Playing the Odds

Trip to Canada

Hurley had to educate himself. ``Before the diagnosis, I didn't even know what the prostate was,'' he says. He turned to the Internet and ran across HIFU. These machines use ultrasound powerful enough to destroy prostate tissue. It works like a magnifying glass focusing sunlight and is accurate to the millimeter. HIFU is popular in Europe and is currently undergoing clinical trials in the U.S.

When Hurley told friends he was considering a trip to Canada, where HIFU is approved, they said he was crazy. ``You'd be astounded by the resistance,'' he says.

Some U.S. urologists dismiss HIFU. ``I think it's a hammer looking for a nail,'' Walsh says.

``It's never been tested in a thoughtful clinical trial,'' Scardino says. ``They don't have any good data. There's a lot of marketing and hype.''

Dr. John Warner, medical director at Maple Leaf HIFU Co., a Canadian company that operates an HIFU machine in Toronto, says HIFU is the future. A urologist, Warner is no stranger to surgery. He's removed 800 cancerous glands.

``It's only a matter of time before this becomes state of the art in North America,'' Warner, 48, says.

Not Much Data

Because it's so new, fans like Warner have little data with which to promote HIFU's effectiveness. A study by doctors in Germany, reported in the journal Urology, showed that 93 percent of men with tumors confined to the prostate had negative biopsies up to five years after HIFU treatment. Five years is a short time when dealing with prostate cancer.

Hurley's urologist recommended surgery or radiation treatment. Hurley wanted more opinions. A health-care consultant in Seattle, a woman who had survived breast cancer, reviewed his Gleason scores and recommended HIFU, the treatment he'd seen on the Internet. ``It sounded so humane,'' Hurley says.

Hurley flew to Toronto on March 29, a Wednesday. He had a preoperative appointment shortly after he landed. Maple Leaf HIFU arranged for a room at the Westin. The next afternoon, Hurley went in. The doctors gave him an epidural to keep him still and a sedative to make him sleep. The procedure took just under 2 hours.

The following day, he had an exam and flew home to New Jersey. By Tuesday, he was back on the scaffolding applying plaster.

Agony

There was one complication. Hurley had to wear a catheter to keep his urethra clear of dead prostate tissue that might migrate there. Two weeks after that catheter was removed, a piece of tissue got lodged. He rushed to Overlook Hospital in Summit, New Jersey; tossed his truck keys to the parking valet; and waited for three hours in the emergency room, in agony from being unable to urinate.

Finally, a doctor inserted a new catheter. When Hurley left the next day, he found the valet had lost his truck. ``It was craziness,'' Hurley says ``But it's a small price to pay.''

Like Hurley and Weinstein, Lewis wasn't about to let the doctors make up his mind for him.

A Rhodes scholar with a Ph.D. in theoretical physics, Lewis worked for U.S. Defense Secretary Robert McNamara in the 1960s, trying to figure out how the U.S. should spend money to win the Cold War. He later became associate provost at Princeton University. He joined McKinsey in 1982 and became head of the McKinsey Global Institute, the firm's economic think tank, in 1990.

Up in the Air

When Lewis was diagnosed with cancer, he'd just retired from McKinsey and was writing a book about why some countries are wealthy and others aren't. He and his wife, Jutta, had purchased land near Carmel, California, where they planned to build a house.

``All these plans were up in the air all of a sudden,'' Lewis says. ``It was quite a jolt.''

Lewis is the epitome of a man aging well. He has a head of gray hair, and he retains a lanky build that helps on the squash court. One of his biggest worries was that prostate cancer would change his sex life.

``Sexuality is very much a part of personality, and until that dies, I didn't want to change my personality,'' he says.

Lewis's biopsy suggested his cancer was relatively benign. His urologist took 14 cores from his prostate, and only one hit cancer. His Gleason score was a moderate 6. The diagnosis, though better than many, left Lewis to choose among treatments, all of which had disadvantages. His doctor recommended a prostatectomy.

Old Microscope

Lewis set out to learn all he could. He got out his kids' old microscope and looked at slides of his biopsy tissue, comparing it with samples put on the Internet by Stanford University to see if he agreed with the pathologist.

He spoke with men who'd had surgery. He talked to doctors at the University of California, San Francisco, about new radiation techniques. Doctors in Florida told him about cryotherapy, in which the prostate is turned into an ice ball to kill the cancer inside it.

Lewis concluded that for him, the risk of incontinence after surgery was one out of three, and that the risk of impotence was about the same.

``The chances are two out of three that you'll get at least one of them,'' Lewis says. ``That didn't sound attractive.''

Then, in June 2003, almost a year after his first abnormal PSA test, his squash partner gave him a booklet by Carter at John Hopkins that had a section on active surveillance.

Right Answer

Lewis had heard about Carter's program. He was impressed that a doctor at Hopkins, an institution known for its prostate surgeons, would be so interested in active surveillance. ``He had the answer I was looking for,'' Lewis says.

Jutta Lewis says she tried not to think about her husband's cancer. She says she believed he would tease out the critical information and present it to her to discuss. ``I trust him to do the best job anyone can do,'' she says.

After three years of active surveillance, Lewis's cancer seems to have vanished. ``It hasn't shown up in any of three subsequent biopsies,'' he says.

Carter says as many as 30 percent of the men who are diagnosed with prostate cancer would be eligible for his active surveillance program because their cancers aren't that severe. Today, just 2 percent of the men who come to Johns Hopkins with the disease enroll with Carter.

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