Playing the Odds

This year in the U.S., more than 230,000 men will learn they have prostate cancer. Doctors disagree about how to treat them. Here's what five men chose to do.

By Anthony Effinger
Bloomberg Markets September 2006

One day in Chicago, Dave Bigg is about to drink a few beers with his buddies and divvy up Cubs baseball tickets when his cell phone rings. It's the doctor, and he doesn't like what he sees. Bigg's biopsy looks bad. The cells from his prostate are warped and buckled. It's cancer.

Bigg can't believe what he's hearing. He's 46 years old. He doesn't look sick. He doesn't feel sick. Hell, he feels great -- he's training for a triathlon. ``It was like a punch in the stomach,'' Bigg recalls.

Bigg phones his wife, Melissa. She's about to have lunch with friends at the Cherry Pit Cafe, near their home in Deerfield, Illinois. She sits in her car and screams. Cancer? How can my husband have cancer?

``You can't wrap your mind around it,'' she says. ``You look at this healthy, energetic guy, and you can't believe it.''

This year, more than 230,000 men in the U.S. will get bad news like Bigg's, according to the American Cancer Society. And, like him, these men will face difficult choices about what to do next. Out of the blue, a diagnosis of prostate cancer will throw them into the middle of a raging medical debate over how to treat this disease -- or whether to treat it at all.

For some, the decisions they make will determine whether they live or die. For others, their choices will mean the difference between an active sex life and impotence.

One man in six in the U.S. will be diagnosed with prostate cancer during his lifetime, the ACS says. After age 40, the danger grows with each passing year. If you live long enough, the question becomes when, not if, you're likely to get this cancer. Autopsies show that 30 percent of U.S. men over 50 have at least some malignant cells in the gland. For men older than 80, that figure climbs to 80 percent, according to the ACS.

Hard to Treat

Prostate cancer kills one in 34 men in the U.S. Virulent tumors often spread to the bone. More than 27,000 U.S. men are likely to die from prostate cancer this year, the ACS says. This form of cancer is more common in men than any other cancer aside from that of the skin. It's more prevalent than cancer of the lung, which strikes one man in 13; of the colon, which hits one in 17; or of the bladder, which besets one in 28, according to the National Cancer Institute.

Prostate cancer is difficult to treat without life-changing side effects. The gland, which helps produce semen, is lodged deep in the abdomen, just below the bladder. It surrounds the urethra, through which urine and semen flow, and borders the rectum. The nerves that control erections lie along the prostate like delicate wires glued to a golf ball. Cut them, and a man becomes impotent. Sometimes, drugs like Viagra can help, provided at least one of the nerves remains intact.

Slow Tumors

Most prostate tumors are slow growing and, as cancers go, relatively benign. Some are fast moving and deadly. Doctors can't always determine which are which.

``We have a difficult time telling which cancers are aggressive and which are not,'' says Dr. Tomasz Beer, director of prostate cancer research at the Oregon Health & Science University Cancer Institute in Portland.

Statistically, prostate cancer is less lethal than many other forms of cancer. It accounts for 9 percent of U.S. cancer deaths, whereas lung cancer accounts for 31 percent, according to the ACS.

If the doctor says you have lung cancer, you usually have one course: surgery, fast. If he says you have prostate cancer, your choice may not be so apparent. Many men who learn they have prostate cancer are left wondering how to treat it. Surgery, radiation therapy, high-intensity ultrasound -- those are some of the options. Another is to wait, watch and hope the cancer never spreads, a strategy known as active surveillance.

Choose surgery or radiation, and there's a chance you'll end up impotent. Wait and watch, and there's a chance you'll die.

Bad Odds

Undergoing a prostatectomy, the surgical removal of the gland, meant impotence for about three in four men as reported in a study published in the Journal of the National Cancer Institute in September 2004. One man in seven was incontinent five years after the operation.

With radiation, the odds of impotence were about the same: 73 percent, according to this study. The incontinence rate was lower, at 4.9 percent. Top surgeons report outcomes that are much better.

Men who undergo treatment get no guarantee their cancer won't return. As many as 40 percent of men relapse, says Dr. Bruce Montgomery, an oncologist at the Seattle Cancer Care Alliance.

Given all this, some doctors advise patients to do something radical in modern cancer care: Wait and see. Dr. Laurence Klotz, a professor of surgery at the University of Toronto, has been monitoring 231 men for about seven years. If their cancer gets worse, he treats them. About two-thirds of these patients are still waiting. Three have died of their disease.

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