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Kinder cuts mean sharper dilemmas

Prostate cancer leaves little room for dignity
By Susan Brink
U.S. News & World Report
reprinted with permission

Charles Dixon, 57, lay belly up on the operating table, his head and feet lower than his gut. Split from his naval to the base of his penis, he is mercifully drugged into oblivion.

Patrick Walsh, chairman of urology at Johns Hopkins Hospital, is carefully slicing free the walnut-sized gland in what is called a nerve-sparing radical prostatectomy, designed to cure the cancer without interfering with sexual potency. "It's a very tricky operation. The nerves are wrapped around the outside of the prostate," says Walsh, who is doing this operation for about the 2,800th time. "The person doing this procedure has to have a lot of experience," he says, then adds, without even the pretense of humility, "I'm able to do it better than most." By virtue of the fact that he invented the technique in the early 1980s and has been perfecting it ever since, he's probably right.

Prostate cancer treatment is in the midst of upheaval, as ripe with promise as it is riddled with uncertainty. Even 15 years ago, diagnosis often came too late, after the cancer had spread to lymph nodes or other organs. And treatment, which almost inevitably resulted in impotence, and often in incontinence, was often viewed as worse than the disease.

But now, men are diagnosed at earlier ages with less advanced disease, and death rates are dropping. So are the dispiriting consequences of treatment, as top centers take the lead in reducing the risk of mutilating side effects. "There are dramatic changes in prostate cancer, unprecedented in the history of oncology," says Robert Stephenson of the urology division at the University of Utah School of Medicine.

That's the good news for the 180,000 men in the United States – all but about 2,600 of them over 50 – who learn they have the disease each year. The bad news is that at every stage in a man's thinking about prostate cancer, from deciding whether to be tested to choosing which treatment, if any, to pursue, he faces varied, even contradictory options. Walsh, for instance, is stalwart about the advantages of his nerve-sparing prostate surgery. But other innovators are just as bullish about two other approaches: precisely targeted, high-dose radiation, and radioactive seeds implanted directly in the diseased prostate.

It can be dizzying for patients. "I went to four urologists who recommended surgery and four radiologists who recommended radiation," says Bill Buckman, a prostate cancer patient from Northbrook, Ill. The wait for medical consensus will be long: Results from the first trials comparing treatments won't be out for nearly a decade.

All camps agree on one thing: Whether deciding on surgery or a form of radiation treatment, men should find physicians who have a lot of experience with the newest techniques. It takes great finesse to remove or destroy the prostate – a 11/2-inch-long gland that produces much of the seminal fluid – without damage to the nerves around it or to the urinary tract, which it straddles. Experts suggest patients ask their doctors how many treatments they do annually, and choose a surgeon or radiation oncologist whose number is above 100.

Even the question of whether to get screened for prostate cancer has no simple answer. Men begin to worry about their prostates some time between ages 40 and 50. Two common conditions are more nuisance than danger: benign prostatic hyperplasia (BPH), or enlarged prostate, which can make urination difficult, and prostatitis, an infection treated with drugs. It is prostate cancer that creates all the fuss and worry.

Test questions

Urologists once diagnosed prostate problems by simply feeling the gland – the so-called digital rectal exam. But in the late 1980s, doctors began using a blood test for prostate specific antigen, or PSA, an enzyme made by the prostate. A high PSA count (above 4) can mean cancer, although it can also mean BPH or an infection. By 1994, the average age at diagnosis of prostate cancer had dropped from 72 to 69.5, and it is expected to drop another three years or so. The number of deaths has declined at the rate of about 2.5 percent a year since 1992. And one measure that cancers are being caught earlier is that the number of men whose cancer has spread has fallen by nearly half.

It all adds up to a gut-level feeling that early diagnosis means more cures. But that remains unproven, and whether or not men should take the PSA test is in dispute. The American Urological Association, the American Cancer Society, and the National Comprehensive Cancer Network recommend that men 50 and older consider an annual PSA test along with a digital rectal exam. The groups also recommend that African-American men, who have higher rates of prostate cancer, and men with a family history of the disease consider the test at age 40 to 45. But the National Cancer Institute has no recommendation either way. And some say the test may lead to unnecessary treatments, especially in elderly men. Because most prostate cancer is slow growing, "a lot of men who get treatment probably were never destined to die of their disease," says Stephenson.

For those who take the test, a positive PSA result, if confirmed by a biopsy diagnosing cancer, sends them on a quest for the best guess, the best shot at a cure. By looking at tissue biopsied from the tumor, pathologists can give patients and their doctors two important numbers, in addition to the PSA score: the stage of the tumor, from 1 to 4, indicating whether it is confined to the prostate or has spread into surrounding tissue, and the Gleason score, which describes how aggressive the cancer appears to be.

The worst news provides the clearest answer. Men with incurable cancer, which has escaped the prostate and spread, are not candidates for surgery, but their disease may be slowed by radiation, hormone therapy, or a combination of both.

Men with early, localized cancer, however, face an array of unknowns: whether treatment is really necessary, whether it will work, and whether it will have the feared consequences – the double indignities of incontinence and impotence. Older patients, even ones whose cancer is caught early, sometimes opt for "watchful waiting." Not quite as passive as it sounds, it involves monitoring PSA levels and easing specific symptoms.

Preserving potency

For men who seek treatment, the looming question is how to beat the cancer back with the least damage to body functions. Advocates for each of the leading treatments – nerve-sparing prostatectomy and two forms of radiation therapy – say their particular approach offers the best odds.

When the cancer has not escaped the prostate, surgery offers the most immediate chance for a complete cure. Walsh claims a nearly 98 percent cure rate in such early cancers, although the number should be viewed with caution: Doctors can't always be sure ahead of time that the cancer has not spread. His nerve-sparing technique also preserves potency in 86 percent of his patients. (After the prostate is removed or destroyed, patients are inevitably sterile, however.) Only 2 percent of Walsh's patients are left fully incontinent, forcing them to wear a diaperlike pad full time.

External radiation treatment is improving, as well. It was once used mainly to slow the disease in men whose cancer had spread. But evidence that it can lead to cures is now making it an earlier line of defense. "I personally believe radiation is a good option for men with early stage [cancer]. My own results are as good as surgery," says Gerald Hanks, chairman of Fox Chase Cancer Center's department of radiation oncology in Philadelphia. About 10 years ago, his center pioneered so-called three-dimensional conformal radiation therapy, which allows the oncologist to more precisely aim the radiation at higher doses, doing less damage to the surrounding tissue. It yields five-year cure rates of more than 80 percent in patients with a PSA level of 20 or less (the number can be above 50 in aggressive cancer), and a rate of side effects about as low as that of nerve-sparing surgery.

A rival radiation therapy option is brachytherapy, or radiation seed implants, introduced and refined over the past 15 years at the Seattle Prostate Institute at Swedish Medical Center. In an outpatient procedure taking less than two hours, tiny high-dose radioactive pellets are placed in the prostate gland, where they give off radiation for weeks or months. John Blasko, developer of the technique, says it's an option for younger men with localized prostate cancer. His 10-year outcomes show that 85 percent of men treated with seed implants have no further evidence of cancer, and he, too, claims low rates of impotence and incontinence.

Experience counts

Whatever the treatment, the younger the man, the better the odds he will emerge with all systems intact. But only the most practiced doctors can achieve the kinds of results that these three specialists claim. "There's a difference in radiation oncologists who treat several hundred patients a year and those who treat five or 10," says Hanks, who has treated more than 1,500 patients. Blasko has performed more than 3,000 radioactive seed implants. "I do seven a week of these things. I've gotten very good," he says.

National averages, which include centers that do few procedures, paint a grimmer picture. Of 1,291 men who had undergone radical prostatectomy, 8.4 percent were incontinent after 18 months and 60 percent were impotent, according to a January review in the Journal of the American Medical Association.

Jim Williams, a lawyer in Short Hills, N.J., was forced to weigh the odds at the unusually young age of 38. His physician, an advocate of early testing, suggested a PSA test more than 10 years earlier than is recommended. It came back positive, as did a biopsy. "I sort of came unglued," he says. Much too young to simply wait, he took his chances with nerve-sparing surgery under the expert hand of Walsh.

"I had a perfect result. My urinary function has been exactly as it was before. I have full erectile function," he says, though after surgery, because the prostate is responsible for producing much of a man's semen, there is no ejaculate. "You have dry orgasms. But everything else is the same, the enjoyment, the sensation," he says. So far, his PSA counts show no signs of cancer.

The odds are getting better that men can be treated for prostate cancer without losing their spirit and vitality. Williams is grateful, he says, but he sees it as a bonus. "When you realize you're dealing with a malignancy, your potency and urinary function fall lower in the order of importance."

© 2000 U.S.News & World Report Inc. All rights reserved. From 4/3/00 reprinted with permission.

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