Prostate cancer treatment: Pick oneBy LISA GREENE, Times Staff Writer
Published June 27, 2004
ST. PETERSBURG - Rufus Anderson was still reeling from the news that he had prostate cancer when he was overwhelmed with options.
What treatment should he order? Radiation: external or seeds? Surgery: traditional, perineal, laparoscopic? Cryotherapy? Hormones? Or nothing at all?
"They have so many choices now," said Anderson, 64, who lives in St. Petersburg. "And in the next six months, they'll probably come out with something else."
The problem Anderson faced is one that more than 230,000 American men will share this year. First, they get diagnosed with the most common male cancer. Then they get not a pill, not a path to a cure, but responsibility: Choose your treatment.
"Normally, when you go to a doctor and you're told you have a health issue, you're prescribed some medicine," said Bob Samuels, founder, CEO and chairman of the Florida Prostate Cancer Network. "When you . . . are told you have prostate cancer, you're told, "You, patient, now have some choices to make.'
"Can you imagine how terrifying that is? Especially for Joe Truck Driver who's never heard of any of this?"
Ultimately, which treatment a man gets may have more to do with his priorities, fears and personality than with science. That's because researchers just don't know what is most effective to treat a cancer that will kill about 29,000 American men this year.
"It's a very confusing cancer," said Samuels, who chose external beam radiation to treat his cancer. "One that confuses the physician community as well as the patient community."
Dr. Frank Mastandrea, a Tampa urologist who also is president of the Hillsborough County Medical Association, agreed.
"There's no real recommendation to which is the best treatment," Mastandrea said. "But people who get treated tend to do better than those who don't."
A study published earlier this month could add to men's concerns. It found that one common option might not be a good one for many men. Because prostate tumors grow so slowly, some men are advised to monitor their cancers instead of getting them removed or otherwise treated.
But after following 223 Swedish men for more than 20 years, the study found that some tumors became more aggressive after 15 years. Of the men who were 70 or younger when they were diagnosed, more than one in five died from prostate cancer.
With many other cancers, "after a few years, you can relax about them," said Dr. Alfred I. Neugut, professor of medicine and epidemiology at Columbia University. "This suggests that at a very late point, (prostate) tumors are going to continue to recur if they're not treated."
Neugut, who wrote an editorial about the study in a recent issue of the Journal of the American Medical Association, said elderly men may still want to watch and wait. But the study boosts a trend toward more aggressive treatment, particularly for younger men.
Over time, "Mortality from prostate cancer increases tremendously," said Dr. Julio Pow-Sang, program leader for the genitourinary oncology program at H. Lee Moffitt Cancer Center & Research Institute in Tampa. "Men who are young, who have a life expectancy of more than 10 years, should be treated instead of being watched."
Within a week of his diagnosis two years ago, St. Petersburg resident Lee Patterson decided to have surgery to remove his prostate.
"I chose the radical surgery because I wanted it out," said Patterson, 59. "I wanted to get it done and over with. I didn't want something in there, not knowing whether it was going to recur."
But when Seminole resident Rudolph Koletic's cancer was discovered six years ago, he quickly rejected surgery. He didn't like the risks of impotence or incontinence.
"For me it wasn't an option, because the aftereffects weren't satisfactory," said Koletic, 74.
Instead, he chose to have radioactive "seeds" placed in his prostate to kill tumor cells, a treatment known as brachytherapy, even though it carries some of the same risks.
Rufus Anderson was leery of the long recovery after surgery. But he didn't like the idea of radiation "burning in my body" either. Doctors told him he could try "watchful waiting," but he rejected that, too.
"No, as long as it's in my body, it's going to worry me," he told doctors.
He researched the issue until he heard that Mastandrea was operating laparoscopically, with smaller cuts and quicker recovery time.
All three men say they are healthy today and satisfied with their decisions.
But should they all have been treated? For many men, it can be hard to say. Men now often are diagnosed after a PSA test, a blood test that detects high levels of a protein made by prostate cells.
Cancer can cause PSA levels to rise. The problem: So can other medical conditions. And a PSA test doesn't prove whether the cancer is aggressive and dangerous, or growing so slowly that it wouldn't be a threat during the man's normal life span.
"It's brought us a much earlier diagnosis, but it may push us to diagnosing more cancers that we don't need to do," Pow-Sang said.
There are big advantages to the PSA. Today, with broader use of the test, two-thirds of prostate cancers are diagnosed while still confined to the prostate. Ten years ago, two-thirds were outside, Pow-Sang said.
But prostate cancer is rarely deadly. In fact, autopsies have shown that most men over age 80 have some sign of prostate cancer - usually, though, it's something else that killed them, Pow-Sang said.
And it's hard to tell which cancers are killers.
"Which are the ones that are going to progress?" he said. "We need a better test than we have now."
Doctors worry that because it's hard to tell, many men are overtreated. And those treatments carry significant side effects - all the usual risks of surgery, plus possible problems with incontinence or decreased sexual function.
Scientists just don't know enough about prostate cancer, Neugut said.
"Considering how common it is, we actually know a lot less about prostate than about breast or many other cancers," he said.
Neugut had several theories on why that's the case: Because of its internal location, the prostate is harder to reach and to study than the breast. Men tend to die of prostate cancer at older ages than women do of breast cancer, so it gets less attention. And men haven't been as active forming groups and pushing for research as women have for breast cancer.
Koletic has noticed that too.
"I wish we men would be, perhaps, a little more aggressive in trying to find cures and support," he said. "Men generally don't talk about their own situations. When I first was diagnosed, I said, "I can't say anything about this, it's a man thing.' "
He gradually became more comfortable talking about the disease, joining support groups and volunteering on a counseling hotline for men just diagnosed. Still, Koletic thinks there are worse things than being asked to decide what treatment is best.
"Modern medicine is wonderful that they give you these different options," he said. "Procedures are available. The man himself needs to make a decision. I think that's a good thing rather than having one procedure fit everyone."
These days, many of Mastandrea's patients come in with information gleaned from the Internet. Sometimes, he said, that information isn't accurate, but he still welcomes such efforts.
"It can be overwhelming," he said. "But there are choices. With choices, come challenges."
Samuels also advises patients to seek out education and different opinions. He thinks men should visit a urologist and a radiation oncologist, so they get different perspectives.
And, even as the science improves, Samuels sees a permanent shift in how men view their health choices.
"The boomers are now hitting their 50s," he said. "They are much more questioning. You've got a whole different group that's going through this disease now. They're not ones to sit there and nod their heads."
Ultimately, he said, asking questions about treatment and pushing for more attention will help not just prostate cancer, but other men's health issues. He pointed to Lance Armstrong's work against testicular cancer and Bob Dole's outspokenness about erectile dysfunction.
"What you're actually seeing," Samuels said, "is the emergence of the men's health movement. And it's being driven by prostate cancer."