But it is a death that’s on a steady decline. Deaths from prostate cancer are expected to fall below 29,000 this year, according to the American Cancer Society–down from 31,500 in 2001 and about –35,000 as recently as 1993. (Women’s deaths from breast cancer, by comparison, over the same decade will go from 43,000 to a projected 39,800.) The prostate decrease is a tribute to better diagnosis and treatment; in comparison to lung cancer, for example, the risk factors for prostate cancer are mostly either unknown or unavoidable. Age is the main one; the incidence is one in 53 for men in their 40s and 50s, but one in seven for men 60 to 79. People with a family history of the disease are at higher risk, as are African-Americans (perhaps because darker skin produces less protective vitamin D in response to sunlight) and farmers (possibly the result of occupational exposure to herbicides). Some evidence suggests that obesity and a diet rich in animal fats may contribute to the disease, and lycopene, a substance found in tomatoes, may be protective–but it strikes plenty of lean, fit, health-conscious men as well. Vasectomies, bicycling and sex (or abstinence) don’t seem to make much of a difference, one way or the other.
In diagnosis, the big breakthrough of the last 20 years was the development of a simple test for prostate specific antigen (PSA), a protein whose blood level reflects changes in the prostate. As a rule of thumb, PSA readings above 4 are cause for concern, although the cutoff varies by age; a reading higher than 2.5 may be suspicious for a man in his 40s, and many doctors believe the trend of successive measurements is more significant than the absolute value. (Complicating the picture, not all men with cancer have high PSA levels, and high readings often don’t indicate cancer–leading some researchers to question the test’s usefulness; page 64) If a high reading is confirmed on a second test, doctors typically order a biopsy. Cancer cells, if present, are rated on the Gleason scale from 1 to 10, with the higher numbers indicating a more aggressive and dangerous tumor.
It’s then up to the man, and his doctor, to decide on a course of treatment–which can be among the most nerve-racking choices in modern medicine (as New Yorkers recall from the public agonizing of former mayor Rudolph Giuliani when his cancer was diagnosed in 2000). The range of treatments is wide, the side effects unpredictable and often unpleasant–and the stakes are, literally, life or death. In older men whose cancer is progressing slowly doing nothing may be the best solution. Bearing in mind that no one decision is right for everyone, NEWSWEEK spoke to six men who took six different approaches to their diseases, and are living now with the consequences. The alternatives were:
RADICAL PROSTATECTOMY: The removal of the prostate through conventional open surgery is the gold standard against which other treatments are measured. “There’s no better way to eliminate a cancer that’s confined to the prostate than total removal,” says Johns Hopkins urologist Patrick Walsh, who has done more than 3,000 such operations, including one recently on Massachusetts Sen. John Kerry. Making the case against halfway measures, Walsh notes that, on average, a cancerous prostate contains seven distinct tumors. “The younger the man and the longer you think he has to live, the more we think we ought to take out his prostate,” says Gerald Andriole, chief of urology at Washington University in St. Louis.
One man who chose that course was Myle Holley, a 59-year-old software consultant from Bedford, Mass. “I wanted the darn thing out, totally,” Holley says defiantly. So far–about three months after the operation–he is healthy, but still adjusting to the usual side effects of the operation, including partial loss of control over his bladder and sexual impotence. The prostate sits inconveniently among a tangle of blood vessels and nerves leading to the bladder and penis, and it is virtually impossible to remove it without causing at least some damage. The effects vary widely depending on the patient and, crucially, the skill and experience of the surgeon. Most men eventually regain bladder control, although a small minority end up permanently impaired; most, especially older men, never regain full sexual functioning and experience at least some difficulty maintaining an erection, although Viagra can help. Without a prostate, ejaculation is impossible; men can –still achieve sexual climax, but they may experience it as less intense, more muted than before their operation. “You wear pads,” Holley says, “and I don’t have the faintest idea about my sexual capacity. My surgeon told me to not even think about it [yet].” He expects the first problem to gradually correct itself, and as for the other, whatever happens, “you’ve still got your life.”
LAPAROSCOPIC SURGERY: This is a variation on conventional surgery that was introduced in 1990 and is gradually gaining acceptance–although relatively few surgeons have mastered it yet. Operating through a small incision, guiding their instruments by a video, doctors minimize the loss of blood and scarring, and patients typically resume their routines sooner, often within days rather than weeks. Incontinence, impotence and bowel complications remain common side effects. Bob Klaus, 55, of Cedar Rapids, Iowa, had laparoscopic surgery on a Wednesday, went home on Friday and returned to work on Monday. “Five years from now, it will be the norm,” he predicts. But there’s “a steep learning curve” for surgeons, says Dr. Harvey Simon, author of “The Harvard Medical School Guide to Men’s Health.” “When you’re first learning the procedure it takes longer and has more complications, particularly rectal injury.”
RADIATION: This can be administered either externally, by a focused beam, or by rice-grain-size seeds of a radioactive isotope (either iodine or palladium) inserted directly into the prostate. Radiation, which was the therapy Giuliani chose, is easier and cheaper than surgery, and requires almost no recovery time. The disadvantage is that it may not eliminate all the tumor cells, and the tissue damage it causes may make future surgery impossible. (Damage to healthy tissue can also, over time, impair sexual function, although less dramatically than surgery.) Radiation is often the choice of older men, who can accept the risk that the tumor might grow back in 15 years. At the age of 73, Aaron M. Bernstein of St. Louis chose seed therapy, which seemed like a worthwhile trade-off to avoid weeks of urinating through a catheter. At 76, and playing tennis weekly, he still thinks so–for now. “I’m an optimist,” he says.
HORMONE THERAPY: Prostate tumors thrive on testosterone, and drugs that eliminate or block the hormone seems to shrink them. This is the treatment of choice for men whose cancer has spread beyond the prostate. “It’s a wonderful treatment for more-advanced disease,” says Simon. By itself, though, it never cures cancer; after a period of remission, which may last years, cancer typically recurs. Hormones can also be used in combination with radiation therapy for tumors that are still confined to the prostate, as an alternative to surgery. That was the choice of 69-year-old Phil Hadley of Gloucester, Mass.–a retired medical-equipment salesman who had seen the inside of too many operating rooms to be sanguine about surgery. He likens the side effects of hormone therapy to menopause: “You get hot sweats, you get headaches, you get irritable.” In combination with radiation-beam therapy, though, it has kept his PSA down to a minuscule 0.1 since his treatment in 2001, and he has “no regrets at all.”
DIET AND LIFESTYLE CHANGE: This–either alone or in addition to another therapy–is the course recommended by Dr. Dean Ornish, the well-known proponent of low-fat diets for reversing heart disease. Last year he reported that his famously stringent regimen–limiting fat to 10 –percent of total calories, three hours of exercise a week plus meditation and support-group sessions–lowered PSA levels by 6.5 percent over three months in an initial group of subjects. That’s a modest improvement, but “it’s not going to cure prostate cancer,” Simon warns. One of Ornish’s subjects was Bob Gorczyca, now 63, a California marketing consultant who chose the Ornish program as a way to postpone more-radical treatment as long as possible. Gorczyca was diagnosed with prostate cancer in December 1999, after a PSA reading of a little over 7; the initial biopsy results, though, gave a reassuring Gleason score of 4, indicating a relatively nonaggressive form of the disease. Horrified at the thought that surgery might leave him wearing diapers, depressed at the possibility of losing sexual function, he put off any decision about treatment for months. In May 2000, he enrolled in the Ornish study, and by September his PSA was down to 4.7. As an added benefit, he lost 15 pounds, and his cholesterol is down to 130. He’s prepared for the eventuality of needing surgery or radiation, but if and when it happens, he says, “I’ve been able to buy time. My clock starts ticking from a later period.”
WATCHFUL WAITING: This is often the recommendation for men older than 75 or 80, who are less able to withstand the rigors of treatment, and likely to die of something else first anyway. But even younger men may decide to wait and see how their disease progresses before taking action. Lawrence Lovett, 65, of Anaheim, Calif., has been checking his PSA levels every three months since a routine checkup in 1998 showed a level of 7. On examination, his doctor found his prostate enlarged, but smooth, with no lumps suggestive of tumors, and over the next five years his readings stayed between 6 and 7–while Lovett, by cutting back on steak and adding regular exercise, lost 28 pounds. Last year his PSA levels began to climb, and when they reached 7.8 he went for a biopsy, which showed abnormal cells. A local prostate-cancer support group encouraged him to take his time before deciding on treatment, and so for the moment, he plans just to continue monitoring his condition. “A urologist usually just stands there with scalpel in hand,” he says. “But you have a lot of options.”
