Playing the Odds

Worth the Wait

Over time, about 1.5 percent of men who could have been saved with surgery or radiation but chose active surveillance instead will succumb, Klotz says.

``I have no doubt that we will lose the occasional patient who is curable,'' Klotz, 53, says in an e-mail.

For most men, the chance of dying from prostate cancer is so small -- and the odds of impotence and incontinence after surgery or radiation are so great -- that active surveillance is worth the risk, he says.

How do you crunch all these numbers? Many men wind up plugging them into computer programs called nomograms -- this many billionths of grams, that degree of cell deformity -- to try to predict how lethal their cancer is and find the best treatment. They must ask themselves hard questions. Am I willing to risk dying to preserve my sex life? Can I afford to wait?

Lucky

Bigg, who makes his living trading corn options on the Chicago Board of Trade, says he's one of the fortunate ones. A blood test during a routine physical provided the first, vital clue that something was wrong. His blood showed elevated levels of prostate-specific antigen, a marker for cancer.

That first PSA test led to a second, which led to a biopsy, which uncovered a dangerous tumor. Bigg underwent a prostatectomy. In the months following his surgery, he had a little trouble controlling his bladder. He says he's fine now.

Bigg says his erections aren't what they used to be but that his sex life is good. Now, at 49, he is cancer free. ``I was lucky,'' Bigg says. ``I didn't have a choice.''

Weighing Advice

Men such as Will Weinstein, whose cancer wasn't as severe as Bigg's, must weigh conflicting medical advice and balance the risks and benefits of various treatments. Weinstein, diagnosed at 56, spent seven months interviewing 44 doctors before deciding on brachytherapy, which involves implanting radioactive pellets in the prostate. Ten years on, Weinstein, a former hedge fund manager who now teaches ethics at the University of Hawaii in Honolulu, says he can get an erection and control his bladder.

He says that if he got the same diagnosis today, he might try active surveillance, provided he could stomach living with cancer.

Jim Hurley, 53, has seen more than his share of this disease. Prostate cancer killed his father at the age of 72 and struck two of his five brothers. Both brothers have had prostatectomies, and both have survived. When his time came, Hurley, a plasterer from New Jersey, turned to the Internet and discovered high-intensity focused ultrasound. HIFU hasn't been approved by the U.S. Food and Drug Administration, and some surgeons scoff at it.

Hoping to avoid impotence, Hurley flew to Canada for HIFU. He says he made the right choice: He can have sex and hold his urine.

Watching and Waiting

And then there's Bill Lewis, 64. A former partner at McKinsey & Co., Lewis took what some surgeons call the most radical route of all: He monitors his condition with twice- yearly PSA tests and annual biopsies. That's it. No surgery. No radiation. No HIFU. His cancer seems to have disappeared.

On the following pages, these four men share their private battles and intimate fears. They're speaking out because other men will face what they have.

A fifth man, one who's well known to Wall Street, shares his thoughts on cancer, too. His name is Michael Milken. The onetime junk bond king of Drexel Burnham Lambert Inc., Milken has raised more than $300 million for prostate cancer research. His Santa Monica, California-based Prostate Cancer Foundation is financing the search for new, more-accurate tests for deadly tumors. Until researchers find one, Milken, 60, urges men to get a PSA test.

Doctors Debate

These five stories tell a larger one. Within the U.S. medical community, sometimes within the same hospital, a debate is taking shape that may upend prostate cancer care. Doctors no longer agree on how to diagnose this disease or what to do about it.

In medical terms, the PSA test -- which doesn't test for cancer but rather for a substance associated with it -- is sensitive and nonspecific. Translation: The test often lies. An infection or having sex before a PSA test can artificially inflate your result. The U.S. Preventive Services Task Force, a division of the U.S. Department of Health & Human Services, says PSA screening often leads to anxiety-provoking false positives and unnecessary biopsies. Neither the agency nor the ACS recommends that doctors require routine PSA screening. Some doctors do; others don't.

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