If you're a man and you live long enough, you have a one-in-six chance of developing prostate cancer. Bruce Nordstrom, a 66-year-old architect from Wilmington, was diagnosed with the disease just over a year ago, after taking a routine PSA blood test. He visited a urologist, a radiation oncologist, and a medical oncologist while trying to make a treatment decision. "They all said I was a good candidate for a wide variety of procedures, everything but watchful waiting," he says.
Nordstrom is typical of the patient diagnosed with prostate cancer these days. Because he was in an early stage of the disease, he was considered a good candidate for one of a dizzying array of treatment options. Eventually, he chose to undergo Image Guided Radiation Therapy (IGRT) rather than have his prostate removed. "It was a tough decision," he says, "but there was a day not that far back when you didn't have all these choices."
Some 220,000 new cases of prostate cancer are diagnosed annually in the U.S., with the disease killing about 27,000 each year, according to the National Cancer Institute. These numbers suggest that many more men will die with the disease than of it. In fact, autopsy studies of elderly men who died of other causes show that between 40 and 100 percent of them had some cancer cells in their prostate, depending on their age.
But for most men who are newly diagnosed, a number that has tripled since the advent of easily administered PSA blood testing in the mid-1980s, there is a dilemma. Should he treat the slow-growing cancer, and, if so, which treatment should he choose?
"It's a confusing situation," says Dr. Glenn Bubley, chief of genitourinary cancers at Beth Israel Deaconess Medical Center. "Unlike with breast cancer, there isn't an obvious standard of care. In breast cancer, they know they have to take out the lump. In prostate cancer, it isn't so clear."
A majority of prostate cancers are diagnosed at an early, curable stage, thanks to the PSA test, which measures the level of a cancer-associated blood protein. Some of these cancers need to be treated; others may not. But it is often hard to determine which cancers will remain indolent and which will grow and become life-threatening. Research is under way in a bid to use molecular markers to differentiate these cancers, but the work is still in its infancy. Some men choose to watch and wait, but, because of the uncertainty, most men decide to be treated.
"Men who see a surgeon are usually told surgery is best," Bubley says. "If they see a radiation therapist, they are usually told radiation is best. And it's hard to distinguish one over another, in terms of cure. Each has side effects, although the side effects are different."
Adding to the conundrum, there are several kinds of surgery and several types of radiation available. Nordstrom, the Wilmington architect, was told that the decision would have to be his own. "Most people I talked to said it was going to be a personal thing and that I would have to find a treatment that I felt comfortable with," he says.
Dr. Philip Kantoff, director of the Lank Center for Genitourinary Oncology at Dana Farber Cancer Institute, says he encourages patients to get as much information as they can. "I strongly advise talking to as many people as possible, getting a second and third opinion, seeing a medical oncologist, reading books, talking to others who have gone through the process," he says.
For most patients with early stage, low-risk cancer, the decision boils down to quality of life issues, he says. Surgery to remove the prostate, a walnut-sized gland found at the front of the rectum that is designed to produce and secrete seminal fluid, has been considered the gold standard to cure early stage prostate cancer. Now, the operation, called a radical prostatectomy, can be done in the conventional open way, or using laparoscopic techniques that employ tiny instruments and cameras to minimize the size of the incisions. Some surgeons do the minimally invasive procedure with the assistance of a robot. There is little data available as to which technique is more effective for controlling the cancer or minimizing surgical side effects, which can include impotence and incontinence.
Radiation is an option for many men, but there are at least five types used against prostate cancer, including external beam radiation and brachytherapy, or the implantation of radioactive seeds in the prostate.
Cryosurgery-the freezing of the prostate-is a new method available, although it hasn't caught on in New England to any great extent.
All of the treatments carry their own risks of side effects. Radiation can cause bladder and bowel damage as well as impotence caused by scarring of the nerves. Bubley says radiation-related impotence can take years to develop, and can often be helped with drugs such as Viagra.
Such drugs cannot help men left impotent by surgery. In about 50 to 80 percent of surgical patients, potency returns in a year or so. In the rest, it never returns. Whether it returns rests on the skill of the surgeon and on whether so-called "nerve sparing" surgery is used. Even the best surgeon using the nerve-sparing technique, however, cannot guarantee a man that he will be potent again. Cryosurgery can also cause impotence.
Dana Johnson, 63, a mechanical engineer from Weymouth, was diagnosed a year ago. He wasn't totally surprised. "I've known a lot of guys who have gone through this," he says. "I had it lurking in the back of my mind that it might happen to me."
He had a friend who underwent the robot-assisted minimally invasive surgery and quickly decided to have it too. "I knew there might be consequences, but I felt the best way to make sure there was no cancer in my body was to take it out," Johnson says. He has no regrets, even though the operation left him impotent.
Another option for early stage cancer is called "watchful waiting." In essence, it means to defer treatment while monitoring the cancer with frequent PSA tests and biopsies to see if it appears to be growing. Though this strategy is usually a good choice for older patients-those with expected lifespans of 15 years or fewer-a growing number of younger men are choosing to watch and wait too.
Some are hoping that by delaying they will eventually be able to benefit from treatments yet to be discovered. Three new studies published in April pinpointed seven variations in DNA that increase the risk of prostate cancer. The discoveries one day may provide new markers and blood tests for prostate cancer susceptibility and aggressiveness, as well as possible new targets for treatment. But that day is still years away.
