In praise of testing

How careful monitoring caught Allan Rock’s prostate cancer in time

JIM PAUPST April 1 2002

In praise of testing

How careful monitoring caught Allan Rock’s prostate cancer in time

JIM PAUPST April 1 2002

In praise of testing


How careful monitoring caught Allan Rock’s prostate cancer in time

As part of his commitment to prostate cancer awareness, federal Industry Minister Allan Rock has permitted his personal physician of 28 years, Dr. Jim Paupst, to tell his story. Rock’s cancer was detected early. He was among patients Paupst was trackingin Toronto using a formula he designed for discovering localized prostate cancer while tests for its presence still showed it in a non-threatening state.


At 6 a.m. on Feb. 13, 2001, then federal health minister Allan Rock and his wife, lawyer Debbie Hanscom, walked hand in hand down University Avenue to the Toronto General hospital. There, two hours later, he underwent surgery to remove his entire prostate gland and the malignancy it contained. The results of a prostate blood test had prompted a biopsy on Jan. 5. The next step was the operating room.

A successful litigator in Toronto, Rock got involved with the federal Liberals in the early ’90s, volunteering to “do anything that helped, licking stamps, knocking on doors and so forth.” In 1993 he won a seat and joined the cabinet as minister of justice. During this same year—he was 43 then and had entered the prostate season—I began a program of serial PSA blood tests. His father had died of prostate cancer, doubling Rocks chance of getting it. And he did.

PSA—prostate specific antigen—is a protein produced almost exclusively in the prostate, where the concentration is thousands of times greater than that found in blood. PSA testing gives us information about what may be going on in the walnut-sized gland surrounding the neck of the bladder: inflammation (prostatitis), aging, benign enlargement or the presence of cancer.

A PSA blood test is easy to perform and easy to interpret. It costs the patient

from $20 to $25, depending on the province. Although cancer is not the only cause of a PSA elevation above the upper limit of normal, there is a way to work around that problem. Critics of this test operate under the rubric “you are likely to die with prostate cancer, not from it.” They say it is not cost-effective (even though the patient pays for it). They say it has not demonstrated its usefulness for screening, and they question the effectiveness of the prostate cancer treatments currently available.

“This kind of thinking has to stop,” says

Dr. John Trachtenberg, director of the prostate centre at Princess Margaret Hospital in Toronto. Its result, he says, is treatment tainted by ageism and sexism. He offers this example: “An active 70-year-old woman would never be asked to forgo treatment for her breast cancer. Seventyyear-old men with prostate cancer often are. They are told to wait—for another disease. As if this were the solution.”

And the critics are wrong about treatment. The total removal of the prostate for localized cancer offers most middle-aged men a cure, giving them a life expectancy

comparable with that of similarly aged men with no prostate cancer. It is absurd for anyone to tell a 53-year-old man that he has prostate cancer, then produce a pie chart displaying an array of diseases such as a stroke, a coronary or overwhelming infection that may cause his death before the cancer could. In fact, about 25 per cent of men diagnosed with prostate cancer die from it. It is impossible to select those who will die of another disease.

Furthermore, one out of 20 men with localized prostate cancer develops the metastatic form in which the cancer travels to other body parts. Clinicians who, in their dogmatism, urge patients to stoically wait it out in the expectation of dying from another disease have forgotten the density of pain that characterizes metastatic prostate cancer—an incurable disease. This pain derives from the cancer cells attacking bone and the spinal cord, with a subsequent rise of calcium and its accompanying mental lethargy, unquenchable thirst and cardiac irregularities. It is not a heroic death.

The British secretary of state for health, Alan Milburn, has given the critics something to think about. For the past year, British men have been encouraged for the first time to undergo screening for prostate cancer, without cost. “We wanted to make the PSA test freely accessible,” Milburn told me, “and bring it in line with screening for breast and cervical cancer. Here in the U.K., prostate cancer is approaching the frequency of lung cancer—the number 1 killer.”

Its the same in Canada. Here, one out of

nine men will develop prostate cancer, matching one out of nine women with breast cancer. About 17,000 men in Canada are diagnosed each year and 4,000 die from the disease.

The key to detecting prostate cancer in its earliest form involves immediate intervention if the PSA level has accelerated 30 per cent in the past year—even if it’s still registering in the normal range. Because the PSA is not specific for prostate cancer, a single reading (like a single mammogram) is only clinically valuable if it is abnormal. But the test becomes singularly valuable if its pattern is tracked sequen-

daily. It is then that an abrupt rise can be seen and the presence of cancer suspected.

Intervention at this stage involves a transrectal ultrasound image of the prostate. With the patient lying on his side, an ultrasonic probe is introduced into the rectum (the patient will feel a sensation of pressure). The probe emits high-frequency sound waves, then the reflected sound waves are converted into visual images on a monitor. If the pale grey image of the prostate displays suspicious areas, a biopsy is conducted during the imaging.

In early 2000, Rocks PSA reading had suddenly risen from 2.0 to 3.67—well above the 30-per-cent standard. Although the level remained below the high end of normal—around 4.0—the change was enough to investigate. In April an ultrasound image showed no irregularities. Still, six months later, as part of the tracking formula, Rock underwent a special test —a free-PSA ratio. Ifs a valuable marker. If the ratio is greater than 0.2, the likelihood of the patient having prostate cancer is about 10 per cent. However, if the ratio is below 0.1, there is a 90-per-cent chance he has cancer. In December, 2000, Rocks free-PSA ratio was 0.09.

Rock was driving to Washington to celebrate Christmas with his wife’s family. Reaching him on his cell phone, I told him the free-PSA ratio had moved into a zone requiring an early biopsy, booked for Jan. 5. His intuition, and mine, was that he had cancer. Later he said, “I knew—even before the result of the blood test—without knowing why.”

For many men, sex is a signature act,

Rock’s tumour was just one millimetre away from the capsule surrounding the prostate. If it had penetrated the capsule, it would have spread.

primal and necessary to their identity. Even mentioning the male reproductive organs induces panic. The image of a needle being fired into the prostate gland by a biopsy gun makes them shudder. A fine needle, attached to the ultrasonic probe, targets the suspicious area. The gun is fired and a filament of tissue is removed. The patient experiences a burst of pressure that blends into the popping sound. After 15 to 20 minutes—the time taken to obtain six to eight core samples —the pain has gone.

By the date of his biopsy, Rock’s prostate image had changed. “What was normal in

April now displays some spotty areas on the right side of the prostate,” reported Dr. Ron McCallum at St. Michael’s Hospital in Toronto. “I took three core samples from this abnormal zone, and three from the left side of the gland. All samples reveal the presence of cancer.” McCallum’s advice to Rock: “In your age group the gold standard of treatment is total prostatectomy.”

The choice was between nerve-sparing radical surgery and radical radiation. External beam radiation—short bursts of intense radiation guided by a computerdriven machine capable of sculpting the beam—targets the prostate gland. This delivery system is designed to spare the surrounding tissue of the bladder and rectum. It is often the choice of treatment for older patients, or patients who are not a good surgical risk.

At such an early stage, surgery usually offers a total cure. In order to preserve bladder control and erectile function, the dissected prostate is removed carefully, leaving the nerves intact. Meeting to make a decision about the choice of treatment, I suggested to Allan and Debbie, “It’s better to be the poster boy for prostate cancer awareness than its patron saint. And surgery will achieve this.”

During the six-week wait for surgery, Rock increased his training and began running eight to 10 km each morning in sub-zero Ottawa weather. His fitness paid off. Dr. Michael Robinette and Dr. John Tsilhias operated on Feb. 13 and Rock was discharged just three days later. The tumour was one millimetre away

from the capsule surrounding the prostate. If it had penetrated the capsule, it would have spread. But the tumour was confined to the prostate. A year later, on March 4, 2002, his PSA was a barely discernible 0.02, proof that the tumour had been eradicated.

Cancer survivors often enter a heightened state of consciousness. Rock is no different. “I now treat as static things that would have irritated me,” he has told me. “I have a pure enjoyment of my family, and my confidence—certainty during the process of decision-making—has been enormously strengthened.” E3