PAMELA YOUNG March 21 1994


PAMELA YOUNG March 21 1994

The prostate debate


A monthly report on personal health, life and leisure


Last year, Kazimer Siepierski was faced with a decision that most men would rather not contemplate. Diagnosed as having cancer of the prostate, he was told by his doctor that he had two choices. The retired Cape Breton steelworker could opt for radiation treatment that offered a good prospect of curing his cancer. Or he could have the tumor surgically removed, which would make a recurrence of cancer even less likely. Both procedures carried the risk of impotence, but the likelihood was far greater with surgery. Despite that, Siepierski, now 60, chose the operation. And he is convinced he made the right choice. “I’d had my fill of sex and enjoyed it,” says Siepierski, who lives in Sydney, N.S., with his wife, Louise. “But I didn’t want to live with cancer in my body.” These days, a growing number of North American men face similar tough choices. And like breast cancer among women, prostate cancer is taking on a higher public profile. Musician Frank Zappa died of it as did actors Don Ameche and Telly Savalas. In fact, prostate cancer is the second most deadly form of cancer (after lung cancer) among North American men, killing an estimated 3,800 Canadian and about 35,000 American men last year. The good news is that improved diagnostic techniques allow doctors to spot the disease earlier.


But the result is a heated medical controversy: many physicians argue that too many patients in their 60s and 70s are undergoing radical prostatectomies—surgical removal of the prostate—without any proven medical benefit. “I think maybe we’re a bit out of control,” says Dr. David Bell, the Halifax urologie surgeon who operated on Siepierski. “Sometimes, we’re operating on patients whose tumors in the! long run wouldn’t affect their lifespan.”

Until recently, the prostate gland was a much-overlooked part of the male anatomy. Most men probably still have only a hazy idea about its location and function. A walnut-sized gland located just below the bladder, the prostate makes the fluid used to transport sperm. The gland can be the site of several afflictions, including benign prostatic hyperplasia, which can cause problems in urinating. Though benign prostatic hyperplasia is usually not life threatening, surgery is often required to relieve the blockage.

Prostate cancer is a far more serious disease. If unchecked in its early stages, it can spread to the bones— including the spine—causing a slow and painful death. Despite that, prostate cancer has traditionally received little attention because in its early stages it is difficult to detect by rectal examination, and because it often develops slowly, killing men who are near the end of their normal lifespans. But in the early 1980s, drug companies began marketing a simple blood test—the

prostate-specific antigen, or PSA, test—that makes prostate cancer much easier to discover. Once it is detected, doctors can initiate lifesaving measures before the disease can gain a foothold.

Many doctors now routinely administer the test, and more and more men are demanding it. As a result, more cases of prostate cancer are being detected and more prostate cancer victims are opting for surgical removal of the prostate—despite the accompanying risks of incontinence and impotence. In the United States, the number of radical prostatectomies rose sharply to 39,157 operations in 1992 from 7,028 in 1987—a 457-per-cent increase. In Canada, the number of radical prostatectomies jumped from 417 in 1986 to 1,148 in 1991—a 175-percent increase.

Some doctors are uneasy about the number of prostatectomies being performed—and about routine PSA screening. The reason: prostate cancer usually strikes men over 50, and often develops so slowly that there is a good chance the victim will die of something else before the cancer becomes a significant health risk. In fact, studies have shown that 30 per cent of all men over 50 have some degree of cancer in their prostate gland. Yet only one in 10 of those men will die of the disease. “I think the value of screening is unproven,” says Dr. Ian Tannock, chief of medicine at Toronto’s Princess Margaret Hospital. “In many cases, PSA testing will turn up a small tumor.

Then, there will be a lot of agonizing over what treatment is appropriate, even though in many cases the patient will never have a problem with prostate cancer, because he will die of something else.” Typically, a man in

them removed or underwent radiation therapy during the course of the studies. Some others received hormonal treatment. After 10 years, 658 of the 757 men with less-aggressive tumors—87 per cent—had not died of prostate cancer. “The message of our study,” Chodak said, “is that, for some men, watchful waiting is a reasonable alternative to surgery or radiation.”

The dilemma that faces physicians is how to decide when to recommend surgery—and when to propose waiting and watching. ‘Take the case of a 65-year-old man with localized prostate cancer who may also have diabetes or a heart condition,” says Bell. “I can treat his cancer, but should I? How do you decide?” Bell hopes that a basis for that kind of decision will emerge from a computer profile that he and Dr. Jerzy Gajewski are trying to develop by analysing the records of about 400 prostate patients treated since 1977 at Halifax’s Victoria General Hospital. Meanwhile, in an effort to resolve the question of whether PSA testing saves lives, researchers at the U.S. National Institutes of Health in Bethesda, Md., have launched a 15-year study to determine whether men whose prostate cancers are spotted early have a better survival rate than men who never have a PSA test.

While debate swirls around the issue of PSA testing and prostate surgery, some researchers are concentrating on another area of prostate treatment: dealing with cancer once it has spread beyond the prostate. When that happens, removal of the prostate is pointless and doctors turn to radiation and hormone treatment. The hormonal approach is often effective because it is the

The operation carries the risk of impotence

his 80s with a slow-growing prostate cancer may die of heart disease. But as North American men live longer, the number of prostate cancer deaths is increasing as well.

The debate has left doctors divided over the wisdom of ordering routine PSA tests for men over 50. ‘We only use the test if a patient has symptoms pointing to prostate disease,” says Dr. John Trachtenberg, director of the Toronto Hospital’s Prostate Centre. “We don’t advocate mass screening.” Other doctors, while sharing some of the concern about the growing number of prostatectomies, defend widespread PSA testing as a way to catch the disease in its early stages. “I’m in favor of assessing men in the 50-to-70 age group annually with PSA and rectal exams,” says Dr. Larry Goldenberg, director of the University of British Columbia Prostate Clinic in Vancouver. “I think we should do anything we can that will save men from the agony of dying from prostate cancer.”

Another school of thought argues that in some cases of prostate cancer the best policy may be to do nothing. Watchful waiting” is recommended by some doctors in cases involving small tumors that have not spread beyond the prostate—and which might take years to develop to a life-threatening level. After analysing the results of six other studies involving men with prostate cancer, Dr. Gerald Chodak, director of the Prostate Centre at Chicago’s Weiss Memorial Hospital, concluded that it is often unnecessary to intervene in cases involving less-aggressive tumors. At the outset, none of the men in the studies had their prostates removed, though a small number had

male hormone testosterone that stimulates the growth of most prostate cancers. Because the testicles are the main source of testosterone, the simplest solution is castration—an operation that many men find psychologically devastating. Instead, a drug called an LH-RH agonist is often used to shut down production of testosterone and shrink the cancer. The snag is that the prostate adapts and within about two years learns to live without testosterone.

A group of Vancouver researchers say that there may be a way of prolonging the effectiveness of LH-RH and other hormone therapies by giving the drugs to patients intermittently, rather than continuously. By starting, stopping and restarting the treatment at roughly eightmonth intervals, says Dr. Martin Gleave, an assistant professor of surgery at the University of British Columbia, “you can delay the cancer’s adaptation to independent growth.” So far, tests of the intermittent therapy in mice and a small number of human subjects have shown encouraging results.

While researchers seek better ways of treating prostate cancer, victims of the disease are turning to each other for mutual support. Us Too, an organization launched in the United States four years ago, now has branches in about a dozen Canadian cities. Norm Oman, a retired Winnipeg high-school teacher, is Us Too’s national organizer in Canada. According to Oman, 64, about 125 prostate cancer victims, as well as relatives and friends, meet once a month in Winnipeg to learn about the latest developments in treatment—and to share their pain. “It’s

such a devastating thing for a man,” says Oman. “It’s so important to be able to talk to others, to ask questions and to see other men who have the disease and are living with it.” By the time Oman’s own cancer was diagnosed two years ago, it had spread beyond the prostate. He is now being treated with an LH-RH agonist. “You know there’s a pit bull in there, and you just hope that it stays under control,” says Oman. “I live in hope.”


Prostate problems

What to watch for:

More frequent urination.

# Slower urine stream or difficulty in urinating.

# Bloody urine.

0 Chronic lower back pain.

The first three symptoms could point to either benign enlargement of the prostate—a non-life-threatening condition that might require surgery— or prostate cancer. Lower back pain can have many causes, one of the most serious being advanced prostate cancer. Men who experience any of the symptoms should see a doctor.