Prostate Cancer Decisions
By Michael Lasalandra
If you're a man and you live long enough, chances are you will develop prostate cancer. Autopsy studies of those who have died of other causes have found most elderly men have traces of cancer in their prostate glands. For those in their 90s, the figure approached 100 percent. For men in their 80's, more than half were found to harbor prostate cancer cells. Even 30 percent of men in their 50s were found to have traces of prostate cancer in autopsy studies.
The good news is that most of these men were likely never bothered by the disease. Most probably didn't even know they had it. That's because prostate cancer is generally slow growing. Some prostate cancers don't ever progress to become problems.
The bad news is that some do. Some men get an aggressive form of the disease that will spread and kill. The disease took the lives of about 30,000 men last year alone in the U.S. , although the death rate has dropped by 25 percent over the last decade.
One in six men will actually be diagnosed with prostate cancer over the course of their lifetimes, usually following a PSA blood test that shows an increased level of a protein linked to the disease.
A biopsy is needed to confirm the presence of cancer cells, but cannot tell with certainty if the cancer is the kind that is deadly or harmless.
As a result, once diagnosed, men face a difficult decision. To treat or not to treat? And if the decision is made to treat, which treatment to choose?
If the cancer is detected at a very early stage and does not appear to be particularly aggressive based on pathology tests, some men will opt to "watch and wait", testing regularly for signs that the cancer may be growing. If there is no change, they may forgo treatment altogether. This option is usually, but not always, reserved for older men.
Because treatment is usually effective in curing early-stage disease, however, most men choose to have it in one form or another. Surgery and radiation are the most common forms of treatment, and each offers a number of variations.
"If you do get diagnosed, there are a larger number of options", said Glenn Bubley, M.D., chief of genitourinary cancers at Beth Israel Deaconess Medical Center.
Surgery, called a radical prostatectomy, involves removing the prostate gland. Many surgeons now offer a "nerve-sparing" variation on the operation designed to help patients maintain potency. Some surgeons perform the operation with the assistance of a robot.
Radiiation treatment can be delivered by external beam or the implantation of tiny radioactive seeds in the prostate – or both.
And cryotherapy – freezing the prostate – is offered in some areas of the country, but has never caught on in Massachusetts.
But all of the treatments carry the risk of side effects — impotence or incontinence or both. For this reason, patients are urged to get whatever form of treatment they choose from an expert with plenty of experience.
"Patients have to do their own research", Bubley said. "And they should have their doctor help them in doing this research."
Some patients who choose to "watch and wait" are changing their lifestyles in the hopes that the changes — low-fat diets, more exercise and a slew of herbal and dietary supplements — will keep the cancer in check. There is as of yet little hard evidence that this works, however.
There is also the hope that diet and supplements, and perhaps certain drugs, may be able to help prevent prostate cancer from developing in the first place. A number of studies are currently underway testing a variety of supplements including selenium, Vitamin E and lycopene. Already, studies have indicated that lycopene-rich tomato products can cut the risk of getting prostate cancer by as much as 17 percent. At the same time, studies indicate that too much calcium may boost the risk of getting prostate cancer.
One major study found that taking a drug called Proscar cut the risk of developing prostate cancer by 25 percent. But the drug, which is given to treat a non-cancerous enlargement of the prostate, is not without its own risks and side effects.
Overall, science is making progress against prostate cancer, but there is still a long way to go, Bubley said.
"The reduction in the death rate is very real", he said. "And that's great news." However, he said prostate cancer remains a confounding disease. "The more we learn, the more we don't know", he said.
For example, he said it is not known whether the declining death rate is due to the advent of PSA testing or the introduction of hormonal therapy for patients with late-stage disease.
"We are learning more, but it is clear this is a confusing cancer", he said.
(This article appeared originally in the spring/summer 2006 issue of Pulse, the newsletter of Beth Israel Deaconess Hospital – Needham, Mass. )
