Playing the Odds

Head in Sand

Dr. Patrick Walsh of Johns Hopkins University School of Medicine in Baltimore, who invented modern prostate surgery, says the PSA test saves lives. The U.S. death rate from prostate cancer fell 27 percent from 1991 to 2001 because more men are getting tested, says Walsh, author of ``Dr. Patrick Walsh's Guide to Surviving Prostate Cancer'' (Warner Books, 2001).

Bigg's surgeon, Dr. William Catalona of Northwestern University Feinberg School of Medicine in Chicago, has performed more than 4,500 prostatectomies and is a vociferous proponent of early screening. In 1991, he showed that PSA could be used to screen for prostate cancer.

Catalona and Walsh say men should get their first PSA test at 40. ``It's such an easy thing to do,'' Catalona, 63, says. ``Otherwise, you're sticking your head in the sand.''

`Apple Pie'

Dr. James Talcott disagrees. A professor at Harvard Medical School in Boston, Talcott, 54, says PSA tests are so unreliable that men should avoid them completely. Talcott, an oncologist who studies medical outcomes, says he doesn't get PSA tests and probably never will. (He says he does get regular rectal exams.)

PSA tests often prompt men to undergo surgery or other treatments that leave them impotent or incontinent, even when there's little chance that prostate cancer will kill them, Talcott says. Talcott knows this view goes against the grain. ``Early detection is like apple pie and motherhood,'' he says.

Doctors are forever telling us to get checked for hypertension and high cholesterol. It's hard to imagine a woman refusing a mammogram because she'd prefer not to know she has breast cancer. And Katie Couric underwent a colonoscopy on NBC's Today in 2000 to raise awareness about colon cancer screening after her husband, Jay Monahan, died of that disease at 42.

Lewis's doctor, H. Ballentine Carter of Johns Hopkins, says many prostate tumors are best left untreated. Often, cancers never leave the prostate, where they pose little threat, Carter, 53, says. ``Fifty percent of the cancers we identify are low risk,'' says Carter, who monitors 350 patients, including Lewis.

Active surveillance isn't about ignoring prostate cancer, Carter says. He calls his program ``expectant management with curative intent'' to reflect his aim for a cure.

To Know or Not to Know

Many men would live just as long -- and be happier -- if they never found out they had prostate cancer, OHSU's Beer, 41, says. Too many men are risking impotence and incontinence to treat tumors that may never kill them, he says.

``If you had a cancer that was never going to kill you, you'd be better off not knowing about it,'' Beer says.

Prostate cancer doesn't care if you're rich or famous. The disease has struck Andy Grove, former chief executive officer of Intel Corp.; John Kerry, the U.S. senator and 2004 Democratic presidential candidate; and Rupert Murdoch, CEO of News Corp. Prostate cancer has killed Wayne Calloway, chairman of PepsiCo Inc.; jazz flutist Herbie Mann; Steve Ross, chairman of Warner Communications Inc.; and rock musician Frank Zappa. It claimed Earl Woods, golfer Tiger Woods's father, in May.

Genes Implicated

No one knows what causes prostate cancer. Dr. Bill Isaacs, a professor of urology and oncology at Johns Hopkins, says men who are stricken relatively young probably inherited rogue genes from their parents. The faulty code predisposes them to the disease. If a man's father or brother has had the disease, the odds that he'll get it narrow to one in three, according to the ACS.

A high-fat diet may foster the disease, Carter says. Fats seem to prompt tumor cells to divide faster.

In almost all men, the prostate tends to swell with age. Sometimes the growth reflects what's called benign prostatic hyperplasia, a non-cancerous enlargement of the gland.

Dr. Peter Scardino, chairman of surgery at Memorial Sloan- Kettering Cancer Center in New York and co-author, with Judith Kelman, of ``Dr. Peter Scardino's Prostate Book: The Complete Guide to Overcoming Prostate Cancer, Prostatitis and BPH'' (Avery, 2005), says testosterone is the likely culprit.

Castration Cure

Prostate cancer feeds on the male sex hormone. Until the 1980s, doctors castrated men to starve their cancers of testosterone. Today, they use drugs in severe cases to achieve the same results.

Bigg says he thought he was too young and healthy to get prostate cancer. Until he got that call from his doctor, in April 2004, Bigg says he never dreamed he'd be among those afflicted, even after his PSA readings came back high.

Bigg is quiet for a guy who makes his living shouting ``buy'' and ``sell'' on the floor of the CBOT. He's 5 feet 11 inches (1.8 meters) tall, weighs 200 pounds and is barrel- chested from a lifetime of swimming. Bigg is bald, with a fringe of close-cropped hair. In profile, he looks a little like Bruce Willis. On the CBOT floor, he wears a lightweight blue trading jacket and carries a stack of folded papers with calculations for options prices -- his ``shopping list,'' he calls it.

Bigg's story begins in 2003. Melissa Bigg, now 52, had taken a part-time job at a local Starbucks, which offered better health insurance than the coverage Bigg was buying for the family. He went in for a physical, grudgingly. He'd seen a doctor once in the previous 20 years, for strep throat.

PSA Test

During the exam, the doctor drew blood for a PSA test. PSA normally leaves the prostate through ducts leading to the urethra. Cancerous prostate cells leak above-average amounts of PSA into the bloodstream. PSA is measured in nanograms, or billionths of a gram, per milliliter. For a man of 45, a PSA reading of more than 2.5 ng/ml is cause for concern, Walsh says.

Bigg's PSA reading came back at 3.6. He says he wasn't alarmed. He'd been biking hard to train for a triathlon, which he'd heard could inflate PSA numbers. ``I was ready to blow it off,'' he says.

Then, four months later, Dave's younger brother Steve got wind of his PSA results. Steve happens to be a urologist. He told Dave to get tested again.

This time, Bigg's results were even worse -- around 4 ng/ml. Bigg's doctor told him to get a biopsy, and he agreed. Working on the CBOT has taught him a few things. ``I'm a believer in the trend,'' he says.

Prostate Biopsy

In a biopsy, a doctor harvests cells by inserting an ultrasound probe into the rectum, along with a gun that shoots a hollow needle through the rectal wall and into the prostate. The needle returns a core sample of tissue about a half inch (15 millimeters) long. Most doctors take a dozen cores.

A biopsy hurts. ``They stick a staple gun in your ass,'' says Charles ``Chip'' Baird, managing director of North Castle Partners LLC, a Greenwich, Connecticut-based private equity firm. Baird, 53, had his prostate removed in 2004.

Bigg's doctor sent the sample to a pathologist, who examined the cells under a microscope. Pathologists look for cells that are misshapen. The more deformed those cells are, the worse the cancer is. Pathologists assess the patterns and assign what's called a Gleason grade, from 1 to 5. The score is named for Dr. Donald Gleason, the pathologist who devised this system in 1966.

A Gleason grade of 1 indicates the malignant cells are close to normal. A score of 5 means the cells are almost unrecognizable as prostate cells -- a sign of severe cancer.

Gleason Sums

Most men have cells that fall into at least two categories, so pathologists add the grade for the most-prevalent type to the grade for the second-most-prevalent type for a combined Gleason score, or sum. Hence, a 2 is the best Gleason score (1 + 1), and 10 is the worst (5 + 5).

Because the first number in the Gleason score indicates the more prevalent cell type, you're better off if the first number is the lower of the two. A Gleason 4 + 3 is worse than a Gleason 3 + 4, for example. In the latter, most of the cells are Gleason 3, not 4. As a rule, a Gleason sum of 6 or less means that the cancer is treatable. A sum of 8 or more suggests cancer cells have escaped the prostate.

Bigg's Gleason grades were bad: 4 + 3, for a combined score of 7. When Bigg and his wife got home that day, they held each other. Dave called his brother and asked his advice.

``I told my brother, `If you don't have surgery, you're crazy,''' Steve says. ``Dying of prostate cancer is one of the worst deaths you can possibly have.''

`The Man'

Steve recommended Dave see Catalona at Northwestern, who removed the prostate of New York Yankees Manager Joe Torre in 1999. Steve Bigg had a connection, too. He'd trained under Catalona. ``He's the man,'' he says.

Prostate surgery takes practice. Results vary from surgeon to surgeon, and it's not always easy to get in to see a top doctor. No U.S. government agency or organization tracks how many of the patients a doctor treats end up impotent and incontinent. Patients have to trust what their doctors tell them.

Catalona says about 85 percent of his prostate surgery patients in their 50s can get erections afterward. Walsh at Johns Hopkins says men who come to him in their 40s and 50s have a 90 percent chance. ``It can take a little Viagra,'' says Walsh, 68.

Get It Out

Bigg told Catalona that he wanted the cancer out, whatever the cost. He says he cared more about surviving than he did about sex. He and his wife have two grown children, ages 22 and 18, and didn't want any more, so Bigg didn't bank his sperm. Men still produce sperm after a prostatectomy, but the sperm no longer reach the urethra, the canal that runs through the penis.

Bigg had to wait for the biopsy holes in his prostate to heal before Catalona could operate. ``That's the longest two months of anyone's life,'' Melissa Bigg says.

Bigg hit the pool, hard. Just before surgery, he placed second in his age group in the 100-yard butterfly in the Illinois Masters Swimming Association championships. He swam faster than he had in high school. ``What's scary is that you can feel so good and have this,'' Bigg says.

Bigg went in for surgery on a Monday in May.

Men who opt for surgery have Walsh to thank. The first documented prostatectomy was performed at Johns Hopkins in 1904. For the next 78 years, the surgery virtually guaranteed that a man would never have intercourse again. Many became incontinent, and 2 percent died within 30 days from loss of blood. Surgeons didn't know where the erectile nerves were. Nor had anyone completely mapped the veins around the prostate.

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