Monday, March 19, 2001
Choice of a Lifetime
Which treatment works best for prostate cancer?
A look at three men who followed three different paths
By PAUL ENGSTROM
Smart health consumers are waking up to the power of knowledge in their war against illness. That's especially true when the marauder is prostate cancer, the second-leading cause of cancer death among American men.
The variety of treatments now available is cause for considerable hope. Countermeasures include removal of the prostate (radical prostatectomy), freezing the cancerous tissue (cryosurgery), inserting radioactive pellets (brachytherapy), different radiation techniques, hormone therapies, chemotherapy, "watchful waiting" (monitoring the slow-growing cancer's progress before taking a specific action, if any) and experimental treatments. Sometimes, circumstances call for a mix of treatments.
The problem for patients is this: Which treatment should they choose?
It's a crucial question, for the right therapy or therapies can have a profound effect on long-term survival. But choosing isn't easy. A man's age, general health and emotional state, the stage of the disease, the effect a therapy may have on his sex life, his insurance coverage and the expertise of his doctor are only a few variables in the equation.
There's also amazingly little agreement among medical professionals about which treatment works best, partly because there haven't been long-term, controlled studies to compare therapies. As a 61-year-old retired engineer in southern Vermont recently told an online prostate-cancer discussion group, P2P: "No one here is able to tell me if I am cured, what I should monitor and when, if I need additional treatment and what it should be, or if I'm going to die from this disease in a relatively short period of time."
The intricacy of the prostate itself doesn't help matters. Located in front of the rectum, behind the base of the penis and under the bladder, this walnut-shaped gland, which produces some of the seminal fluid that protects and nourishes sperm cells, is surrounded by blood vessels and nerves that regulate erections.
"It's about as complicated as brain surgery when you operate down there," says Mark Scholz, an oncologist in Marina del Rey, Calif., whose sole focus is prostate cancer.
The following are case studies of three men with prostate cancer who chose different courses of treatment. Their stories highlight some of the many issues that, for better or worse, influence this choice.
"Like father, like son." If there's any truth to that saying, Jack Talsky, 59 years old, stubbornly defied it when he weighed the options for treating his prostate cancer.
Like his father, Mr. Talsky, an architect in Culver City, Calif., was a 58-year-old sexually active man when a slight pain in the groin prompted him to visit his doctor. But unlike his father -- who underwent a radical prostatectomy in 1975 only to learn from a pathology report afterward, when he was irreversibly impotent, that in fact he had been cancer-free -- Mr. Talsky chose cryosurgery instead.
Cryosurgeons freeze the prostate by pumping a super-cooled gas through metal probes, killing both cancerous and healthy tissue. The probes are inserted through the perineum, the area between the anus and scrotum, and guided by ultrasound.
Clearly, the psychological baggage associated with his father's experience steered Mr. Talsky away from prostatectomy. But his own extensive research had an even greater influence on the decision.
He concluded that cryo-surgery, which has been around since the early 1990s, posed the least long-term damage to his body; if the cancer had indeed migrated beyond the prostate, a much more invasive prostate removal didn't make much sense. In any case, says Mr. Talsky, statistics show that survival rates for mainstream therapies, including cryosurgery, are all about the same after five to seven years.
Furthermore, given his relatively young age and the potential regrowth of sexually important nerves near the prostate after cryosurgery, the technique seemed to offer the best chance -- 65%, according to his physician -- that he would regain enough potency to be able to have sexual intercourse without using artificial devices or drugs. And his health-maintenance organization had recently begun covering cryo-surgery, as Medicare had in early 1999.
Men with prostate cancer commonly walk a fence when they consider all the treatment choices. One day, they settle on Therapy A as the best alternative; the next, after more deliberation or research, Therapy B appears more promising. Even Mr. Talsky, who was highly skeptical about prostatectomy from the outset, didn't completely rule it out.
At one point, "I pretty much decided, 'You know, Jack, don't be a coward. Do the radical prostatectomy. You're a young guy. If you do the radical, make sure your doctor is top-notch -- that he can do nerve-sparing surgery successfully. Just do it. Bite the bullet. Gamble.'"
His urologist rejected that idea, however. Mr. Talsky says the urologist thought he wasn't psychologically prepared to handle the possible side effects of prostatectomy, such as lifelong incontinence, that might prove "catastrophic." Also, 18 months of watchful waiting had elapsed since the diagnosis of Mr. Talsky's early-stage cancer, suggesting he wasn't fully committed to any one therapy. And the impact of his father's ordeal -- even though it had occurred 25 years earlier, at a time when prostate-cancer diagnosis and treatment were primitive compared with today's standards -- couldn't be discounted.
The surgery and its aftermath proved to be a trial. Under general anesthesia, the ultrasound device was inserted through his rectum and five one-eighth-inch-thick tubes for the probes were inserted through his perineum, causing extreme soreness for about two weeks and severe hemorrhoids. Back on the job after two weeks, Mr. Talsky temporarily lost some urinary control; he realized he probably had returned to work too early.
Otherwise, his recovery is progressing well. Based on follow-up tests of erectile function, Mr. Talsky says his doctors are optimistic that the nerves controlling his sexual functions will have completely regrown by August, the one-year mark after surgery.
"There are times when I really wonder if I did the right thing," he says, adding that he wished he had more thoroughly explored radiation as a possible treatment. In November, he felt "pretty good. Two weeks ago, I felt pretty lousy -- I decided I would never be able to get an erection again.
"The only thing I have to worry about is if my nerves grow back. Other than that, I'm cured. I'm of the mind I will live another 40 years."
Fun and relaxation weren't uppermost on Everett Rosemond's mind as he boarded a jet one Friday evening in the spring of 1998 to begin a vacation. He was unnerved that his urologist hadn't called.
Mr. Rosemond, 62 at the time and chairman of the language department at a private high school in San Francisco, was anxiously awaiting the results of a prostate biopsy after a prostate-specific antigen, or PSA, blood test had raised a red flag. The first physical signs of something amiss, he remembers, were a slight "twinge" while urinating and a "different sensation" during orgasm. His family history also warranted caution. One brother had died of prostate cancer at age 62, and another had been diagnosed with the disease, though he died of other causes at age 70.
While vacationing with his sister in Charleston, S.C., the call finally did come -- from Mr. Rosemond's wife. The message she conveyed was short and not so sweet: The doctor wants to see you. What followed was an emotional roller-coaster ride leading up to a radical prostatectomy about two months later.
Right after the diagnosis, Mr. Rosemond's urologist gave him a folder of helpful information describing prostate-cancer therapies and their side effects. The decision was entirely his. But Mr. Rosemond wanted more details and perspective. For one thing, radical prostatectomy -- the gold standard of treatments, given its long history -- seemed so invasive. And the potential side effects, such as permanent incontinence, were chilling. Might other therapies work just as well and take a smaller toll?
He harvested more information online and consulted several experts -- among them, the radiologist father of one of his students in San Francisco, a physician in Boston who referred him to a cryosurgeon in Los Angeles, even a pharmacologist friend abroad who queried the urologist for the king of Spain. His hopes rose and fell as he learned about the promises and then the perils of each treatment. The volume of information -- some of it contradictory -- was overwhelming.
At one point, when Mr. Rosemond told his urologist on the phone that he wanted to investigate cryosurgery further before ruling it out, the physician became impatient. "I said, 'Well, doctor, you did tell me to apprise myself of what is out there.' I hung up. I felt hot, I was so angry." They mended fences in a follow-up phone call the next day.
He concluded that radical prostatectomy indeed was the way to go, given his particular situation. Cancer had invaded the prostate lobes, so reaching it with brachytherapy would be difficult. The disease didn't appear to have metastasized, which otherwise might have called for chemotherapy or radiation. And the lack of data regarding long-term survival after cryosurgery inspired little confidence.
In hindsight, Mr. Rosemond believes he chose wisely. The surgeon couldn't spare the surrounding nerves that would have preserved his sexual function, because they were too close to the cancer. On the other hand, a biopsy during the operation suggested the cancer hadn't moved into the pelvic lymph nodes, and Mr. Rosemond completely regained bladder control after three months.
Mr. Rosemond's give and take with others on this journey taught him, the consummate teacher, that most men are clueless about prostate cancer. Could that be their undoing?
Rick Ward, a prostate-cancer survivor in Las Vegas who has lobbied state and federal government officials to promote more awareness of the disease, thinks so. "The way I look at it," he says, "is that even if we had the silver bullet today -- the one that
without a doubt would cure you -- we would still lose men if we don't make them aware of the problem in the first place."
Mr. Ward, 63, received something special on Valentine's Day in 1996 -- so special, it may have saved his life.
On that day, surgeons placed 51 palladium pellets, each about the size of a grain of rice, at very precise locations in his cancer-infested prostate through thin needles guided by transrectal ultrasound. The radioactive "seeds," encased in titanium to ensure a long-lasting effect, attack the disease internally. They cause little discomfort if placed properly.
But brachytherapy was only one of the weapons in Mr. Ward's arsenal. In combination with that treatment, he received hormone therapy to shut down the production of testosterone, which feeds prostate cancer. He also underwent external-beam radiation therapy, a procedure similar to an extended X-ray that assaults the disease from outside the body, because the seminal vesicles outside his prostate appeared to be cancerous, too.
In addition, he took and still takes an herb called saw palmetto that can reduce enlarged prostates, making brachytherapy a simpler task, and may help keep prostate cancer in check.
His battle didn't end there, however, given the possibility that some cancerous cells may have escaped those treatments and spread to other tissues. Today, about five years later, Mr. Ward, an Air Force veteran and former manager of a general-insurance agency, gets a PSA test every six months. He also avoids threats, such as high-fat foods, to his body's defenses against the cancer.
"My immune system is my main line of resistance," he explains. "It's the only thing between me and recurrence, really, so I won't do anything to compromise it in any way. That includes stressful situations -- I walk away from those in a skinny minute." Mr. Ward's journey began in September 1994 in Deer Lodge, Mont., when he spotted a small newspaper ad announcing free prostate-cancer screenings at a local clinic.
More remarkable than the fact that he had been getting up frequently at night to urinate, Mr. Ward recalls, was his almost offhand decision to visit the clinic. He knew very little about the prostate and its function.
Moreover, "I was the typical American male: We, of course, don't go to doctors," he says, noting that even in early childhood, our culture holds males and females to different behavioral standards. "If your sister fell down and hurt herself, she was cuddled. If you fell down and hurt yourself, you were told, 'Don't cry -- be a man.' We're stoic, stiff-upper-lip and all that stuff." When a high PSA reading of 14 and subsequent biopsies confirmed that he had prostate cancer, Mr. Ward says he immediately went into a problem-solving mode rather than a funk. (Generally, a reading below four is considered normal, though it varies by age.)
Among other things, he called the National Cancer Institute at 1-800-4CANCER, tapped an online support group and began researching his treatment options. From that time until the brachytherapy, about 14 months later, his prostate more than tripled in size.
Several factors steered Mr. Ward away from radical prostatectomy and cryosurgery. His mother, a retired nurse, advised against prostate removal based on the surgical outcomes she had witnessed, as did an elderly friend who experienced a slew of difficulties after the procedure.
Also, outcome statistics on the Internet simply didn't support the assurances of one urologist he consulted that radical prostatectomy rarely led to incontinence or impotence. At the time, cryosurgery had similar drawbacks and lacked a track record, at least according to the experts Mr. Ward spoke with and the reading he did.
The surgery took place at Wilford Hall Medical Center at Lackland Air Force Base in Texas. Afterward, the external-beam radiation therapy, in addition to causing a sunburn-like condition around the anus, sapped his energy. Mr. Ward started riding the bus instead of walking the 1.1 miles from his temporary living quarters to the hospital. The hormone therapy gave him hot flashes and bouts of diarrhea.
But on balance, Mr. Ward is pleased with the outcome.
"The bottom line is, you're going to be in the biggest crapshoot of your life," he says. "You're going to roll the dice, because there are no absolutes out there -- none."
About Prostate Cancer
|Approximate number of
prostate-cancer deaths in U.S. in 2000
|Approximate number of new cases each year
|Lifetime risk of developing prostate cancer among American men
(risk doubles if there is a family history of the disease)
||1 in 6
|Percentage of men who live at least five years after diagnosis ||92%
|Percentage of men who live at least 10 years after diagnosis
|Five-year survival rate for men whose cancer is confined to the
prostate at diagnosis ||100%
|Five-year survival rate for men whose prostate cancer has spread to
distant parts of the body at diagnosis ||31%
Sources: American Cancer Society; National Prostate Cancer Coalition
--Mr. Engstrom is a writer in Sebastopol, Calif. Write to Paul Engstrom at firstname.lastname@example.org