Tough Choices On Prostate Cancer

Surgery? Radiation? "Watchful waiting"?

Prostate cancer, called the silent killer for the way its symptoms don't appear until the disease is well advanced and almost incurable, has not been so silent lately. New York City Mayor Rudolph Giuliani recently joined a list of celebrities suffering from the disease, putting him alongside media tycoon Rupert Murdoch, New York Yankees manager Joe Torre, golf great Arnold Palmer, and General Norman H. Schwarzkopf of Persian Gulf War fame.

But as common as the disease is--it strikes one in every six men--a new survey shows an alarming lack of knowledge and corresponding fear of prostate cancer. Indeed, physicians appear to assume men know far more than they do about the disease. That can lead to a dangerous disconnect between doctor and patient that may prevent patients from getting the best treatment or addressing the disease's side effects.

WATCH AND WAIT. More than virtually any other cancer, prostate cancer cries out for a well-informed patient. While most malignancies must be surgically removed or treated with chemotherapy or radiation, there is no consensus among doctors about the best treatment for prostate cancer. Neither is there consensus about the risk of recurrence or even the necessity for universal screening. Prostate cancer is possibly the only cancer where a standard method of treatment is called "watchful waiting"--a doctor does nothing more than closely monitor the progress of this slow-growing tumor.

The one thing medical experts do generally agree on is the need for men to discuss their options openly and fully with their doctors and get a second opinion. But even that is not happening. In a Roper survey of 302 urologists and 307 men with prostate cancer, released on May 2 at an American Urological Assn. meeting in Atlanta, 94% of doctors said they discussed all treatment options with their patients--but 32% of patients said their doctors only discussed one therapy option. Only 39% of patients said they had consulted a second physician, and less than a third did any in-depth research on their own--although more than 90% of doctors assume their patients are doing just that. And although prostate cancer can have a large impact on a patient's quality of life, 52% of patients said their doctors didn't discuss emotional side effects. "This reflects the fear that surrounds this disease," says Dr. David McLeod, program director of the Urological-Oncology Division at Walter Reed Army Medical Center in Washington. "It's different from other cancers in that it's in a very awkward area. You're challenging their sexuality."

The prostate is a small, walnut-sized gland that lies beneath the urinary bladder and surrounds the urethra. The gland accounts for about 30% of semen volume. As a man ages, the gland grows, causing a benign condition called prostatic hyperplasia (enlarged prostate) in more than 50% of men over 50. But for an estimated 318,000 U.S. men this year, the enlarged prostate will be diagnosed as malignant, and 40,000 will die from the disease, making it the second largest cancer killer of men. The good news is that if treated early, prostate cancer is almost 100% curable.

Screening with a PSA blood test, which measures a prostate-related enzyme that increases as the gland enlarges, can catch the disease early, although false positive readings can run as high as 75%. The test is usually coupled with a rectal exam by the doctor. A second blood test, called the free-PSA, has recently become available that can give a more accurate reading.

If the PSA test is positive, doctors usually recommend a biopsy to confirm whether cancer is present. If it is, the patient must start making tough decisions. But because prostate tumors are so slow-growing--researchers assume most men have had one for some 12 years before diagnosis--a patient doesn't need to rush. He can take months before deciding on what step to take next.

That next step boils down to choosing surgery vs. radiation. If the patient picks surgery, known as a radical prostatectomy, the entire prostate gland plus some surrounding tissue is removed, either through an incision in the abdomen or between the scrotum and anus. A variation of this technique attempts to spare the nerves on either side of the prostate that are necessary for erection. But Dr. Howard Scher, chief of the genital-urology service at Memorial Sloan-Kettering Cancer Center in New York, cautions that patients should make sure they choose an extremely experienced surgeon and be prepared for side effects. A large-scale study, published in January in The Journal of the American Medical Assn., found that among men who underwent prostate surgery, 60% were impotent and 8.4% were incontinent 18 months after the surgery.

"SEEKING SALVATION." The alternative is radiation, either by X-ray or with rice-sized pellets implanted directly on the tumor. Once again, impotence or incontinence can result. So this is where the choice for the patient is tricky. There has been no large-scale study of radiation vs. surgery, and survival data on both treatments are similar and loaded with biases, depending on whether a surgeon or a radiologist conducted the study. "Getting prostate treatment is like seeking salvation," says McLeod. "You go to a Protestant and he'll tell you one thing, a Catholic another, a Buddhist a third."

Surgeons recommend surgery, and radiologists prefer radiation. To complicate things further, once the initial treatment is completed, the patient has more options to consider: whether to follow up with chemotherapy or a variety of hormone replacement treatments, all meant to prevent the cancer from recurring or spreading.

All these choices must be made against the widespread perception that with prostate cancer, the cure can be worse than the disease. That is not true for most, particularly younger, men, but doctors acknowledge that a man in his 80s, particularly one with other medical conditions, would be best off choosing watchful waiting. Chances are, he will die before the tumor can kill him. For everyone else, doctors stress the need for annual screening, lots of information, and a knowledgeable specialist. Survivor support groups are also recommended, to help patients with the emotional issues surrounding the disease. Prostate cancer may be silent, but patients should be anything but.

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