impotent."
3. Hormone therapy
Prostate-cancer cell growth is boosted by the male hormone testosterone. Drugs that interfere with its production can block the growth of prostate tumors, at least for a while. Diethylstillbestrol, an oral estrogen, is one drug used;others are leuprolide acetate, goserelin acetate, flutamide and ketoconazole.
Hormone treatment is usually reserved for the most advanced prostate cancers, but brief courses of the therapy may be used to shrink tumors prior to surgery and radiation. It can produce hot flashes (similar to those women experience during menopause), as well as irritability and weight gain. Ninety percent of patients become impotent and have no sex drive.
Cancer cells eventually mutate to resist the drugs. How soon this happens varies, but only about 25 percent of prostate-cancer patients treated with hormone therapy survive more than five years. To foil resistant cancer cells, researchers are experimenting with a regimen of six months on hormones, six months off. During the off-time, libido returns and the menopausal symptoms fade. Early results are encouraging, though the strategy is still being tested.
"Watchful waiting." This course is pursued by many older men and some younger ones with uncertain diagnoses, Patients get no treatment, just frequent monitoring---PSA testing, plus ultrasound imaging, DRE and biopses as needed.
There's no set age when doctors with typically suggest leaving a tumor alone. And no long-term medical studies exist to show that watchful waiting is a good strategy. When patients and doctors choose this regimen, they make an educated guest that the cancer won't grow out of control. According to new guideliness by the American Urological Association, patients "must understand at the outset that delay may compromise the effectiveness of subsequent treatment, if any should become necessary."
"All issues surrounding watchful waiting need to be fully discussed with the patient, including the need for possible subsequent biopsies," says University of Pennsylvania Medical Center and Health System urologist Dr.Alan Wein. "I feel this is reasonable for some older men, but risky for younger patients."
4. Alternative therapies.
These include chemotherapy drugs such as Taxol, Taxotore, estramustine phospate and etoposide. Researchers are also working on vaccines to help a man's immune system fight his cancer.
Larry Karl, 51, of Pittsburgh underwent an experimental treatment called cryosurgery. In this procedure, doctors freeze the prostate by insetting liquid-nitrogen probes into it. When the gland thaws, cancer cells rupture and die. Karl had four treatments; the procedure doesn't always kill all cancer cells the first time. Surgeon Jeffrey Cohen of Pittsburgh's Allegheny General Hospital reports that about 80 percent of 500 men have "no biopsy evidence of cancer" two years after cryosurgery.
The main reason for caution regarding cryosurgery is its short track record. The procedure is less accepted than brachytherapy and is reserved for patients who are poor candidates for surgery or radiation.
The options for screening and treating prostate cancer keep increasing. Ultimately, the course of action a man elects to follow depends on his age, health, extent of disease and quality-of-life preferences.
After seeking all the advice he could get, Ron Slaymaker decided on prostate surgery preceded by hormone therapy to shrink the tumor. Today, he's recovered and back on the job.
"I'm one of the lucky ones," says Slaymaker. He urges men to get as much information as possible---because ignorance is not bliss.
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