Fighting Prostate Cancer by Doing Nothing
Treatment itself can be dangerous. And, scientists now say, it might not be necessary -- even for younger men.
By Susan Brink
But for some men, neither a rush to treatment
nor the old, passive wait-and-see approach is appropriate. "I spend half my time
talking guys down out of the tree," Doctor Scholz says. If surgical or radiation
treatment were akin to, say, treatment for basal cell carcinoma in which the
common skin tumors are removed and the patient suffers no serious consequences,
then early diagnosis followed by universal treatment would be a no-brainer. But
with prostate cancer, the usual treatments can have emasculating side effects.
"If we had a nontoxic treatment, you wouldn't care," Scholz says. "But we're
making them impotent, making them leak urine."
( there are no major studies which show that either surgery or radiation will
increase a mans life expectancy once he has prostate cancer.) This statement is
true but not part of the article written by Ms. Brink.
But for some men, neither a rush to treatment nor the old, passive wait-and-see approach is appropriate. "I spend half my time talking guys down out of the tree," Doctor Scholz says. If surgical or radiation treatment were akin to, say, treatment for basal cell carcinoma in which the common skin tumors are removed and the patient suffers no serious consequences, then early diagnosis followed by universal treatment would be a no-brainer. But with prostate cancer, the usual treatments can have emasculating side effects. "If we had a nontoxic treatment, you wouldn't care," Scholz says. "But we're making them impotent, making them leak urine."
"It's a chink in the armor of manhood," Cano says. "It's a dastardly disease that affects you in the seat of what some people conceive of as maleness. It can affect your sexual function, and then evolve into something that can kill you. You're damned if you do, and damned if you don't."
Risks of treatment
Because the prostate sits so near the nerves that govern erection as well as the ability to control urine flow, it takes great finesse to remove or destroy the 1 1/2 inch-long gland while leaving those nerves intact.
Some physicians — prostate cancer support groups call them medical artists — have decades of experience with thousands of either surgical or radiological patients, and, using techniques that spare the nerves near the prostate, end up with a far lower incidence of impotence and incontinence.
But the national averages for side effects remain grim. More than half of treated men will have permanent sexual dysfunction, and up to 30% will have some degree of chronic urinary incontinence. Most of them will be cured of their cancer, though an unknown number won't know that they didn't need the cure. And a small number of men getting surgery or radiation will have cancer that has already spread beyond the prostate. For them, the ultimate indignity is that they could well suffer side effects of treatment, and still have a growing cancer in their bodies.
In a study begun in 1996, Dr. Laurence Klotz, urology professor at the University of Toronto, has been attempting to shed light on the gray area of who needs treatment and who will live a long, healthy life without treatment. Men who are good candidates for waiting are those with a PSA of less than 10; a Gleason score, the number used to grade prostate cancer for potential aggressiveness, of less than 6; and fewer than a third of cores taken in biopsy with cancer cells.
Follow-up monitoring includes a PSA test every three months, and periodic repeat biopsies.
Deemed good candidates, the 500 men in Klotz's study waited, as Cano is doing, and chose a therapy only if their cancer took a turn for the worse.
So far, about a third of the active surveillance group have gone on to have surgery or radiation. About 20% got treatment after experiencing a rapid doubling time of their PSA count — that is, the number doubled in less than three years. And 5% received treatment after follow-up biopsies showed an increase in their tumor grade. PSA doubling time and increase in tumor grade are both indications that it's time to act more aggressively.
Another group of men in the active surveillance group, with no danger signs, opted for treatment anyway. "About 12% just got nervous," Klotz says. "It's the word 'cancer' that's a problem. The word puts into gear the whole freight train of adverse expectations about the future."
That leaves about two-thirds of the volunteers still waiting, and still healthy. In the entire group, those remaining on active surveillance, and those treated after waiting, there has been a 99% survival rate, with three prostate cancer deaths. "And those three died very rapidly," Klotz says. Their disease, he speculates, had likely already escaped the prostate and traveled to other parts of the body.
The study is being expanded, supported in part by the Canadian and U.S. National Cancer institutes, to look at 2,100 men. Results of that larger comparison study are years away — not soon enough to help Cano with his decision.
Faced with a decision
Three years ago, Cano's urologist did what many surgeons do. He recommended immediate surgery. A radiologist recommended radiation. Another radiologist recommended brachytherapy. A month after diagnosis, the urologist scheduled surgery because Cano thought he was ready.
He cried with his wife, went over provisions in his will, and thought about his daughter. "I was 53, happily married, and my child was 14," he says. "I began to think that I'd rather walk her down the aisle than worry about whether I had sexual function. Having a great sex life doesn't help you if you're dead."
But while waiting for his date with the scalpel, he began to hear of an alternative that appealed to him: triple blockade hormone therapy. The treatment was once thought to be the last arrow in the quiver for men whose cancer had spread, sometimes in spite of prostate removal or radiation treatment. Using it early on in treatment, as Cano did, is controversial and as yet unproven, but a handful of doctors recommend the therapy, which blocks testosterone production, in an attempt to control the cancer. Koltz thinks it's far too toxic, with side effects that include impotence and sometimes personality changes, to use routinely on men whose cancer is low-risk.
But Scholz supported Cano's decision, and began working with him in monitoring his disease. Cano canceled his scheduled surgery and began a regimen using the hormone blockade therapy for a year. It rendered him impotent during the year of treatment, and afterward reduced his sex drive — a consequence he thinks could just as well be a result of getting older — and continues to play a few games with his short-term memory, he says. But his PSA has dropped to 1.3 and a follow-up biopsy found no evidence of cancer. He's hoping that with continued monitoring, he'll be able to avoid drastic treatment for more years, giving medical science more time to refine and improve techniques.
Murray Corwin, 78, also took his time deciding. But in 1991, when he began his slow and careful disease monitoring, there wasn't much support for stalling — not even at home. "Families apply enormous pressure to do something," he says. "That's what my daughter said to me: 'What are you going to do?' "
For a while, he did nothing to his body, though he worked his engineer's mind hard seeking information. He waited, returning to his doctor every three months for a new PSA test. Frustrated by a lack of information, he helped found the Fullerton Prostate Forum (www.prostateforum.org) to seek and share new information. (Cofounders Bill Dehn and Dan O'Conner have both since died of the disease.)
Even now, he unfolds a taped-together chart of his early PSA numbers.
"I use it to show how I was able to feel comfortable waiting," he says. He had carefully charted his numbers over a period of more than two years, and points to the red dot on the chart that told him he could wait no longer. His PSA, which had been flat all that time, suddenly spiked. It was time to get treatment, and he opted for radiation.
The big risk of waiting is that without, and perhaps despite, diligent monitoring, the cancer could spread beyond the reach of the knife or radiation beam. Lou Pfeffer, 78, of Hacienda Heights knew the risk of waiting, took it anyway, and now has lost the opportunity to be cured.
Following his 1993 diagnosis, he wandered around in a daze. "I thought I had the worst case of cancer in the world, and I was going to die next week," he says. "It's a very hard decision to figure out what to do."
Physicians urged him to have medical treatment. "They'd put their arm around me and say, 'You know, if you were my dad, I'd say, get it out and get on with your life,' " he says. Instead, he waited. He read about alternatives and studied prevention research. Soon, he went on a macrobiotic diet and lost 65 pounds in half a year.
Being overweight is associated with an increased risk of prostate cancer, and crucifers such as broccoli — as well as lycopene, found in tomatoes — may help prevent it. Supplements including selenium and vitamin E are also associated with a reduced risk of prostate cancer. And a study in the July 1 journal Clinical Cancer Research found that an 8-ounce glass of pomegranate juice daily for treated men increased the length of time PSA levels remained stable.
Pfeffer tried dietary improvements and supplements — too late to prevent his prostate cancer, but hoping to keep it in check.
He monitored his PSA counts, had follow-up biopsies, and held steady for more than nine years. Then a color Doppler ultrasound image, a new imaging technique that can help pinpoint the location and growth of cancer, showed that his tumor was getting larger. Unfortunately, it had also started to grow outside the prostate. Now he's taking hormone blockade therapy and hopes to control his cancer indefinitely. Some 13 good quality-of-life years after his diagnosis, he has no regrets.
As Cano monitors his own numbers, he also closely watches worldwide research on prostate cancer, hoping that what looks promising in petri dishes, lab rats or clinical trials might ultimately prove to be a better treatment with a lower risk of destruction.
For now, he's his own health sentry, on full alert for signs of change.
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