The Private Pain of Prostate Cancer

By Christine Gorman

If there is a single leading reason why middle-age men dread going to the doctor, it is the prostate examination. Routinely recommended for those 50 and over, the procedure calls for a physician to insert a gloved finger into the rectum to probe the chestnut-size prostate gland, which is near the bladder and produces some of the fluids in semen. But however uncomfortable and embarrassing the exam may be, it could be a lifesaver. The rate of prostate cancer in the U.S. has been steadily rising over the past several years. It strikes 1 in 11 American males and kills more than 30,000 annually. Prostate cancer ranks second only to lung cancer as the most deadly malignancy in men.

No one knows why the disease is spreading. The aging of the American population only partly explains the increase. No one knows why the cancer develops less often in Asians than in Americans or Europeans. Perhaps a low- fat diet plays a role in prevention. No one knows why black Americans suffer and die from prostate cancer more frequently than do white Americans.

But doctors are hopeful that they can force the death rate back down -- through earlier and better detection and treatment. The effort begins this week and next, as the Schering-Plough pharmaceutical company, based in New Jersey, sponsors free prostate screenings all over the U.S. An estimated half a million American men will allow themselves to be poked, prodded and bled in hopes of being reassured of their good health or of spotting trouble before it gets serious. In addition to the rectal exam, men can undergo a new blood test that measures levels of a protein called prostate-specific antigen. If present in large quantities, PSA may signal malignancy. The goal is to detect cancer while it is still confined to the prostate and therefore more likely to be curable. Men can call the American Cancer Society at 800-ACS-2345 for a listing of local screening sites.

As worthy as the goal may be, however, the effectiveness and value of the mass screening are matters of dispute within the medical community. One-third of the tumors picked up by the rectal exam are already inoperable. Yet the PSA blood test is also far from infallible. It misses at least 20% of malignancies and can often give an indication of cancer where none exists. Furthermore, prostate cancers are not all the same; many grow so slowly that they do not need to be treated at all. A man could easily die of something else before his prostate condition proved fatal. If millions of men 50 and older take the blood test, some doctors fear that a great deal of unnecessary treatment will take place.

Whatever the merits of this particular type of mass screening, there are strong reasons to believe that early and accurate detection of prostate cancer can prolong life. When the disease has not spread beyond the prostate, 95% of men survive for at least five years. For half the men in whom the cancer has metastasized, life expectancy is two to three years. Moreover, techniques for surgically removing the prostate -- the standard treatment for the cancer -- have improved dramatically. Just a few years ago, the operation usually caused impotence and incontinence because it damaged nerves in the area. But by using a nerve-sparing operation developed by Dr. Patrick Walsh at the Johns Hopkins Hospital, doctors can prevent those side effects in most patients.

With the progress in detection and treatment has come a wave of publicity about this very private kind of cancer, which was once rarely talked about. Many prominent men, from ABC News chief Roone Arledge to musician Frank Zappa, have revealed that they have the disease. Others, like Kansas Senator Robert Dole, who underwent an operation for early prostate cancer last December, are actively encouraging men 50 and older or with a family history of the illness to get tested and become familiar with the warning signs: frequent or difficult urination, blood in the urine, painful ejaculation or continuous lower-back pain.

A major element of the controversy over early detection is the test for PSA, a protein that is produced by the prostate and is believed to play a role in preventing semen from coagulating. High levels of PSA in the blood indicate an enlarged prostate, which is common in older men and is only sometimes the result of cancer. Research studies show that 20% to 25% of men with a PSA level between four-billionths and ten-billionths of a gram per milliliter of blood harbor a cancer in their prostate.

Unfortunately, even a low PSA level is no guarantee of good health. "A third of the men I operate on have PSAs less than 2.8," says Walsh. "So the idea that if your PSA is low, you don't have cancer, is wrong. But if you have a negative rectal examination and a low PSA, you probably don't have prostate cancer."

Everyone agrees that PSA tests should be given in tandem with rectal exams. But what if the tests seem to contradict each other? It is not unusual to have a PSA level in excess of four-billionths of a gram per milliliter and a rectal exam that reveals nothing. In that case, the next step might include further observation, an ultrasound exam or even a biopsy, a procedure in which bits of tissue are removed from the prostate and examined under a microscope. Should men with high PSA levels undergo expensive, anxiety-producing biopsies year after year to make sure they do not have cancer? Not necessarily. More important than the absolute level of PSA may be the change in levels over time. A dramatic rise is more likely to indicate the presence of cancer. A steady high level may suggest nothing more than an enlarged prostate.

Although doctors have found the PSA test helpful in spotting small prostate cancers, there is no guarantee that early detection is beneficial. The test may be turning up the less troublesome tumors and not ferreting out the killer cancers. Researchers are working on ways to improve the blood test. And the National Cancer Institute is launching a $97 million study to investigate whether early diagnosis translates into longer lives. But the results will not be available for another 16 years.

Until then, physicians and their patients will have to use their own judgment. Because prostate cancer runs in some families, men with affected relatives may want to take fewer chances with a high PSA level. For others, the best approach may simply be to wait and see. Rather than treat the diagnosis as an immediate call to action, or ignore the problem altogether, they will need to follow the situation closely with frequent examinations.

That kind of restraint will not be easy. Over the past several decades, much of American medical practice and public expectation has been geared toward the idea that if someone has cancer, it should be treated without delay, observes Dr. Gerald Chodak, a urologist at the University of Chicago. But as blood tests and biopsies detect ever smaller cancers, physicians and patients will have to make more sophisticated decisions about treatment.

It does not make sense for everyone to be tested -- particularly patients who are within 10 years of the end of their expected life-spans. "The perfect example is an 86-year-old guy I just saw in my office," says Chodak. Another doctor had found an elevated PSA level in the patient. "He went for a biopsy, and he's got prostate cancer. Now, this guy is not going to benefit at all from his diagnosis. The last thing I would do for an 86-year-old guy is test him."

But for every anecdote about overtreatment, there is one about saving a life. "Five years ago, I would not tell a man who came into my office to have a PSA test," says Dr. Perinchery Narayan, chief of urology at the Veterans Affairs Medical Center in San Francisco. "I would say, 'Let's do a digital rectal exam, and if everything's fine, we'll do another next year.' Today when any man 50 or older comes into my office, I'll sit down with him and tell him about prostate cancer and advise that he get a PSA test." For too long, there were no options left by the time prostate cancer was diagnosed. Used wisely, the PSA test is an opportunity to improve the odds of survival.

With reporting by David Bjerklie/New York and David S. Jackson/San Francisco